**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #4 was admitted to the facility in October 2020 with diagnoses including diffuse traumatic brain injury, unspecified dementia, history of falling, difficulty in walking and weakness. Review of Resident #4's most recent Minimum Data Set (MDS) indicated that the Resident scored a 3 out of possible 15 on the Brief Interview for Mental Status exam indicating that he/she has severe cognitive impairment. Further review of the MDS indicated that Resident #4 requires extensive assistance with dressing and supervision with walking. Review of Resident #4's Nursing Progress notes indicated the following: 4/5/23: Pt. (patient) sitting on buttocks on floor, legs out straight, head against upright walker. Heels out of Skecher shoes when pt. found on floor, had previously noted shoes on properly when ambulating with walker. Skecher shoes replaced with alternate pair of shoes. 5/19/23: Resident was pacing around in usual his/her state, went to another resident's room and fell. Review of Resident #4's Activities of Daily Living self-care performance care plan dated 10/6/2020, indicated the following intervention: *Dressing: The resident requires total dependence by staff Review of Resident #4's fall care plan, dated and revised 7/4/2023, indicated the following interventions: *Dated 4/6/23: Ensure resident has proper fitting footwear on at all time s/p (status post) fall 4/5/23 *Dated 5/23/23: Encourage resident not to wear slide shoes Review of Resident #4's quarterly fall risk assessments dated 1/9/23, 4/10/23 and 7/5/23, indicated that the resident is a high risk for falls. Review of the facility investigation dated 4/5/23, provided by Nurse #1 indicated that Resident #4 was found sitting on his/her buttocks with legs out in front, head upright against walker. His/her heels were out of shoes when pt. was found on floor. Further review of the investigation indicates the following: *Was appropriate footwear on resident? No was marked with a note reading slip on shoes, heel not in tight *Did they have appropriate footwear on? No was marked with a note reading perhaps loose fitted as heels out when found on floor *New intervention of check pt every shift for properly fitting footwear Review of the facility investigation dated 5/19/23, provided by Nurse #2 indicated Resident #4 paces around the unit and went to another resident's room and fell. Further review of the investigation indicates the following: *Was the appropriate footwear on resident? No was marked with a note reading slide shoes on *Additional comments: Resident's shoes was out (one) during fall, she/he may have tripped During a phone interview on 7/28/23, at 11:26 A.M., Nurse #1 said Resident #4 had worn slip on shoes and also had flip flops which lets his/her ankle go back, part of his/her new interventions was for proper footwear to be worn. During an interview on 7/28/23, at 11:36 A.M., Nurse #2 said Resident #4 wanders a lot and was not wearing his/her proper footwear when he/she fell on 5/19/23. The shoe was not secured around his/her ankle and his/her foot was hanging out and he/she tripped and fell. During an interview on 7/28/23, at 11:58 A.M., Unit Manager #1 says Resident #4 is totally dependent, he/she wanders and recently fell in another resident's room. She said she believes it was due to the Resident wearing the incorrect shoes. During an interview on 7/28/23, at 12:10 P.M., Certified Nursing Assistant (CNA) #1 said Resident #4 is totally dependent on staff and gets help with being dressed which include putting on his/her shoes. She continued to say that the Resident used to wear slip shoes but now has regular sneakers. During an interview on 7/31/23, at 10:34 A.M., the Administrator said he would expect care plan interventions to be followed. Based on observation, record review and interview, the facility failed to 1.) develop and implement care plan interventions related to falls for one Resident (#76) resulting in a fall with injury and 2.) failed to implement a fall care plan for wearing the appropriate footwear for one Resident (#4), out of a total of 21 sampled Residents. Review of the facility's Managing Falls and Fall Risk policy, dated December 2007 indicated: *Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Findings include: 1. Resident #76 was admitted to the facility in June 2023 with a right hip fracture after falling in the community. