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During an interview on 2/27/26 at 10:02 a.m., PA-A stated R4 needing extensive assistance with bed mobility and transfers. R4 identified as high risk for skin breakdown which is why the recommendations for the IDT to review R4's needs and for RD to evaluate R4 were made. R4's MASD and evolution to a pressure ulcer was multi-factorial. PA-A stated the care center was expected to act on their recommendations for repositioning and wound care, having an APM installed at the start of the wound would have helped slow down the wound progression. PA-A stated it was hard to say whether the wounds were avoidable or not because the recommendations were not followed. A facility Skin Assessment & Wound Management policy, dated 2/2025, identified guidelines for assessing and managing wounds.

This included completion of a Braden Scale, implementation of appropriate skin measures, completion of the skin evaluation and risk factors forms, and routine ongoing skin monitoring by the staff.

The policy identified a section labeled, Pressure Wounds, which directed steps when a new ulcer was found.

This included notifying the provider, completing education with the residents and family, initiating a skin and wound evaluation, referring them to dietary if needed, reviewing and updating the care plan interventions.

The past noncompliance harm-level finding was corrected prior to the onsite survey exited on 2/27/26.

The facility implemented multiple actions to address the noncompliance which included education provided to the nurse leadership team on expectations with a developed pressure wound, the nurse leadership team on MDS completion, and the nurse leadership on care planning and skin interventions. In addition, a sample of current residents with pressure ulcers were reviewed and identified no additional concerns with the care provided.