**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review, the facility failed to: 1. Have a consistent leadership of an Administrator, DON (Director of Nursing), and DSD (Director of Staff Development), which led to the lack of training for the nursing staff for both the Licensed Nurses and the Certified Nursing Assistants (CNAs). These failures had the potential for the nursing staff's inability to provide accurate assessments and safe provisions of care to the residents to ensure residents received high quality of care and effective care was being delivered. 2. To assess and treat Resident 11, who had been complaining of his coccyx/buttocks (lower/backside/behind) region feeling chapped and hurting since 5/30/23, until the surveyor had two CNAs turn Resident 11 on his side, after they finished his care on 6/2/23 at 9:45 a.m. Resident 11 had three open areas, one located on his left coccyx, another on his left lower buttocks region and another open area on his right lower buttocks to thigh region. The surrounding area looked red and irritated. Resident 11's Licensed Nurse was not aware of Resident 11's coccyx/buttocks skin breakdown until the surveyor asked one of the CNAs to get Resident 11's nurse in order to assess Resident 11's coccyx/buttocks region. This failure led to Resident 11 being uncomfortable for three days, because the appropriate treatment was not provided, feeling neglected, and the possibility of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) developing if Resident 11's coccyx/buttocks had not been assessed and treatment had not been started. On 6/5/23 at 10:47 p.m., due to the facility's failure to provide documentation and proof that an Annual Skill Competency check for both the nurses and the certified nursing assistants (CNAs) were being done annually and the lack of consistent Administrator and DSD in the building, Administrator 1 and the Interim DON were officially notified of an Immediate Jeopardy (Immediate Jeopardy is a situation in which provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident [State Operations Manual, Appendix Q]). During a concurrent interview and Administrator Job Description record review on 6/6/23 at 10:23 a.m., Administrator 1 clarified the Administrator's job description. The Administrator stated the Administrator was expected to be in the facility, in person, 75 percent (%, fractions that are counted out of 100) of the time and 25% outside the facility, conducting marketing (any actions a company takes to attract an audience to the company's product or services). When asked if the Administrator was expected to be in the facility, the administrator stated, Yes. On 6/8/23, at 2:30 p.m., the facility's Immediate Jeopardy Removal Plan was received and included, but was not limited to: 1) The Director of Nursing and/or designee auditing the annual competency evaluations for Licensed Nurses and Certified Nursing Assistants over the past year and ensuring all active Licensed Nurses and CNA's competency evaluations were completed by 6/9/23. 2) The Director of Nursing and/or designee in-servicing Licensed Nurses and CNAs on the facility's policy for, wound care, with an emphasis on wound assessments, prevention, treatment, and reporting of pressure ulcers (PU's, an injury that breaks down the skin and underlying tissue, when an area of skin is placed under pressure). Also, with a focus on providing accurate assessments including skin assessments and safe provisions of care to the residents, which would be completed by 6/7/23. 3) The Interim DON or the designee will conduct a weekly audit of newly-hired nursing staff to ensure completion of initial competency evaluations. 4) On a monthly basis the Director of Nursing and/or designee will audit nursing staff to ensure the completion of annual competency evaluations. The Director of Nursing will report the audit findings to the Administrator in the morning stand-up meeting, weekly. 5) Monthly, the Director of Nursing and/or designee will report their audit findings to the QAPI committee for further review and follow-up. The QAPI committee will reassess the need for further monitoring quarterly. 6) A new Director of Staff Development (DSD) was on-boarded on 6/6/23, and a newly-hired local (existing in or belonging to the area where the facility was located) Administrator was scheduled to report for duty in the building on 6/21/23. 