**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The State Operations Manual (SOM) defined the various presure ulcers as follows: A stage one pressure injury is intact skin with a localized area of redness that is non-blanchable (does not turn white when pressed). A stage two pressure ulcer is partial thickness loss of the skin with exposed dermis, presenting as a shallow open ulcer. It may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) are not present. A stage three pressure ulcer is full thickness loss of the skin in which subcutaneous fat may be visible. Additionally, slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or eschar may be visible but does not obscure the depth of the tissue loss. A stage four pressure ulcer is full thickness loss of the skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible on some parts of the wound bed. Undermining and or tunneling often occur. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer. An unstageable pressure ulcer is obscured full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If slough or eschar is removed, a stage three or stage four pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then reclassified stage should be assigned. A deep tissue pressure injury (DTPI) is intact skin with localized area of persistent non blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 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. If necrotic tissue, subcutaneous tissue (deepest layer of skin), granulation tissue (new connective tissue), fascia (connective tissue), muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. R33's Medical Diagnoses form indicated a right knee effusion, mild cognitive impairment, muscle weakness, difficulty in walking, deficiency of other specified B group vitamins, type 2 diabetes mellitus with diabetic polyneuropathy (a type of nerve damage that affects multiple nerves in the body), disease of the spinal cord, other tear of the lateral meniscus, current injury of the right knee, and chronic pain. R33's quarterly MDS dated [DATE], identified intact cognition, did not reject care, had impairment in range of motion (ROM) to one side of upper and lower extremities, was independent in rolling from lying on the back to the left and right side, was 60 inches tall and weighed 229 pounds, and had no or unknown weight loss. R33's quarterly MDS dated [DATE], identified a cognitive assessment was not completed, did not reject care, was 72 inches tall and weighed 230 pounds, did not have 5% or more weight loss in the last month. Further, R33 was at risk for pressure ulcer development and had one or more stage one pressure ulcer. R33's Optional State Assessment (OSA) MDS dated [DATE], identified R33 required extensive assistance with bed mobility, transfers, and toileting. R33's CAA dated 5/30/24, identified R33 was at risk for pressure ulcers due to the need for extensive assistance with bed mobility and incontinence, and did not have a pressure ulcer but would be addressed in the care plan to avoid complications and minimize risks. R33's nutritional status care plan dated 5/27/24, identified R33 was on a regular diet with no concerns reported. R33 had the following interventions: diet per physician order, obtain weight monthly, registered dietician or culinary director to consult as needed, the resident is on a regular diet with no concerns. Further an intervention dated 7/10/24, was written, Dietary Preferences (Specify). No dietary preferences were documented. R33's alteration in mobility care plan dated 5/27/24, identified R33 required an assist of two with transfers and partial to moderate assistance with rolling left to right in bed. R33's risk for alteration in skin integrity care plan dated 5/28/24, indicated R33 had a stage one pressure ulcer to the left heel and had the following interventions: • 5/28/24, pressure redistribution cushion to wheelchair, and chair. • 6/14/24, monitor skin integrity daily during cares. Weekly skin inspection by the nurse. • 6/14/24, turn and reposition or reminders to offload every two to three hours and as needed as resident allows. • 9/19/24, heel boots at all times while in bed. • 10/21/24, low air loss air bed, pressure redistribution. The care plan lacked an intervention for a wedge cushion in the bed. R33's skin integrity care plan dated 9/24/24, indicated staff were to follow current risk/benefit form, and interventions included a risk benefit form was completed an on file for skin integrity noncompliance with skin interventions 9/24/24. R33's alteration in blood sugar care plan dated 10/2/24, indicated R33 had a potential for alteration in blood sugar due to diabetes, and interventions included providing a diet as ordered and encourage R33 to follow the prescribed diet. R33's group sheet indicated R33 had wounds and required assist of one for bed mobility. R33's physician orders indicated the following orders: • 5/27/24, regular diet, regular texture, regular thin consistency. • 8/8/24, weekly skin inspection by licensed nurse. • 9/19/24, 1. left heel wound, skin prep to heel and allow to dry. 2. boots and float heels freely. • 10/21/24, air mattress monitor working order and replace as needed. The physician orders were reviewed and lacked any orders for any nutritional supplement. R33's Braden Scale for Predicting Pressure Sore Risk forms were reviewed and identified the following: • 7/9/24, R33 scored a 16 indicating R33 was at risk for developing a pressure sore. • 9/19/24, R33 scored a 16 on the Braden scale. • 9/26/24, R33 