Based on observation, interview and record review, the facility failed to ensure a resident's call light was answered timely to provide toileting assistance for one of three residents (R1) reviewed for call lights in the sample of three. This failure resulted in R1 soiling herself while waiting for assistance and sitting for several hours and causing her emotional distress. Findings include: The facility's Resident Rights policy, dated 2/2021, documents Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity. The facility's Dignity policy, dated 2/2021, documents Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: promptly responding to a resident's request for toileting assistance. The facility's Resident's Call System policy, dated 9/2022, documents Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. R1's current electronic medical record documents R1 has diagnoses of Urinary Tract Infection, Chronic Diastolic (congestive) Heart Failure, Acute and Chronic Respiratory Failure, Morbid obesity and Chronic Kidney Disease stage 3. R1's current Care Plan, dated 4/24/25, documents (R1) will remain in homelike atmosphere at (the facility) and continue to have her needs met. (R1) will be continually monitored for safety and assisted so that her needs are met. R1's Toileting assessment, dated 4/21/25, documents R1 requires assistance of one staff for toileting. R1's current Brief Interview for Mental Status assessment (BIMS), dated 4/7/25, documents R1 has a BIMS of 14 indicating R1 is cognitively intact. On 4/25/25 at 12:45 PM, R1 was sitting in her room in a wheelchair. R1 stated sometimes she has to wait a while for her call light to be answered. R1 stated I need assistance to get up and when using the toilet. Last night I had to go to the bathroom and a CNA (Certified Nursing Assistant, unknown) came in at supper time and I told her that I needed to use the toilet. The CNA said she would go get someone to help her transfer me, but she never came back. I hit my call light, but I didn't see anyone until 11:30 PM. I had already soiled myself because I couldn't hold it that long. I can't transfer safely because my legs get wobbly, so I need help with going to the bathroom, so I just had to sit in the mess and wait. When the staff came in at 11:30 PM, they helped get me cleaned up. I don't know if it was a staffing problem or what. While waiting for someone to come I just felt very dirty. I was so upset that it happened, and I wish it didn't. On 4/25/25 at 12:55 PM, V8 (Certified Nursing Assistant) confirmed she is working on R1's hall. V8 stated (R1) was very upset this morning when I came in the see her. She said first thing when I entered her room that last night, she had a CNA (unknown) that told her she would come back and help her but never did. She said she ended up wetting herself and that she didn't receive help with getting cleaned up for several hours. (R1) is a nice resident and rarely pushes her call light because she doesn't want to bother. I felt bad for her because I could tell it made her so upset and she had it on her mind throughout the night. I am not sure how many were here at that time yesterday, but she needed assistance to the bathroom and was upset that she couldn't hold it. On 4/26/25 at 2:45 PM, V1 (Administrator in Training) stated he is handling nursing and nursing assistant concerns right now due to the facility not having a Director of Nursing or Interim director in that role, currently. V1 stated he was unaware that R1 waited several hours for toileting assistance or that she had an incontinent accident as a result. V1 confirmed waiting even one hour to receive assistance is not acceptable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to remove a resident's wheelchair pedals during a sit to stand transfer from the wheelchair to the recliner for one of four resident (R52) reviewed for accidents in the sample of 33. This failure resulted in R52 hitting her left outer calf on the wheelchair pedal during the transfer, resulting in R52 sustaining a seven cm (centimeter) long full thickness, painful, gaping laceration of the left, lower leg requiring R52 to be transferred to the emergency room to received internal and external sutures of the laceration. Finding include: The facility's Using a Mechanical Lifting Machine policy dated July 2017, states The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. This same policy states 4. Prepare the environment: a. Clean an unobstructed path for the lift machine; b. Ensure there is enough room to pivot. R52's Minimum Data Set assessment dated [DATE], documents R52 is