7) During the absence of a Director of Nursing, the facility will designate Licensed Staff N, a qualified Registered Nurse, as the interim Director of Nursing in the absence of the DON. On 6/9/23 at 9:28 a.m., the removal of Immediate Jeopardy occurred in the presence of the Interim DON, the Administrator and another Administrative Staff after interviews and observations confirmed the facility implemented the corrective plan of actions. Findings: 1. During an interview on 5/30/23 at 9:50 a.m., the supplies manager verified the DON, Administrator, Infection Preventionist (IP) Nurse, the Minimum Data Set (MDS) Coordinator and the Director of Staff Development (DSD) were not in the building. During an interview on 5/30/23 at 12:07 p.m., the Medical Records Director (MRD) stated the corporate (relating to large companies) Administrator, and the corporate DON were not yet in the building. The MRD stated the Administrator did not come in the facility in person but was available via phone if needed. When asked how long it had been since the facility had an Administrator who came in the facility, the MRD stated she was not sure of the date, but it would have been since early May. The Administrator arrived in the building on 5/30/23 at 1:12 p.m. During an interview on 6/01/23 at 1:35 p.m., Licensed Staff B who was a long time employee stated he could not recall when the last time was he had an annual competency check done by the DSD. During an interview on 6/01/23 at 1:40 p.m., Unlicensed Staff H, Unlicensed Staff F and Unlicensed Staff P stated they could not recall whether they had received the annual competency skill check this year or last year. Unlicensed Staff H, Unlicensed Staff F and Unlicensed Staff P stated they could not recall the last time they were evaluated by the DSD. During an interview on 6/1/23 at 5:47 p.m., the Interim DON stated the annual competency test for both Licensed Nurses and CNAs should have been done yearly, per facility policy. The Interim DON stated the last annual competency skill done for the Licensed Nurses and the CNAs was in 2021. The Interim DON stated there had been so many management and DON changes over the year and lack of communication between the outgoing and incoming DON. The Interim DON felt this was the reason the annual competency skill check fell through the cracks. The Interim DON stated the reason why an annual competency skill check was completed, was to ensure staff were caring for the resident's safely, to learn new things and keep up with nursing changes and updates. The Interim DON stated the annual competency skill checks were conducted to ensure staff were able to care for the residents safely. During an interview on 6/02/23 at 9:21 a.m., Licensed Staff J stated it was important to ensure staff had annual competency skills checks. Licensed Staff J stated the competency skills check was important for residents' safety. Licensed Staff J stated, not having the annual competency skill check done for CNA's and nurses could negatively impact the way staff took care of the residents. Licensed Staff J stated there could also be missed opportunity for staff to learn how to perform tasks safely and appropriately. During an interview on 6/2/23 at 9:49 a.m., Unlicensed Staff O stated she was not sure the last time she received an annual competency skill check. Unlicensed Staff O stated it was very important to receive annual skill competency training. Unlicensed Staff O stated the annual competency skill check was important as this would provide feedback that would ensure staff were providing safe care to the residents. Licensed Staff O stated, ensuring the annual competency skill check was done annually, consistently and as needed, would benefit the staff and the residents by ensuring staff was providing care to their residents safely. During an interview on 6/2/23 at 11:37 a.m., the Administrator stated the Co-Administrator was the acting Administrator in charge of the facility's overall compliance, the general operation of the facility and the department and dealt with any issues as they arose. The Administrator stated it would be beneficial if the facility had an Administrator who could oversee the facility's general operation to ensure the systems in place were working or updated if need be. The Administrator stated he expected the nursing staff to have annual competency skills check to ensure staff were providing safe care to the residents. The Administrator stated the lack of annual skills competency check for staff could cause harm to the residents. The Administrator stated it would benefit the residents to ensure staff had a competency skills check completed annually, and stated there was an issue with oversight of the facility operation and maintenance system. The Administrator stated there was a fault somewhere in the management in the facility, and stated it was the responsibility of the Administrator to ensure the facility's system was working. During a concurrent interview and annual competency skills check for both licensed nurses and CNAs record review on 6/2/23 at 12:08 p.m., the Interim DON stated she was the Interim DON at the facility from 4/1/23,until the facility finds a new DON. The Interim DON stated the previous DON vacated the position on 3/31/23, and another DON started the following week. The Interim DON stated this DON was trained and worked for the facility for one week but resigned the following week. The Interim DON stated the DSD was in charge of ensuring annual skill competency checks were done for both the nurses and the CNAs. The Interim DON verified the facility currently had no DSD in place. The Interim DON stated she currently oversaw the DSD program. The Interim DON stated Licensed Staff B was hired as a DSD before the previous Administrator left but had not started the training yet. The