The Oaks At Belmont

buttocks.

The nurses were not wearing gowns as required for direct contact with EBP. RN F immediately identified that Resident #104's bedding and the back side of her shirt was soaked with a fluid that left a brown discoloration on the sheets and pad. Resident #104 was assisted by both nurses to turn on her left side.

Observed Resident #104's buttocks red, macerated, had deep creases from the bedding, multiple pin-point areas of bright red bleeding, and a nickel sized wound on the left buttock that was covered in slough.

There was no sign of a topical cream on the resident's bottom.

Staff used disposable wipes to clean the resident buttocks and then looked for Triad cream in the resident's room. RN F reported that the CNA's apply the topical creams including the prescription Triad and that it was very thick and would still be visible if applied that day.

Staff was not able to find Triad cream therefore applied petroleum barrier cream over her entire buttocks area.

Staff did not clean Resident #104 on her front side and/or provide catheter care because the fluid that soaked the resident's bed was not urine, it was drainage from her legs, and the resident should have already had front incontinence/catheter care performed that morning by the CNA. RN F reported that she thought the resident's protective boot for her right foot was in the laundry.

Review of Resident #104's Wound Management Reports revealed no current record of wounds on the buttocks or feet.

There was a history of pressure ulcer on left buttock, extending slightly into right buttock, and also a stage 3 pressure ulcer on the left lower buttocks that were both documented as resolved on 5/7/25.

There was also history of an unstageable pressure wound on the left heel.In an interview on 8/11/25 at 3:52 PM, Assistant Director of Nursing (ADON) C reported that staff are required to wear gloves and a gown when providing direct care and linen changes for Resident #104. ADON C reported that Triad cream is a topical medication that the nurse should apply twice daily to Resident #104's buttocks and should be kept in the medication cart. ADON C reported that at that time Resident #104's Triad cream was not found in her room and/or the medication cart. ADON C reported that the facility had implemented a new process after Resident #101's pressure ulcer finding, requiring the CNA's to document any skin concerns on a skin observation form and submit it to the nurse and to the DON. ADON C reported that Resident #104 did not have any skin observation forms on record at that time.

Review of the Fundamentals of Nurse ([NAME] and [NAME]) revealed, When you identify the presence of a skin wound or pressure injury, closer assessment is required.

Assess the type of tissue in the wound base so that you can plan appropriate interventions.

The assessment includes the amount (percentage) and appearance (color) of viable and nonviable tissue .

Soft yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and it must eventually be removed by a qualified clinician or by an appropriate wound dressing before the wound is able to heal.

Black, brown, tan or necrotic tissue is eschar, which also needs to be removed before healing can occur .

Assessment of wound exudate should describe the amount, color, consistency, and odor of wound drainage.

Excessive exudate indicates the presence of infection.

Wound pain, including the location, distribution, type, quality and intensity, and any aggravating or relieving factors, also should be assessed ([NAME], 2016).

Examine the skin around the wound (periwound) for redness, warmth, and signs of maceration, and palpate the area for signs of pain or induration.

The presence of any of these factors on the periwound skin indicates wound deterioration. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME].

Fundamentals of Nursing - E-Book (p. 1247).

Elsevier Health Sciences.

Kindle Edition.

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