cognitively intact with a Brief Interview for Mental Status of fifteen out of fifteen. R52's Plan of Care dated 8/31/23, states My (R52) transfer status is to stand lift with two staff assist. R52's Plan of Care also documents R52 is on anticoagulant therapy and staff are to use caution to avoid bumping or scraping (R52's) skin. On 10/30/23 at 11:40 a.m., R52 had a 4 inch by 4 inch bandage on her left outer calf. R52 stated she had a laceration on her left outer calf that had 15 stitches on the outside and two on the inside. R52 stated this laceration resulted from staff not removing the foot pedal from her wheelchair before transferring her with the sit to stand mechanical lift. R52 stated when the injury occurred there were large puddles of blood and R52 sent to the local emergency room. R52 stated It hurt like crazy. R52's Accident Report dated 10/24/23 at 4:15 p.m., documents Outcome-Deep Laceration. R52's nurse was called into R52's room by two Certified Nurse Aides (V8 and V9) due to a laceration on R52's left lower extremity caused by the wheelchair pedals during a transfer. R52's nurse noted a moderate amount of bleeding coming from R52's laceration to lower left leg. Pressure was applied to laceration and area cleansed the best possible to assess the wound. R52 was sent to the local Emergency Department for evaluation and treatment. This same report documents Contributing Factors: Wheelchair pedals were not removed from wheelchair prior to (sit to stand mechanical lift transfer). Corrective Actions Taken: Education was provided to both (V8 and V9) Certified Nurse Aides involved regarding the importance of removing the wheelchair pedal prior to transfers. V8's Statement dated 10/24/23, states (V9/Certified Nurse Aide) and I were transferring (R52) with sit to stand lift from wheelchair to recliner when her left leg caught on her wheelchair foot pedal. We noticed bleeding and I went to get the nurse. The local Hospital Emergency Department Note dated 10/24/23 at 6:38 p.m., states (R52) presents with a 7 centimeter long full thickness, stellate gaping laceration of the left, lower leg. The area was draped and prepped per norm. Closure was achieved with two 3.0 running (2 running stitches, approximately 15 total tosses) Ethilon sutures in the skin. On 11/1/23 at 1:30 p.m., V7 (Infection Preventionist) removed the bandage from R52's laceration/wound on the left outer calf area. Under the outer bandage was another type of dressing that was sticking to R52's sutures. V7 was able to count multiple stitches but did not want to pull on the bandage that was stuck to the sutures. V7 stated the facility's Nurse Practitioner is scheduled to remove R52's sutures early next week. V7 stated R52's laceration was caused when R52's wheelchair pedals were not removed prior to a sit to stand mechanical transfer when the pedal caught her leg. R52 stated the staff were educated the staff should always remove the pedals. On 11/1/23 at 2:00 p.m., V1 (Administrator) stated R52's laceration to her lower left leg was caused by the staff (V8 and V9) not removing the wheelchair pedals prior to transferring R52 from her wheelchair to the recliner. V1 stated V8 and V9 were educated to always remove wheelchair pedals prior to transferring residents to prevent injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure staff were knowledgeable about an implanted urinary sphincter device, assessing for low urine output, sudden weight gain, and development of edema for one of three (R1) residents reviewed for competent nursing staff in a sample of three. These failures resulted in R1 requiring hospitalization where R1 was diagnosed with not having R1's bladder drained enough, with 2 (two) liters of urine found on ultrasound in R1's bladder, a weight gain of 35 pounds in four days, Congestive heart Failure (CHF) and small pleural effusions. Findings include: An admission Criteria policy dated as revised 3/2019 states, Our facility admits only residents who's medical and nursing care needs can be met. A RN/LPN (Registered Nurse/Licensed Practical Nurse) job description policy dated 4/2022 summarizes a nurse's job as, provides direct nursing care to the resident and supervises the day-to-day activities performed by CNAs (Certified Nurse Aides) in accordance with current Federal, States, and local standards-of-care and as required by the DON (Director of Nurses). This policy also includes in the nurses' duties, Provide treatments as necessary and appropriate, and Communicate with direct care staff the needs of the residents, and Monitor significant weight loss/gain, alerting