Interim DON was not sure of the exact date on when the Previous Administrator left the company, but stated it could be early 5/2023. The Interim DON confirmed nurses and CNAs lacked the annual competency skills check. The Interim DON stated she was cognizant there was a need to look at some of the facility's systems, like the annual competency skills check not being done for staff. The Interim DON stated the last time an annual competency skills check done for the nurses and CNAs was on 2021. The Interim DON stated the facility had no consistent DSD to train staff. The Interim DON stated she was not sure when last time the nurses were checked for competency in wound identification and assessment. During a concurrent interview and record review of the last 15 months of DON and DSD hired and term dates form, on 06/05/23 at 10:53 a.m., the Interim DON verified the facility had multiple turn over as far as the DON was concerned. The Interim DON verified the DON's hired between 2022 and 2023, only lasted between two to four months. The Interim DON stated the last DON, prior to her assuming the Interim DON position, lasted for about a week. When asked the reason for the high turnover, she stated, I don't know. During an interview on 6/6/23 at 4:30 p.m., Licensed Staff C stated the residents were not receiving the quality care they needed. Licensed Staff C stated she could not recall when the last time was she had an annual skill competency check. Licensed Staff C stated the lack of management to give directions and assist the staff on patient care issues was too much to bear. Licensed Staff C stated, due to lack of management oversight, she often wondered what could happen to her nursing license. Licensed Staff C stated it would be great for the residents if staff received annual competency skill checks from the DSD, but the facility did not have one [DSD] for a very long time. Licensed Staff C stated the facility had no consistent managers to guide the staff at all. During a review of the Facility Assessment, dated 3/29/23, under the responsibility tab, it indicated the Administrator would attend the daily morning meetings and conducted daily rounds in the facility. Under the responsibility tab of the Facility Assessment, it also stated the Administrator's goal was to ensure each Department Managers were performing essential duties to correctly operate their department and to ensure compliance with facility protocols and regulations. During a review of the Facility Assessment, dated 3/29/23,under the responsibility tab, it indicated the DON oversaw the overall management of the nursing department, including nursing personnel performances education, training and monitoring. During a review of the Facility Assessment, dated 3/29/23, under the responsibility tab, it indicated the DSD ensured there was staff education and training to ensure protocols and regulations were being followed. During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, dated 1/2018, the P&P indicated the job performance of each employee should be reviewed and evaluated at least annually. 2. A review of Resident 11's, admission Record, indicated Resident 11 was admitted on [DATE], with diagnoses including disease of the spinal cord, Type Two Diabetes (a disease that occurs when one's blood sugar was too high), chronic pain syndrome, major depression, severe obesity, anxiety, amongst others. A review of Resident 11's Quarterly MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 3/6/23, indicated Resident 11 had a BIM (Brief Interview of Mental Status) score of 15, meaning cognitively intact, and he needed two-person physical assist with bed mobility (how a person moves to and from lying position, turns side-to-side and positions body while in bed). During an observation and interview on 5/30/23 at 4:45 p.m., 5 p.m. and 5:11 p.m., Resident 11 was positioned on his back. Resident 11 had an egg-crate mattress topper (has bumps, dips, and curves designed to contour the body, provide support and alleviate any pressure on muscles and joints, and helps prevent pressure sores) and an oversize bed. Resident 11 stated he had been positioned on his back all day. Resident said, Call light not answered. I will have to call out and staff ignore me. The staff sees my light and ignore it. CNAs only come in when they have to come in to talk to me. A review of Resident 11's care plan, initiated 10/24/22, indicated Resident 11 had a history of MASD (Moisture-Associated Skin Damage is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, and/or sweat). Resident 11's care plan for, High Risk for Skin Integrity Impairment, related to disease process, incontinent of bladder and bowel, included interventions/tasks such as cleanse and apply barrier cream after incontinent episodes, keep clean and dry, and turn and reposition every two hours and as needed and chooses to use a brief. Additional interventions included avoid friction when repositioning resident in bed or wheelchair, monitor skin daily with ADL (Activities of Daily Living: The tasks of everyday life. Basic ADLs include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet), and