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #76 scored an 11 out of a possible 15 indicating moderate cognitive impairment and that he/she required assistance with ambulation and transfers. On 7/28/23, at 8:15 A.M., Resident #76 was observed sitting in bed eating his/her breakfast meal. A floor mat was propped against the wall. Review of Resident #76's Activities of Daily Living care plan dated 6/15/23, indicated Resident #76 ambulates with physical assistance and requires one person assistance with transfers. Review of Resident #76's Fall care plan, effective 6/15/23 - 7/20/23 indicated only one intervention related to falls: [rehab] consult for strength and mobility. There were no other individualized interventions implemented for fall prevention. During an interview on 7/28/23, at 8:39 A.M., Unit Manager #3 said that when a resident is admitted to the facility after having a fall in the community, care plan interventions are implemented and include monitoring, the use of assistive devices, answering call lights timely, and de-cluttering the room, (none of which were indicated in Resident #76's plan of care). Unit Manager #3 said that interventions are added as time goes on and as the facility assesses the resident's status. Review of Resident #76's Nurse progress notes indicated: 6/17/23: Patient is alert and confused, multiple attempts to get out bed without calling for help. Resident walking without use of walker during the night. Encouraged calling for help when needed. 6/26/23: Patient is alert and confused awake off and on during the night. Patient hallucinating stating he/she was in another place and time.Multiple attempts out of bed. 6/29/23: No hallucinations during this night, close supervision for safety. 7/1/23: Patient remains alert and confused. Patient sat out in the chair. 7/5/23: Patient is alert and confused. Patient sat out in chair, brought out to dinning area after supper for safety as patient was found ambulating unsafely in [bedroom]. 7/6/23: Patient is alert and confused. Sat out in the chair, brought to dinning area for supper for safety. 7/7/23: Patient is alert and confused. Sat out in the chair, brought to the dinning area for supper for safety. Notes dated 7/10/23, 7/14/23, 7/17/23, 7/18/23 indicated Resident #76 was alert and confused and sat out on chair during the 3:00 P.M. - 11:00 P.M. shift. Despite the documentation of Resident #76's cognition, instances of ambulating alone without calling for assistance, making multiple attempts to get out of bed and being supervised in a sitting area during the 3:00 P.M. - 11:00 P.M. shift, there were no updates or interventions added to Resident #76's falls care plan. Review of the facility investigation dated 7/20/23, indicated that at approximately 12:15 A.M., Resident #76's roommate rang his/her call light and called for help after Resident #76 got out of bed unassisted. Resident #76 was found on the floor by the foot of his/her bed and complained of hip pain. Resident #76 was transferred to the hospital. The incident report failed to indicate where Resident #76's call light was located at the time of the fall. Review of the hospital paperwork dated 7/23/23, indicated Resident #76 was diagnosed with a left hip fracture. During an interview on 7/28/23, at 9:33 A.M., Nurse #5 said that on the night of Resident #76's fall, she and the assigned Certified Nurse's Assistant (CNA) were taking care of other residents, when she heard a call light going off. Nurse #5 said she then heard yelling in the hallway and poked her head out of the room and saw Resident #76's roommate in the hallway yelling that Resident #76 was on the floor. Nurse #5 said she then saw the nurse from the 3:00 P.M. - 11:00 P.M., at the nurses station documenting and called out for her to assist. Nurse #5 then said that the nurse supervisor heard Nurse #5 calling out for help and he went to Resident #76's room and found Resident #76 on the floor by the foot of the bed. Nurse #5 said when she arrived to his/her room, Resident #76 had been put back in bed and was wearing shoes. Nurse #5 said the nurse supervisor said that he thought Resident #76 may have broken his/her hip and was sent to the hospital. Nurse #5 said that Resident #76 was admitted to the facility after having a fall at home. Nurse #5 said Resident #76 was confused and known to ambulate by himself/herself when he/she needed assistance and would never use his/her call light. Nurse #5 said I don't think [he/she] even knows how to use the call light. Nurse #5 said that Resident #76 was at risk for falls and the overnight CNAs would usually station themselves outside of his/her room during the shift but can't always be there as they have other residents to attend to. During an interview on 7/28/23, at 11:00 A.M., the Director of Nursing said that when a resident with a history of falls is admitted to the facility, care plan interventions include monitoring for fall risks and safety and making sure their call light is within reach. The Director of Nursing said that the interventions are individualized and that resident's who are confused would need more monitoring. The Director of Nursing then said that more interventions could have been implemented to address Resident #76's fall risks.