the physician and family as appropriate. In addition, this policy states that nursing staff must have, the ability to take initiative, make independent judgements, and promote teamwork is required to successfully fulfill this job's responsibilities. An admission Assessment and Follow up: Role of the Nurse policy dated as revised 9/2012 states, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS (Minimum Data Set). In addition, this policy instructs nurses to, Notify the supervisor and the Attending Physician of immediate needs that the resident may have, and Report other information in accordance with facility policy and professional standards of practice. A Weight Assessment and Intervention policy dated as revised 3/2022 states, Resident weights are monitored for undesirable or unintended weight loss or gain. R1's hospital Discharge Orders and Summary dated 7/14/23, which was in R1's facility medical records, describes R1's hospital course as having been admitted to the hospital following a fall at home and was found to have had a Myocardial Infarction (Heart Attack) with Acute on Chronic systolic heart failure (CHF). This summary includes that R1 was admitted with an artificial urethral sphincter for emptying urine from R1's bladder because of urinary incontinence. This summary documents R1 was assessed for dementia and scored as moderately cognitively impaired. R1's physician's orders dated 7/14/23 document R1 has diagnoses including Acute on chronic systolic (congestive) heart failure, non-st elevation Myocardial Infarction. These same orders include instructions for R1 to be weighed daily between the hours of 6:00a.m.- 2:00p.m., and to be administered the diuretic Spironolactone 25mg (milligrams) once daily. R1's admission referral from the hospital record dated as printed 7/13/23 by V2 (Director of Nurses) documents R1 was accepted for admission to the facility by V1 (Administrator) as of 7/12/23. This same referral record includes a physician's progress note that documents R1's most recent hospital recorded weight at the time of the referral was 209lbs and 14 oz (ounces) and that R1 had medical history of Type 2 Diabetes Mellitus, Prostate Cancer with Prostatectomy, and Neuropathy. In addition, R1's hospital physician's progress note dated 7/12/23 documents that R1 had no swelling or peripheral edema. R1's nursing progress notes dated 7/14/23 at 5:43p.m. documents the facility received a nursing report on R1's condition prior to R1's admission which included that R1 had a prosthetic urinary sphincter in place. This nursing progress note does not indicate R1 was admitted with any edema. R1 does not have any other nursing progress notes documented until 7/16/23 at 7:13p.m which state, (R1's) Family came to this nurse with concerns regarding resident's current weight of 232.8lbs. Family stated (R1's) abdomen is more distended than normal and has some swelling to his feet and legs. This nurse assessed (R1). (R1) reported he wasn't having any pain. Heart and lungs WNL (within normal limits). Obtained 80ml of yellow urine. Abdomen non-tender but distended. Bowel sounds normal. (R1's family) requested that (R1) be sent to ER for evaluation and would not like to hold the bed. At 7:32p.m. R1's nursing progress note documents that R1 was transferred via ambulance to the hospital. R1's care plan does not include interventions to address how to care for R1's implanted urinary sphincter. R1's hospital emergency room physician's progress note dated 7/16/23 at 7:48p.m. states, (R1) presents to the ED (emergency department) c/o (complaining of) edema onset a few days. (R1) was just admitted to (the Facility's) acute rehab. (R1) reports sx (symptoms) of LE (lower extremity) edema and sits in a chair for prolonged periods without feet elevated. (R1) has a prosthetic urinary sphincter and reports that the nursing home staff was not assisting with draining his bladder. This same progress note documents that upon the emergency room physician's assessment of R1's genitourinary area they found that R1 had lower abdomen tenderness and distention. R1's emergency room physician's emergency department course progress note dated 7/16/23 states, (R1) presents to the emergency department for severe edema, not having his bladder drained enough, concerning for fluid overload with potential for acute renal failure secondary to obstructive uropathy. Bedside ultrasound performed by me had approximately 2L of urine in the bladder. (R1) has mild AKI (Acute Kidney Injury) and mild evidence of CHF with fluid overload including small pleural effusions (fluid around the