reeducate/encourage resident regarding repositioning as needed. A review of Resident 11's Nursing-Weekly Summary Notes -V3, dated 4/15/23, indicated Resident 11's skin was clean and intact and there was no new skin breakdown noted. This was the last, Nursing-Weekly Skin Assessment - V3, found in Resident 11's electronic medical record. A review of Resident 11's MAR (Medication Administration Record), dated 5/2023, indicated Resident 11 had an order to be repositioned every two hours, start date, 7/7/21, and based on nursing signatures, Resident 11 was being repositioned every two hours. During a concurrent observation and interview on 6/2/23 at 9:45 a.m., after Unlicensed Staff F and Unlicensed Staff Q completed cleaning Resident 11's backside and performing peri care (cleaning private area), the surveyor asked Unlicensed Staff F and Unlicensed Staff Q to ask Resident 11 if it would be okay to see his backside, which Resident 11 agreed to. Resident 11 turned well with assistance from Unlicensed Staff F and Unlicensed Staff Q. Three open areas were noted: Left coccyx region and lower buttocks and right lower buttocks to thigh region. The area looked red and raw. Unlicensed Staff F stated Resident 11's buttocks did not look like that last week when she cared for him. Resident 11 stated his coccyx/buttocks area was burning. Unlicensed Staff Q applied a cream to the areas, which looked clean. Resident 11 wore a brief and was positioned on his back most of the time per multiple observations in the past three days (5/30-6/1/23). Resident 11 stated the nurses had not been treating his coccyx/buttocks region. Licensed Staff B came into assess Resident 11's skin breakdown, looked at Resident 11's coccyx and buttocks region and stated he was not aware of the new skin breakdown. Licensed Staff B started measuring the areas and was going to notify Resident 11's physician. Licensed Staff B stated each scheduled nurse per shift did their own wound care for their assigned residents based on the physician's orders. Licensed Staff B stated the facility did not have a scheduled wound nurse. During a concurrent observation and interview on 6/2/23 at 10:10 a.m., Resident 11 was being turned by a CNA. Resident 11 stated 50% of the nurses and CNAs were qualified to care for him. Resident 11 stated he was changed no more than twice per shift. Resident 11 stated the staff did not want to work with him. During a concurrent observation and interview on 6/2/23 at 4:28 p.m., Resident 11 was positioned on his back. Resident 11 stated being positioned on his back was the most comfortable position. During a concurrent observation and interview on 6/5/23 at 11:45 a.m., with the approval of Resident 11 and with the assistance of CNAs, the surveyor looked at Resident 11's coccyx/buttocks with another surveyor. Resident 11 stated the coccyx/buttocks region hurt. The area had been covered up with cream. The area looked purple/maroon in color, breakdown was still present, which looked like Suspected Deep Tissue Injury (STDI: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). Resident 11's egg-crate mattress had been replaced with a low air loss mattress (air mattress covered with tiny holes. These holes are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture). A review of Resident 11's electronic medical record on 6/5/23 at 11:22 a.m., there was no SBAR (Situation, Background, Assessment, Recommendation: Is a verbal or written communication tool that helps provide essential, concise information, usually during crucial situations) and no, Nurses Progress Notes, addressing Resident 11's new skin breakdown. There was a new order to apply barrier cream (prevent excess moisture) every shift and if needed during incontinent care, starting 6/2/23 at 11 p.m. During a concurrent observation and interview on 6/5/23 at 1:25 p.m., Physician 2 assessed Resident 11's coccyx/buttocks region. Physician 2 stated she felt the skin breakdown was MSAD caused from Resident 11 wearing a brief. Physician 2 stated the open area at the right lower buttocks to the thigh region was caused from shearing of Resident 11's brief. The Interim DON and Unlicensed Staff Q were present too. During an interview on 6/5/23 at 1:42 p.m., Physician 2 was shown pictures of Resident 11's backside region (coccyx and buttocks) taken by surveyor, dated 6/5/23 at 11:37 a.m. Physician 2 stated what she saw on the pictures was not what she assessed today. Physician 2 stated the breakdown looked like STDI. During a concurrent observation and interview on 6/5/23 at 2:03 p.m., Physician 2 assessed Resident 11's coccyx/buttocks region for the second time. Physician 2 stated the areas were blanchable, so to her the skin breakdown was MSAD, caused from wearing a brief. The right buttocks to thigh breakdown was because of the brief causing shearing. Physician 2 stated the discoloration located at the lower backside was permanent discoloration she saw a lot from a resident being on their backside. During an interview on 6/5/23 at 3:56 p.m., Resident 11 stated he received his low air loss mattress yesterday, 