Based on interview, policy review, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent new ulcers from developing and provide ongoing assessment and treatment of a pressure ulcer for one Resident (#18), out of a total sample of 19 residents. Specifically, the facility failed to effectively implement the facility's pressure injury prevention policy, ensure timely identification of a deep tissue injury (DTI), and document, monitor, and treat Resident #18's DTI resulting in a worsening of the DTI of the heels. Findings include: Review of the facility's policy titled Prevention of Pressure Injuries, revised April 2020, included but was not limited to the following: Risk Assessment - Assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. (The facility's form is titled Licensed Weekly Nursing Skin Assessment) - Identify any signs of developing pressure injuries (i.e., non-blanchable erythema) - Inspect pressure points (heels, buttocks ., etc.). Monitoring - Evaluate, report and document potential changes in the skin - Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised March 2014, included but was not limited to the following: Assessment and Recognition - the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates (drainage) or necrotic tissue b. Pain assessment c. Resident's mobility status d. Current treatments, including support surfaces; and e. All active diagnoses Review of the facility's policy titled Pressure Injuries Overview, revised March 2020, included but was not limited to the following: -Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Avoidable/Unavoidable Avoidable means the Resident developed a pressure ulcer/injury and that one or more of the following was not completed: -Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice. -Monitoring or evaluation of the impact of the interventions; or Revision of the interventions as appropriate. Review of the facility's policy titled Pressure Injury Risk Assessment, revised March 2020, included but was not limited to the following: Steps in Procedure - Conduct a structured pressure injury risk assessment using a facility-approved tool (facility uses the Weekly Skilled Nursing Skin Assessment). - Conduct a comprehensive skin assessment with every risk assessment. - Once inspection of skin is completed, document the findings on a facility approved skin assessment tool. - If a new skin alteration is noted, initiate a (pressure or non-pressure) for related to the type of alteration in skin. - Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition and the resident's stated wishes and goals. - The interventions must be based on current, recognized standards of care - The effects of the interventions must be evaluated - The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Documentation The following information should be recorded in the resident's medical record utilizing facility forms: - The type of assessment (s) conducted - The condition of the resident's skin (i.e., the size and location of any or tender areas), if identified. - Any problems or complaints made by the resident related to the procedure. - Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted - Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care if indicated - Documentation in medical record addressing family, guardian, or resident notification if new skin alteration noted with change of plan of care if indicated Review of the National Pressure Injury Advisory Panel (NPIAP)Classification System includes but is not limited to the following: Stage 2 Pressure Injury: -Partial thickness skin loss with exposed dermis and partial thickness loss of skin. The wound bed is viable, pink, or red, moist and may also present as an intact/ruptured serum filled blister. Deep Tissue Pressure Injury (DTPI-DTI): -Intact or non-intact skin with localized area of persistent, non-blanchable, deep red, maroon or purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature changes often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss A partial thickness wound is confined to the skin layers; damage does not penetrate below the dermis and may be limited to the epidermal layers only A full thickness wound indicates that damage extends below