lungs). (R1) would be admitted for IV (intravenous) diuresis (increasing urine production to rid body of excess fluid) and will require frequent manual decompression of the bladder with his prosthetic sphincter. On 7/24/23 at 9:51a.m. V9 (R1's Family) stated that R1 was admitted to the facility for therapy after he fell at home and had some cardiac issues. V9 stated that R1 has a prosthetic urinary sphincter which must be manually released for R1 to urinate. R1 stated that because R1 was on a diuretic, he had received a large amount of fluids in the hospital, had new onset heart issues, and because he had to have his prosthesis manually released to urinate, R1 was supposed to receive daily weights and be closely monitored by nursing staff. V9 stated nurses did not assess R1 after he was initially admitted on [DATE] until V9 complained to CNA staff that R1 was not being weighed daily or having his urine output monitored. V9 stated that on 7/16/23 during the late afternoon, she asked R1's CNA (Certified Nurse Aide) if R1 had been weighed for the day yet. V9 stated the CNA said R1 had not been weighed yet and that there was no documentation that R1 had been weighed the previous day. V9 stated that facility nurses and CNAs were not familiar with R1's prosthetic sphincter and did not know how to care for it or engage it manually as it was supposed to be. V9 stated that when R1 was initially admitted to the hospital, the hospital nurses were not familiar with the type of prosthetic sphincter that R1 has, so those nurses looked on the internet to learn about how the sphincter works and how to care for it. V9 stated that none if the facility's nursing staff were knowledgeable about R1's prosthetic sphincter. V9 stated that the CNA's were the ones caring for R1's prosthetic sphincter and she does not believe they knew how to care for it appropriately. V9 stated that she was shocked and upset when she came to the facility to visit R1 on 7/16/23 and noted he had severe swelling to his legs and feet and his abdomen was also swollen. V9 stated that when the CNA weighed R1 he weighed 232 pounds. V9 stated that given R1's extreme weight gain, nursing staff could not have been properly assessing R1 for edema, weight, or urine output. V9 stated that on the afternoon of 7/16/23, when R1 had such a dramatic weight gain, she insisted that R1's nurse send R1 to the hospital for evaluation. V9 stated that the nurse tried to convince her that R1 should stay at the facility and be evaluated by the facility's physician the next day on Monday. V9 stated that she insisted R1 go to the emergency room. V9 stated that once R1 was in the emergency room, the physician performed an ultrasound on R1's bladder and found that R1's bladder was in danger of rupturing because it contained 2 liters of urine. V9 stated the emergency room physician stated that R1's bladder could not have been emptied appropriately for it to contain that much fluid. V9 stated the 2 liters of urine were removed from R1's bladder and R1 was admitted to the medical floor of the hospital for treatment. On 7/24/23 at 10:59a.m. V1 (Administrator) stated that if a resident is admitted to the facility and requires an unusual treatment or has an unusual appliance, the facility has education staff and an education consulting group who can train nursing staff on how to manage the care of that resident. V1 stated that the facility's nursing staff are very vocal about when they need education. V1 stated, We haven't' had to do any training for an unusual appliance or unusual resident needs recently, or for any new resident. On 7/24/23 at 12:31p.m. V4 (Registered Nurse/RN) stated that he was R1's nurse on 7/15/23 and 7/16/23 day shift. V4 stated that, (R1) had some sort of urinary sphincter device, but that V4 didn't know anything about it. V4 stated, The CNA's took care of it. V4 stated he did not know if R1 was supposed to have his urine output monitored but that R1's weight was supposed to be checked every day. V4 stated that he was planning to look up some information on how to care for R1's urinary sphincter device the next time he was R1's nurse, but R1 was discharged before V4 worked again. V4 stated it was V5 (Certified Nurse Aide/ CNA) who knew how to take care of R1's urinary sphincter. V4 stated that R1 was somewhat confused and became more confused as the day went on. V4 stated that R1 did not have very much urine output when he cared for R1. V4 stated he did not think R1 ever emptied his own bladder by manually engaging R1's urinary sphincter. V4 stated he didn't think R1 could urinate without the sphincter