6/4/23. Resident 11 said, You are making a difference in the quality of my care. Thank You. During a concurrent interview and electronic record review on 6/6/23 at 9 a.m., Resident 11's SBAR, dated 6/2/23, for Resident 11's new skin breakdown (excoriation and redness, MSAD to right buttocks and left upper gluteal fold) first assessed/found on 6/2/23, by the surveyor, had not been signed by Licensed Staff B until 6/5/23 (verifying when the SBAR was completed). The Interim DON stated Resident 11 did not have any, New Progress Note, addressing the new skin breakdown, the SBAR was the new note. A review of Resident 11's, Physician Note, dated 6/6/23 at 2 p.m., and signed by Physician 1 on 6/5/22 at 11:10 p.m., indicated Resident 11's skin breakdown was conferred as MASD and Physician 2 had likewise evaluated as MASD. A review of Physician 2's, Surgical Consult, dated 6/6/23, indicated Physician 2 evaluated Resident 11's coccyx/buttocks area on 6/5/23 (Note: first found/assessed on 6/2/23 at 9:45 a.m. by surveyor). Physician 2 indicated: Location: Right Buttocks: MASD. Lesion Condition: erosion (breakdown of the outer layers of the skin). Lesion Description: Small area of epithelial (outer layer of skin) breakdown. Recommend application of triad cream (Infection Protection Ointment for bed sores, pressure sores, diabetic wounds, ulcers, cuts, scrapes, and burns) daily and as needed. Location: Left Infragluteal Fold (the crease right under the butt): Shear injury related to rubbing from brief. Dressing Used: Skin prep and foam dressing. Tissue Type: 30% Granulation (pink in color and is an indicator of healing) and 70% Epithelial. Length: 0.5 centimeters (cm: 0.4 inches) and Width: 0.5 cm. Patient has a wound at the left infragluteal fold. The patient is also at risk for developing a pressure ulcer given the following factors: Diabetes, Depression, and Limited Mobility. During a concurrent interview and record review, on 6/6/23 at 4:50 p.m., the Interim DON was asked if Resident 11's, Nursing-Weekly Summary Notes - V3, dated 4/15/23, which included a skin assessment, was the last one complete for Resident 11. The Interim DON stated there should be a, Nursing-Weekly Summary Report, for Resident 11, which included an assessment of his skin, done every week. The Interim DON looked in Resident 11's electronic medical record and the last, Nursing-Weekly Summary Notes - V3 the Interim DON could find was dated, 4/15/23. The Interim DON stated she did not know why Resident 11's, Nursing-Weekly Summary Notes - V3, has not been completed weekly, since there was enough staff. The Interim DON was asked how often a resident had a skin assessment. Resident 11's last assessment titled, Skin Evaluation, was dated 2/7/23. The Interim DON stated part of the resident's, Nursing-Weekly Summary Notes. included an assessment of the resident's skin, which was supposed to be completed weekly. On 6/5/23, there was 47 residents residing in the facility. Based on part of the facility IJ removal plan, all residents had a skin assessment completed on 6/5/23. Four other residents were identified with skin issues, Unsampled Resident 28 and Resident 208 and Sampled Resident 19 and Resident 47. A review of residents, Progress Notes, dated 6/5/23, indicated the following new skin findings: *Resident 28 had redness to left groin. *Resident 208 had redness to buttocks. *Resident 19 had a blister to his left heel measuring 2.5 x 2.5. Treatment ordered. Redness to buttocks. *Resident 47 had an open area 1 x 2. Treatment ordered. A review of Resident 47's, admission Record, indicated Resident 47 was admitted on [DATE], with diagnoses including Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle weakness, lack of coordination, need for assistance with personal care, failure to thrive (happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), cognitive communication deficit, amongst others. A review of Resident 47's, Hospice Election Statement, indicated Resident 47 was started on Hospice, 3/8/23. A review of Resident 47's, Significant Change of Condition MDS, dated [DATE], indicated Resident 47 had a BIMs of 3 (severely cognitively impaired) and needed one-person physical assist with bed mobility. A review of Resident 47's, Nursing-Weekly Summary Notes - V3, dated 5/21/23 and 5/28/23, indicated Resident 47's skin was clean and intact. Resident 47's Nursing-Weekly Summary Notes - V3, dated 5/21/23, indicated Resident 47 had a special mattress, but he did not. Resident 47's care plan: Open Area to Coccyx, initiated on 6/6/23, indicated Hospice to provide Resident 47 a low air loss mattress on 6/6/23, which occurred on 6/6/23. A review of Resident 47's, Risk for Skin Integrity Impairment, care plan, initiated 2/15/23, indicated: Give peri care frequently, monitor skin daily with ADLs, reposition every 2 hours and as needed, and weekly skin sheets for any pressure ulcers. A record review of Resident 47's weight indicated on 1/26/23, he weighed 121 pounds and on 5/4/23, Resident 47 weighed 98 pounds. Resident 47 lost 23 pounds in a little over three months (3 months/9 days). During multiple