the epidermis and dermis (all layers of the skin) into the subcutaneous tissue or beyond (into muscle, bone, tendons, etc.). NPIAP-Off-loading Heels Effectively in Adults to Prevent Pressure injuries Interventions -Place a pillow vertically under each lower leg between the knees and ankles so that the heels are off-loaded in such a way as to distribute the weight of the leg along the calf without pressure to the popliteal space or Achilles' tendon. -Place pillow horizontally on top of vertical pillows. -Heel suspension devices can be used instead of a pillow to off-load [distribute the load to other areas which are not susceptible to pressure] the heels. Follow the manufactures guidelines and consider the implementation. Considerations in the Guidance when using these devices. Resident #18 was admitted to the facility in November 2021 with diagnoses including chronic low back pain, laminectomy (spinal surgery), impaired mobility, and DTI of the right and left buttocks. Review of the Minimum Data Set (MDS) assessment, dated 11/2021, indicated Resident #18 was frequently incontinent of bowel and bladder, required extensive assistance of two staff for dressing and bed mobility and totally dependent for bathing. The Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Record review indicated the Resident had been seen by the Nurse Practitioner (NP) on 1/3/22 at 9:16 A.M. The visit note included but was not limited to: DTI- right heel, entire heel, approximately 4 centimeters (cm) x 4 cm, intact. Review of a Nurse's Note, dated 1/3/22 at 11:31 A.M., included but was not limited to: Has a DTI on right heel. Record review of the December 2021 and January 2022 Treatment Administration Records (TAR) indicated the following: -Apply Skin Prep (protective film on skin) to bilateral heels every day and evening shift for preventative skin care. Document what the site looks like in progress note. Further review of the TAR and Progress Notes for December 2021 and January 2022 indicated there was no documentation as to the appearance of the bilateral heels. Review of the Licensed Weekly Nursing Skin Assessment, dated 1/3/22 at 6:33 P.M., included but was not limited to the following responses: 5a. Any blisters? Answered NO 6a. Any open ulcers? (Indicate even if being treated) Answered NO 9a. Any impaired skin on heels and ankles? (Blisters, skin discoloration, boggy, opened area) Answered YES Comments-Dryness due to psoriasis. The weekly skin assessment failed to indicate a new 4 cm x 4 cm DTI on the Resident's right heel, as required, and did not initiate a pressure or non-pressure form as per facility policy. Review of the January 2022 TAR indicated a new treatment for: -Float heels all the time when in bed, every shift. (day/evening/night) Start date 1/3/22 -1500 (3:00 P.M.) Record review indicated no documentation by nursing that addressed the initial appearance, of the right heel with stage, length, width and depth, presence of exudates (drainage) or necrotic tissue, pain assessment, mobility status, current treatments, and the procedure/device that would be implemented to float Resident #18's heels. There was no documentation in the medical record as to physician notification, family/guardian, or Resident notification of the DTI. Review of Physician's Note, dated 1/4/22, indicated the Resident had a Decubiti right heel. On 1/4/22 the Resident was seen by the Wound Consultant. The initial visit note, included but was not limited to the following: Resident has a DTI of the right heel for at least 1 day's duration. There is no exudate or indication of pain. Etiology: Pressure Stage: Unstageable DTI with intact skin Wound size (L x W x D): 4 cm x 4 cm x not measurable. Exudate: None Dressing Treatment Plan: Skin prep, apply once daily. Followed by an abdominal pad (ABD), wrap with Gauze roll (Kerlix) daily. The wound consultant also applied Reston foam (Versatile padding that adheres well to a variety of surfaces. Pads, cushions, and protects skin from damage) to the area and indicated to keep the foam in place, apply once daily. Review of a Nurse's Note, dated 1/4/22 at 12:51 P.M., included but was not limited to: Wound MD wanted skin prep and ABD and Kling to blister right heel. Blister didn't break. There was no further documentation from 1/4/22 indicating the wound consultant had made a visit, a physician's order that the Resident may be seen by the wound consultant, and that recommendations had been conveyed to or approved by the physician or NP. Review of the Physician's Orders on 1/5/22 indicated a telephone order (TO) was obtained from the physician for: -Skin prep to right