button being pushed. V4 stated, Why did they (facility) admit someone with something like that if no one knows how to use it? Did they know he had that when they admitted him? On 7/24/23 at 12:52p.m. V5 stated she was one of R1's CNAs from 8:30a.m to 9: 00a.m on 7/15/23. V5 stated she had never been taught how to use a manual urinary sphincter device. V5 stated nursing staff did not instruct her on how to empty R1's urine using this device. V5 stated R1 showed her how to push an area on the left side of R1's scrotum which opened the sphincter and allowed urine to empty from the bladder. V5 stated that R1 instructed her to push on the area again to re-engage the sphincter so urine didn't leak out. V5 stated that was the only time she cared for R1 but also stated she demonstrated to V6 (CNA) how to use the device since V6 was one of R1's day shift CNAs. On 7/23/23 at 1:00p.m. V6 (CNA) stated that she took care of R1 on 7/15/23 and 7/16/23 during the day shift. V6 stated she did not open R1's urinary sphincter to empty urine from R1's bladder during her shift. V6 stated that V5 was the only CNA to empty R1's bladder. V6 stated there was no schedule for emptying R1's bladder and that CNA staff only went into R1's room when he used his call light. V6 stated, But he could urinate around it (sphincter). V6 stated she knew he could urinate around the sphincter because she could hear some urine dribble into the toilet when she took R1 into the bathroom for a bowel movement. V6 stated she had never heard of a device like R1's urinary sphincter before. On 7/24/23 at 1:43p.m. V2 (Director of Nurses) stated she did not know about R1's implanted urinary sphincter which required manual manipulation to empty R1's bladder until today. V2 stated she reviewed R1's nursing documentation from the day R1 was admitted [DATE] and noted that the nurse who took report from the hospital documented R1 had this device. V2 stated she would have expected nursing staff to relieve R1's bladder on a schedule to make sure R1's bladder was appropriately emptied. V2 stated she does not believe residents have their output monitored unless they have the diagnosis of CHF or other similar diagnosis. On 7/24/23 at 2:10p.m. V1 (Administrator) stated that she is also a nurse, and it was V1 who accepted R1 as a new resident at the facility. V1 stated that she did not know R1 had an implanted urinary sphincter which required staff to manually open the sphincter to drain R1's urine from R1's bladder. V1 stated she does not know much about this device. V1 stated that when R1 was admitted , R1's nurses should have informed her they did not know how to manage R1's sphincter device. On 7/24/23 at 2:51p.m. V7 (Licensed Practical Nurse/LPN/ Evening Supervisor) stated that on 7/16/23 she was working as a floor nurse on another hall when staff told her that R1's family had concerns about R1's feet being swollen. V7 stated that R1 had only one compression stocking because the other stocking was cut off at the hospital. V7 stated that she gave R1 a new compression stocking so he would have one for each leg. V7 stated that R1's family mentioned R1 had a urinary sphincter device. V7 stated, I said we would make sure the nurses would show the CNAs how to care for it. I told V4 to show the CNAs how to use it at around 11:30a.m. on that date. V7 stated that V4 told her V4 knew how to use the device. V7 stated that the CNAs told V7 that R1 knew how to use the device himself. V7 stated that later in the day, V8 (LPN) told her that R1's family wanted R1 sent to the hospital because of R1's edema. V7 stated that V8 told her R1 had no signs of CHF exacerbation and that V8 thought R1's edema was no different from when he was first admitted . V7 stated that she and V8 went to R1's room and attempted to empty R1's bladder by pushing on R1's sphincter device. V7 stated that V8 was only able to get around 100ml of urine to drain from R1's bladder. V7 stated she and V8 did not attempt to open R1's sphincter a second time to see if more urine would drain out. V7 stated that she didn't know anything about how R1's urinary sphincter worked. V7 stated, I didn't read up on it and I'm not sure if (V8) did. On 7/24/23 at 4:39p.m. V8 stated she took care of R1 only one time from approximately 2:30p.m.