The facility reported a census of 36 residents, with 12 sampled, including four residents sampled for pressure ulcers. Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to prevent pressure ulcers (PU, localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) by failure to perform skin assessments under a medical immobilization device for Resident (R) 3, allowing an unstageable (full thickness tissue loss in which actual. depth of the ulcer is completely obscured) PU to develop. Findings included: - The 11/28/22 Electronic Health Record (EHR) documented R3 had the following diagnoses: fracture of the left tibia (bone of the lower leg) and fibula (one of the two bones of the lower leg) shafts on the left side, hemiparesis (muscular weakness of one half of the body) on the left, hemiplegia (paralysis of one side of the body) on the left, and peripheral vascular disease (PVD- abnormal condition affecting the blood vessels). The 10/19/22 admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 12, indicating moderately impaired cognition. R3 required extensive to total assistance of two staff for all activities of daily living (ADL). The MDS noted R3 had a pressure reducing device for the chair and the bed, and R3 had one stage two (expands into deeper layers of the skin. It can look like a scrape, abrasion, blister, or a shallow crater in the skin) PU present on admission. The 11/07/22 Interim Payment Assessment MDS documented a BIMS of 13, indicating intact cognition. R3 had no PU. The 10/19/22 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R3 on admission needed nearly total assistance with ADL but R3 had improved with therapy and required limited to extensive assistance with most ADL. The 10/19/22 Pressure Ulcer CAA, documented R3 admitted with a stage two PU to the right trochanter (hip area) that had healed since admission. Licensed staff should perform a skin assessment weekly and observations of skin by care staff with cares. R3 required an immobilizer to her left lower extremity (LLE). The 11/14/22 Care Plan documented R3 had an actual impairment to skin integrity related to a medical device (immobilizer to LLE). Staff were to perform daily skin and circulatory checks to the LLE related to the immobilizer. The EHR Physician Orders lacked documentation of daily skin assessments from 10/12/22 until an order dated 11/14/22 which instructed staff to loosen the immobilizer to assess skin daily. On 11/09/22, the Daily Skilled Progress Note documented R3 received skilled nursing and skilled nursing services. The resident required assistance of two staff for transfers, bed mobility and toileting. The resident had an immobilizer in place to her left leg. On 11/11/22, the Daily Skilled Progress Note documented R3's skin was warm, dry, and intact, and the immobilizer to right leg remained in place. On 11/12/22, the Daily Skilled Progress Note documented R3 continued to receive skilled services. She required assistance of two staff for transfers and toileting. The immobilizer remained in place to her LLE due to fractures. On 11/13/22, the Progress Note documented the resident had an unstageable pressure injury to her left lateral malleolus (the bony prominence of the ankle), related to a medical device. The resident had a tibia/fibula fracture and had an immobilizer in place. The wound measurements/description documented as 2.3 cm by 1.5 cm (centimeters), circular in dimension. The wound bed had 100 percent (%) firmly adherent yellow/tan slough (dead tissue, usually cream or yellow in color). The wound edges were defined and attached to the wound base. The area cleansed with normal saline, plurogel (wound dressing) applied to the wound bed to promote autolytic debridement (a form of wound removal of dead, damaged, or infected tissue). The wound covered with Opti foam gentle (a foam dressing with a silicone adhesive border). The resident complained of pain during the dressing change, rated six out of 10 (pain scale). Staff administered as needed (PRN) oxycodone (narcotic medication used for severe pain). On 11/28/22, the Progress Note documented R3 started on Keflex (an antibiotic) 500 mg (milligram) for the wound to the LLE. The weekly Skin Assessments documented the following: On 10/22/22, noted the skin was intact. PU to right trochanter healing well. On 10/23/22 the resident has stage two PU to the right trochanter, present on admission is now closed. On 10/29/22, noted R3's skin was intact. On 11/05/22, noted R3 had skin tears, On 11/12/22, noted R3 only had redness behind her left thigh. On 11/29/22 at 08:24 AM, observed Licensed Nurse (LN) G perform a dressing change to R3's left outer ankle. LN G stated she did not measure the wounds because the director of nursing (DON) measured wounds weekly. On 11/29/22 at 02:03 PM, R3 sat in the common area, and wore an immobilizer on her LLE. On 11/29/22 at 08:45 AM, R3 stated she was mad at the facility because they made her get the wound on her leg. On 11/30/22 at 09:45 AM Certified Nurse Aide (CNA) M stated R3 came to the facility with the immobilizer on her left leg and at first the CNAs were not allowed to take it off, even at night. CNA M stated she did know R3 had a wound, and it was on her left, weaker side, so R3 may not have even felt the sore start. On 11/30/22 at 11:46 AM, LN H revealed R3 had little feeling to her left side, so she was probably unable to know the wound was forming. LN H stated when she completed the wound care, sometimes, she would measure it and give it to the DON who measured them weekly. On 11/30/22 at 11:57 AM, Administrative Nurse D revealed she expected her or her staff to have noted the unstageable PU to R3's left outer ankle with the skin assessments. Administrative Nurse D confirmed she did not believe the unstageable PU could have developed in the day or two that the documentation noted in the assessments. Administrative Nurse D stated as soon as it was brought to her attention, she obtained orders for dressings and assessments. On 12/01/22 at 11:51 AM, Physician GG reported the pressure ulcer should not have progressed from intact skin to an unstageable pressure ulcer as it did. The facility's Skin Integrity, Pressure Injuries Nursing Protocol policy, revised May 2022, documented staff were to identify residents at risk for developing PU on admission, and should implement, monitor, and modify interventions to attempt to reduce or remove underlying risk factors. Staff were to implement interventions for the prevention and care of skin issues. The facility failed to identify and provide care consistent with professional standard of practice, to prevent the development of an unstageable pressure ulcers for R3.