observations on 5/30/23, Resident 47 was on his backside without a low air loss mattress. On 5/30/23 at 11:21 a.m., and 5/30/23 at 4:03 p.m., Resident 47 was on his back. There was no observation of Resident 47 being turned since 11:21 a.m. On 5/30/23 at 5:21 p.m., Resident 47 was still upright in bed after dinner, positioned on his buttocks and slightly turned to his right. During an observation on 5/31/23 at 8:50 a.m., Resident 47 was on his back and turned slightly to his right side. Pillows were under his lower extremities (legs) to relieve pressure, but he was still positioned on his buttocks. During a concurrent observation and interview on 5/31/23 at 6:01 p.m., Resident 47, who was in bed, stated he would like to get up but had not been up all day. During an observation on 6/01/23 at 9:24 a.m., Resident 47 was upright in bed, in a hospital gown and positioned on his back. A review of Resident 47's SBAR, dated 6/5/23, indicated Resident 47 had a new facility-acquired (pressure injury that developed after admission to the facility) open area on his coccyx measuring 1 x 2 cm. A review of a, Hospice order, dated 6/7/23, indicated Resident 47's new facility-acquired wound was a Stage 2 pressure ulcer (PU: when the sore digs deeper below the surface of your skin). The Hospice nurse was to perform wound care one time per week and as needed, using wound cleanser and cover with a bordered foam dressing. The facility staff was to perform wound care two times per week and as needed. A review of Resident 19's, admission Record, indicated Resident 19 was admitted on [DATE], with diagnoses including cellulitis of the right lower leg (serious bacterial skin infection), chronic total occlusion of the artery of the extremities (blockage of blood flow to the heart), stroke, muscle weakness, diabetes, amongst others. A review of Resident 19's Quarter MDS, dated [DATE], indicated Resident 19 had a BIMs of 5 (severely cognitive impaired), and he needed one-person bed mobility. A review of Resident 19's, Impaired Skin Integrity, care plan indicated Resident 19's admission assessment, dated 8/23/22, showed Resident 19 was admitted with cellulitis of the right lower limb and his left foot had a black blister on the planter area (sole of the foot), but care plan was not initiated until 9/29/22. Interventions included: The resident requires supplement protein, amino acids (building blocks for proteins), vitamins (a nutrient that the body needs in small amounts to function and stay healthy) and minerals (a nutrient that is needed in small amounts to keep the body healthy), as ordered, to promote wound healing, treat pain, as ordered, prior to treatment/turning to ensure resident's comfort, amongst others. A review of Resident 19's weight indicated on 3/6/23, Resident 19 weighed 144 pounds and on 6/8/23, Resident 19 weighted 134 pounds. Resident 19 had lost 10 pounds in three months. A review of Resident 19's, ADL care plan, initiated 9/29/22, included Bed Mobility interventions: The resident is totally dependent on one staff for repositioning and turning in bed ever two hours and as necessary, and Transfer: The resident is totally dependent on one staff for transferring. A review of Resident 19's, Nursing-Weekly Summary Notes - V3, dated 4/26/23 and 5/3/23, indicated Resident 19's skin was clean and intact. No skin issues were identified. The skin assessment indicated Resident 19 had a special mattress, but he did not. A review of Resident 19's, Nurse's Progress Note, dated 6/8/23, and physician's order dated 6/8/23 at 10:30 a.m., indicated Resident 19's physician ordered for Resident 19 to have a low air loss mattress on 6/8/23, which was carried out on 6/8/23, related to limited mobility. Resident 19's, Nursing-Weekly Summary Notes - V3, dated 5/10/23, 5/18/23, and 5/24/23, indicated Resident 19's skin was clean and intact. No skin issues identified. The, Nursing-Weekly Summary Notes - V3, dated 5/31/23, indicated Resident 19's skin was clean and intact. There was no mention of a blister on Resident 19's left heel. Resident 19's, SBAR, dated 5/30/23, indicated Resident 19 had a blister on his left heel measuring 2.5 x 2.5. A review of Resident 19's, Impaired Circulation, care plan, initiate 9/22/22, interventions included elevating legs when resting. During an observation on 5/30/23 at 11:48 a.m., Resident 19 was positioned on his back sound asleep. No special mattress was on his bed and there were no pillows positioned under his lower extremities, so his heels were floating (suspended in air) to relieve pressure on his heels. During a concurrent observation and interview on 5/31/23 at 5:53 p.m., Unlicensed Staff R stated staff tried getting Resident 19 up, but often after ten minutes he wanted back in bed. Resident 19 was positioned on his back, and his bed was lowered to 25 degrees after dinner. During an observation on 6/5/23 at 4:34 p.m., Resident 19's head was elevated 30 degrees, positioned to the right side, a pillow was under Resident 19's knees, and he had boots on. A review of Resident 19's SBAR, dated 6/6/23, indicated Resident 19's buttocks was red.[TRUNCATED]