-6:00p.m. on 7/16/23. V8 stated she was not R1's admitting nurse and didn't know anything about R1 before 7/16/23. V8 stated she had never used a urinary sphincter device before and did not know anything about how it worked. V8 stated she did not receive any instruction from the facility on how to manage this device. V8 stated that at first R1 seemed a little confused but she thought he may not have understood what she was asking him when she asked about the sphincter device. V8 stated that she initially checked on R1 because R1's family was concerned that R1's weight had not been monitored and they did not believe the weight the CNA recorded for that day was accurate. V8 stated she reweighed R1 and the weight V8 recorded was within 0.2 pounds of the CNAs weight. V8 stated she looked through R1's medical records and could not find documentation that R1 had been weighed the day before. V8 stated that when she and V7 attempted to empty R1's sphincter device, only 80ml of urine drained from R1's bladder. V8 stated R1 was visibly edematous to his legs and his abdomen. V8 stated R1's bladder was firm. V8 stated she and V7 did not attempt to drain R1's bladder a second time to ensure it was empty. V8 stated R1 was sent to the hospital shortly after she drained the 80ml of urine from R1's bladder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify risk factors and implement measures to prevent the development of pressure ulcers for one of four residents (R26) reviewed for pressure ulcers in a sample of 25. These failures resulted in R26 developing an unstageable pressure ulcer to the left heel and a stage two pressure ulcer to the coccyx. Findings include: A Prevention of Pressure Injuries policy dated as revised 4/2020 states, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. This policy instructs to, Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge, and Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary team, and Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. R26's Minimum Data Set (MDS) assessment dated [DATE] documents R26 is moderately cognitively impaired with inattention and an altered level of consciousness. In addition, R26's MDS assessment documents R26 requires extensive assistance of two people for bed mobility, transfers, toilet use, personal hygiene, and is unable to walk. In addition, R26's MDS assessment documents R26 is at risk for developing pressure ulcers and has had a weight loss of 5% (percent) or more in the last month or a loss of 10% or more in the last six months. R26's Braden Risk for pressure ulcer development dated 4/19/22 documents R26 is at moderate risk for developing a pressure ulcer because R26 has very limited sensory perception, is chairfast, probable inadequate nutrition, is occasionally moist and has the potential for skin breakdown related to friction and shear. R26's Wound assessment dated [DATE] to 8/7/22 documents R26 developed an unstageable pressure ulcer to the left heel which measured 6 cm (centimeters) long x 6cm wide which was white in appearance on 7/2/22. This same assessment documents that over the course of the next four weeks R26's left heel wound increased in size measuring 7.4 cm long x 6.8 cm wide when last measured on 8/7/22. R26's Wound assessment dated [DATE] to 8/6/22 documents R26 developed a stage two pressure ulcer to the coccyx on 7/24/22 measuring 1.4 cm long x 1cm wide x 0.2cm deep which had a pink center with scant drainage. R26's Nurse Practitioner's (NP) Progress Note (dated 4/22/22), the first practitioner's assessment since R1's admission, documents R26 had a red area to her buttocks at the time of the assessment. This note also states that R26 was confused and weak; had a poor appetite and would spit out food. R26's Clinical Monitoring Detail Report dated 4/18/22 to 8/2/22 documents R26's admission weight was 232 lbs. (pounds). This same report documents that over the course of the next 10 weeks following R26's admission to the facility she suffered a 20.13% (percent) weight loss. On 4/25/22, R26's weight dropped to 223.6lbs, a 3.62% weight loss. On 4/29/22, R26's weight dropped to 217.6, a 6.21% weight loss. On 5/24/22, R26's weight dropped to 201.4lbs, an 11.47% weight loss. On 6/7/22, R26's weight dropped to 202.4lbs, a 12.76% weight loss. On 6/14/22 R26's weight dropped to 197, a 15.09% weight loss. On 6/21/22, R26's weight dropped to 196.7 lbs, a 15.17% weight loss. On 6/28/22 R26's weight dropped to 190.4 lbs, a 17.93% weight loss. On 7/2/22, R26's weight dropped to 185.3lbs, which is a 20.13% weight loss. R26's care plan dated 4/19/22 documents one of the focus areas of R26's care plan is for skin integrity concerns and states, I am at high risk for skin breakdown. This same care plan includes interventions dated 4/19/22 which instruct, Please help me to reposition frequently to help relieve pressure to my skin, and Please ensure I have a pressure relieving mattress