scored a 14 indicating R33 was at moderate risk for developing pressure ulcers. R33's weights were reviewed and indicated the following: • 5/25/24, 232.8 pounds • 5/26/24, 230 pounds • 6/2/24, 231.5 pounds • 6/16/24, 230.7 pounds • 6/30/24, 230 pounds • 7/7/24, 229 pounds • 8/4/24, 230 pounds • 9/24/24, 219 pounds • 10/11/24, 217 pounds R33's Clinical Nutrition Evaluation form dated 5/30/24, indicated R33's height was documented as 60 inches and weighed 230 pounds and BMI (body mass index) was not documented. R33's Clinical Nutrition Evaluation form dated 7/10/24, Under the heading, Dietary Preferences Likes/Dislikes indicated large portions, likes cereal, bacon, eggs, and toast, juice, milk. Further, under the heading, Skin Condition indicated R33 had no skin issues noted. Under the heading, Additional Information indicated R33's current weight was 230 pounds and his height was 72 inches tall with a BMI of 31.1 with preferences for large portions. R33's Clinical Nutrition Evaluation dated 9/22/24, indicated a height of 75 inches and the most recent weight of 230 pounds was from 8/4/24. Under the heading, Supplements indicated, NA. Further, under the heading, Skin Condition indicated No skin issues noted and R33 preferred large portions. R33's nurse practitioner noted dated 9/16/24, indicated R33 had bilateral foot pain specifically in the heels without breakdown in hands or heels. R33's PT notes dated 10/21/24, indicated R33 was given a heel float wedge to improve his ability to float heels if he did exercises or bed mobility on his own. Pillows required much re-adjusting to truly float heels. R33's progress notes were reviewed and indicated the following: • 5/28/24 at 12:18 p.m., R33 did not have skin breakdown upon admission and presented with a poor appetite. • 6/12/24, physician note indicated R33 had a poor appetite. • 9/19/24, at 8:52 a.m., R33 had an unstated pressure sore on the left heel and verbalized pain. • 9/19/24 at 1:25 p.m., indicated nursing staff found an area of discoloration on the left heel and pressure injury interventions were initiated including heel boots and offloading while in bed and would be followed on wound rounds. • 9/20/24 at 12:10 p.m., R33 was compliant with heel boots and floating heels. • 9/26/24 at 1:42 p.m., R33 preferred floating heels with pillows versus boots and a risk versus benefits was on file. • 10/4/24 at 3:11 p.m., monthly nutrition risk note from the dietary department indicated R33 had a stage one pressure ulcer on his heel with an effusion to the right knee, mild cognition impairment, muscle weakness, diabetes with a current weight of 219 pounds which was down from 230 pounds on 8/4/24. The note indicated R33 ate 100% and preferred large portions. Large portion and double meat would be added, would offer a sandwich at bedtime, and would monitor and document meal intakes and obtain weights per policy. The note lacked documentation R33 was provided Glucerna or equivalent per facility protocol, Juven or Prosource 30 milliliters by mouth twice daily. • 10/10/24 at 1:43 p.m., R33 preferred floating heels with pillows rather than boots. • 10/15/24 at 11:15 a.m., R33 stated he did not like his mattress because it made him uncomfortable and was agreeable to an air pressure reducing mattress. • 10/17/24 at 1:22 p.m., R33 remained non compliant with heel boots and preferred offloading with pillows. • R33's progress notes were reviewed and lacked documentation R33 refused repositioning, or supplements. A dietary progress note was later added on 10/24/24 at 10:17 a.m., that indicated R33 had refused supplements in the past and originally when asked that morning, but was later willing to try. R33's Risk vs Benefits Form signed on 9/24/24, indicated R33 had limited compliance with repositioning with grab bars, floating heels, offloading pressure to backside, not wanting to be in the wheelchair, preference to lie flat on back in bed, and using heel boots. The form identified risk of non compliance included worsening or new skin breakdown, increased weakness, and muscle wasting. R33's Task Offload Heels with Heel Boots at all Times in Bed form dated 9/19/24, through 10/24/24, indicated R33 refused to offload his heels 7 times. R33's Behavior Task form dated 9/25/24, through 10/24/24, indicated R33 refused cares one time. R33's Amount Eaten Task form dated 8/26/24, through 10/24/24, indicated R33 refused meals 57 times. Further, R33 ate 0-25% of meals 6 times, 26-50% of meals 35 times, 51-75% of meals 41 times, and 76-100% of meals 20 times. R33's IDT Care Conference form dated 7/17/24, indicated dietary had no concerns. Further, R33 required significant assist with activities of daily living and was a poor participant in therapy. R33's IDT Care Conference Form dated 9/22/24, and locked on 10/8/24, indicated dietary had no new concerns and R33's weight was stable. The form lacked documentation regarding R33's left heel wound. R33's IDT Care Conference Form dated 9/30/24, and locked on 10/9/24, indicated nursing had no concerns but had a healing wound on foot. Under the heading Dietary, indicated R33's weight was stable and had no changes. R33's weight was documented as 219 pounds. The dietary director portion of the note was signed by the facility administrator on 9/30/24. Social services indicated R33 had intact cognition. The other team members and family in attendance included R33, nursing, and R33's family member. R33's Weekly Skin Inspection form dated 9/11/24, indicated R33's skin was normal in color with minimal dryness noted