heel, cover with ABD pad, wrap with Kerlix daily. (This order did not include the Reston foam which had been recommended by the wound consultant.) There was no order obtained or transcribed on the TAR for 1/4/22 and 1/5/22 for the above recommendations. Subsequently, the physician's order was transcribed and entered into the Electronic Medical Record (EMR) on 1/6/22 (a new recommendation had been made on 1/6/22, and was different from the above). Review of a Nurse's Note, dated 1/5/22 at 2:03 P.M., indicated: -Right heel blister, applied skin prep, Reston foam, ABD, and Kling. Review of a Nurse's Note, dated 1/6/22 at 1:03 P.M., included but was not limited to: Blister right heel broke, small amount of serosanguinous (bloody and serous) drainage. Review of the Wound Consultant's telemedicine visit note, dated 1/6/22, included but was not limited to: Exudate: Moderate serous Wound progress: deteriorated Dressing Treatment plan: Add: Vaseline Gauze *Discontinue: Skin Prep Continue with the ABD pad and Kerlix. *Continue: Please keep the Reston foam in place. The order recommended by the Wound Consultant on 1/6/22 (telemedicine visit-wound care was not physically provided by the wound consultant) was not initiated until 1/7/22. Review of a Nurse's Note, dated 1/7/22 at 6:33 P.M., included but was not limited to: Reston foam removed, Normal Saline Wash (NSW), Vaseline gauze, ABD, Kling applied to right heel, Ace wraps on in am off in p.m. Some pain noted no drainage. Review of a Licensed Weekly Nursing Skin Assessment, dated 1/10/22 at 9:19 P.M., included but was not limited to: 5a. Any blisters? Answered NO 6a. Any open ulcers? (Indicate even if being treated) Answered NO 9a. Any impaired skin on heels and ankles? (Blisters, skin discoloration, boggy, opened area) Answered YES Comments-Dry, flaky due to psoriasis. The weekly skin assessment did not indicate/include in the assessment/documentation of the DTI on the Resident's right heel as required. Review of the Wound Consultant's Note, dated 1/11/22, included but was not limited to: Etiology: Pressure Stage: Unstageable -Necrosis (1/4/22 Unstageable DTI with intact skin, no necrotic tissue was present) Wound size (L x W x D): 4 cm x 4 cm x not measurable. Exudate: Moderate Serous Thick adherent black necrotic tissue (Eschar is dead or devitalized tissue that is hard or soft in texture; usually black brown or tan in color and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound), 80% Granulation tissue: 20% The area was debrided to remove the necrotic tissue and establish the margins of viable tissue. Dressing Treatment plan: -Add: Santyl (Collagenase is an enzyme. It works by helping to break up and remove dead skin and tissue). -Discontinue: Vaseline gauze Add: ACE bandage 6 inch Continue: Xeroform Sterile Gauze, followed by an abdominal pad (ABD), wrap with Gauze roll (Kerlix) 4.5 inch, and keep the Reston foam in place. Review of a Physician's Note, dated 1/11/22, included but was not limited to: -Decubiti right heel (seen by Wound MD -status post debridement). Review of a Nurse's Note, dated 1/12/22 at 12:55 P.M., included but was not limited to: Right heel wound cleaned and changed per wound orders (There had been no orders obtained, transcribed, or entered in to the EMR on 1/12/22.) Review of a NP's Note, dated 1/13/22 at 11:52 A.M., included but was not limited to: -Right heel necrotic, approximately 3.5 cm x 3.5 cm. Seen with nursing. Wound care, including Santyl applied. Assessment and Plan: -off-load -Wound consultant following Review of a Nurse's Note, dated 1/13/22 at 12:36 P.M., included but was not limited to: Right heel, NSW, Santyl ointment, xeroform, ABD and Kling. NP looked at the wound and will continue to monitor. There was no documentation, nurse's note, approval obtained by the physician or NP or interim order/T.O. in the record that addressed the treatment recommendations by the wound consultant on 1/11/22. Further review of the medical record indicated the new treatment was entered into the EMR on 1/15/22, with no supporting documentation/progress note indicating why there was a delay in obtaining and entering the order into the EMR. Review of a Nurse's Note, dated 1/14/22 at 12:59 P.M., included but was not limited to: -right heel wound, healing well, NSW, Santyl ointment, xeroform, ABD, Kling. Seen by physician and followed by wound doctor. Off-loading as tolerated. Review of a late entry Nurse's Note, dated 1/11/22 at 11:24 A.M. and entered in the EMR on 1/18/22, indicated the following: -Resident seen by wound consultant for unstageable Right heel wound measuring 4 cm x 4 cm, moderate serous drainage, 