on my bed, and cushion in my wheelchair, and Apply preventive barrier cream to my skin after cleansing me, and as needed. This care plan does not include any revisions for the prevention of skin integrity issues, such as pressure ulcers, until 7/5/22 which is after R26 developed the unstageable pressure ulcer to her left heel. R26's care plan intervention dated 7/5/22 states, Apply heel protectors to both my feet and off load my heels when I lay down. This care plan does not include any additional interventions were added after 7/5/22 until 8/2/22, which is after R26 developed the stage 2 pressure ulcer to her coccyx on 7/24/22. R26's care plan intervention added as of 8/2/22 states, I take high protein supplements to help my skin heal. On 8/9/22 at 10:30a.m. R26 was seated in a recliner in her room with her feet elevated on a footrest. There were fabric quilted boots on R26's feet with cut out areas in the heels leaving the heels exposed. R26's heels were resting on the footrest of the recliner without any part of the boot protecting R26's heels. R26's left foot appeared to be bent abnormally forward indicating R26 had foot drop. R26 was also seated directly on her buttocks/coccyx without a pressure relief cushion in place. There was a high-backed wheelchair in the corner of R26's room which also did not have a pressure relieving cushion in place. V3 (Certified Nurse Aide/CNA) and V4 (CNA) entered R26's room and proceeded to transfer R26 to the bed using a mechanical lift. Once R26 was lowered to the bed, V3 and V4 provided total assistance to turn R26 from side to side while they performed a skin observation and incontinence care. V3 verified R26 did not have a pressure relief cushion in her recliner stating that R26 has never had a cushion in her recliner since R26's admission to the facility. V3 also verified R26 did not have a cushion to her wheelchair stating that R26 currently does not sit in her wheelchair anyway. R26 had an open wound without a dressing to the top of R26's left buttock which was approximately 1.5cm long x 0.8cm wide x 0.2 cm deep with a pale pink wound bed. R26's left heel was covered with a gauze dressing. V3 and V4 completed R26's incontinence care, and without applying protective cream to R26's buttocks area, V3 and V4 reapplied R26's incontinence brief and covered R26 with a blanket. Before leaving the room V3 placed a pillow under R26's feet. R26's legs weighed down the pillow making R26's left heel rest on the mattress. V3 stated R26 was not able to move very much when she was first admitted to the facility but is now able to move her right leg and foot. V3 stated R26 is not able to move her left foot very well and that R26's left foot has a foot drop. V3 and V4 left R26's room, with R26's left heel wound resting on the mattress and R26 laying on her back with R26's weight on her coccyx wound. At 11:10a.m. V5 (Registered Nurse) entered R26's room to perform dressing changes to R26's left foot and left buttock wound. V5 stated R26's left buttock wound is considered a stage 2 coccyx pressure ulcer and R26's left heel is considered an unstageable pressure ulcer. When V5 removed the soiled dressing from R26's left heel, R26's entire heel, approximately the size of a baseball, was covered in black/brown tissue. On 8/9/22 at 12:36p.m. and on 8/11/22 at 2:25p.m. V1 (Administrator) stated she is a member of the interdisciplinary team (IDT) and a nurse. V1 stated that all residents are turned and repositioned every two hours. V1 stated that the facility and IDT did not assess R26's tissue tolerance to see if her individualized turning and repositioning schedule should be more frequently than every two hours. V1 verified that no additional pressure ulcer prevention measures were put into place after the initial interventions were added 4/19/22 until after R26 developed a left heel unstageable pressure ulcer on 7/2/22. V1 verified no new pressure ulcer preventive measures were added after R26 developed her left heel pressure ulcer and before she developed the stage 2 pressure ulcer to her coccyx 7/24/22. V1 stated that R26's weight loss was addressed by the facility's Registered Dietitian, but no new pressure relief interventions were implemented based on R26's increased risk for the development of pressure ulcers as a result of significant weight loss. V1 verified that R1's pressure relief boots were not implemented until after R1 developed the unstageable pressure ulcer to her left heel. V1 stated that R26 did not use a pressure relief cushion in her recliner because it made R26 sit too high and increased her fall risk.