80% necrotic tissue, 20% granulation tissue, continue treatment as ordered. The late entry note did not indicate there was a treatment change and that the physician or NP had approved the change. Record review of the January 2022 TAR indicated the Resident's heels were being floated while in bed. Review of the Nurse's Notes, dated 12/24/21 through 2/23/22, indicated the Resident frequently refused to go to bed, and his/her preference was to sleep in a recliner. The order to float the heels, when in bed, every shift, did not address the Resident's preference to sleep in a recliner. There was no documentation indicating that a review of the current treatment for effectiveness, as it should have included an approach for the floating of the heels when the Resident was not in bed. The treatment order did not indicate what should be used or implemented to float the Resident's heels. Review of the January 2022 and February 2022 TARs indicated the Skin Prep to bilateral heels every day and evening shift for preventative skin care was still in effect, even though the wound consultant had discontinued the Skin Prep to the right heel on 1/6/22. There was no documentation in the progress notes as to the appearance of the area, specifically the left heel. During an interview on 2/28/22 from 8:40 A.M. to 9:24 A.M., the surveyor, the Director of Nursing (DON) and Unit Manager (UM) #1 reviewed the care and treatment concerns identified by the surveyor for Resident #18's pressure ulcer. The DON and Unit Manager #1 confirmed the lack of documentation, lack of implementation of effective off-loading, failure to implement the wound consultant's recommendations timely and correctly, failure to follow the facility's policies regarding care and treatment of a pressure injury, including notification, documentation, implementation of existing treatments as ordered by the physician. During the interview, the DON spoke to UM #3 regarding the appearance of the DTI when it was initially identified and indicated that the area was a flat, dry dark area, brownish/purple in color; the area began filling with fluid and looked like a blood blister. The DON agreed that the initial appearance was never documented in the Resident's medical record and that the nursing staff were documenting the area as a blister (according to NPIAP classification- the area would be a Stage ll and not a DTI). The DON further said that when the wound consultant is not in the facility on any given week, the Unit Managers are responsible for performing a comprehensive assessment of the wounds on their assigned unit. The DON said the weekly wound documentation is a paper form which is located on the individual units. The DON said she did not have a policy regarding this, but the Unit Managers are aware of this expectation and are responsible for completing the comprehensive wound assessment. During an interview on 2/28/22 at 10:15 A.M, UM #3 confirmed the initial appearance of the DTI was described a flat, dry dark area, brownish/purple in color, that began filling with fluid and looked like a blood blister. Review of the Skin Impairment True Decubitus weekly log included but was not limited to: The documentation required for the wounds was to include measurements, drainage, odor, peri wound, pain, and status of the wound. The week of 1/18/22 (visit not made by wound consultant) indicated the measurement of the wound to be 4 cm x 4 cm. There was no comprehensive assessment of the wound as required. During an interview on 2/28/22 from 8:40 A.M. to 9:24 A.M., the surveyor asked how/what was used to float the heels and indicated that the Resident frequently refuses to go to bed, and that there were no documented interventions in place to float the heels when the Resident slept in the recliner. The DON and Unit Manager #1 said that the facility uses pillows to float heels and agreed that the intervention needed to address the Resident's preference to sleep in the recliner. The facility did not review the effectiveness/appropriate interventions with a resident centered approach for Resident #18 for the off-loading/floating of the heels, as per the facility policy. During an interview on 2/28/22 at 11:00 A.M., the DON said the pressure ulcer prevention and treatment policies that were previously given to the surveyor were all the facility had. The DON verified that from 1/4/22 to 1/11/22, Resident #18's heel area deteriorated and was debrided due to necrosis/eschar which covered 80% of the wound bed. The DON further said the facility failed to implement an effective program for the care and treatment of Resident #18's pressure injury/ulcer.