on the feet and no notable issues or concerning changes observed. R33's Weekly Skin Inspection form dated 9/19/24, indicated R33 had a new alteration in skin integrity on the heel and skin prep was applied to the heels and feet were floated. R33's Weekly Skin Inspection form dated 10/2/24, indicated R33 continued with optimal skin with only mild dryness that was apparent on both feet and no new skin issues were noted. R33's Weekly Skin Inspection form dated 10/9/24, indicated R33's skin was good & healthy in color. Pt have an abrasion wound on the left heel that is follow every week by a wound clinic. Further, the note indicated there were no significant skin issues observed. R33's Weekly Skin Inspection form dated 10/16/24, indicated R33's skin was documented as, Intact. R33's Weekly Skin Inspection form dated 10/23/24, indicated R33's skin was good & healthy in color. Pt have an abrasion wound on the left heel that is follow every week by a wound clinic. Further, the note indicated there were no significant skin issues observed. R33's Skin and Wound Evaluation form dated 9/19/24, indicated R33 had a new facility acquired stage one pressure ulcer to the left heel. The exact date was not documented in the form. The wound measured 4.6 cm long by 3.6 cm wide with no eschar to the wound bed. Further, the note identified the wound as an intact blister. The note lacked information whether the wound the healable. Additionally, under a heading, Additional Care, identified check boxes next to mobility aid(s) provided, nutrition/dietary supplementation, positioning wedge, repositioning devices, and turning and repositioning program. Under the heading, Notifications identified check boxes next to practitioner notified. There were no checked boxes next to resident/responsible party notified, dietician notified, or therapy notified. R33's Skin and Wound Evaluation form dated 9/26/24, indicated R33 had a stage one pressure ulcer to the left heel that measured 5.6 cm long by 3.4 cm wide. The wound bed was documented as intact unbroken skin and did not identify whether the wound was healable. Additionally, under a heading, Additional Care, identified check boxes next to mobility aid(s) provided, nutrition/dietary supplementation, positioning wedge, repositioning devices, and turning and repositioning program. The wound progress was documented as stable. Under the heading, Notifications identified check boxes next to practitioner notified. There were no checked boxes next to resident/responsible party notified, dietician notified, or therapy notified. R33's Skin and Wound Evaluation form dated 10/2/24, indicated R33 had a stage one pressure ulcer to the left heel that measured 6.1 cm long by 5.3 cm wide. Further, the note identified the wound as an intact blister. Additionally, under a heading, Additional Care, identified check boxes next to mobility aid(s) provided, nutrition/dietary supplementation, positioning wedge, repositioning devices, and turning and repositioning program. The wound progress was documented as stable. Under the heading, Notifications identified check boxes next to practitioner notified. There were no checked boxes next to resident/responsible party notified, dietician notified, or therapy notified. R33's Skin and Wound Evaluation form dated 10/10/24, indicated R33 had a stage one pressure ulcer to the left heel that measured 5.9 cm long by 3.4 cm wide. The wound was filled with 50% eschar tissue and was identified as an intact blister. Additionally, under a heading, Additional Care, identified check boxes next to mobility aid(s) provided, nutrition/dietary supplementation, positioning wedge, repositioning devices, and turning and repositioning program. The wound was documented as improving. Under the heading, Notifications identified check boxes next to practitioner notified. There were no checked boxes next to resident/responsible party notified, dietician notified, or therapy notified. R33's Skin and Wound Evaluation form dated 10/17/24, indicated R33 had a stage one pressure ulcer to the left heel that measured 3.6 cm long by 4.1 cm wide. The wound bed was filled with 100% eschar tissue. Additionally, the heading, Additional Care, identified a check box next to air flow pad and the wound was documented as improving. The Notifications heading indicated there were no checked boxes next to practitioner, resident/responsible party notified, dietician notified, or therapy notified. R33's nurse practitioner (NP)-A wound consult note dated 9/19/24, indicated R33 had a stage one pressure ulcer to the left heel and R33 weighed 230 pounds. The note further indicated the nurse manager was to supply prevalon boots for additional offloading and encouraged aggressive offloading and repositioning, good diabetes control, and proper nutrition and hydration. Under a heading, Plan indicated R33 had multiple comorbidities that affected wound healing and wound progression including diabetes mellitus type two, limited mobility, muscle weakness, and risk for malnutrition. Additionally, the note indicated R33 was at risk for malnutrition and suggested supplementation with Glucerna or equivalent per facility protocol, Juven or Prosource 30 milliliters by mouth twice daily, and suggested following a dietician as needed. Additionally, under the heading, Plan, R33 required skin prep to the heel and allow to dry, boots and float heels freely and offload and reposition. The current diagnoses portion of R33's note indicated R33 had unspecified protein-calorie malnutrition. R33's NP-A wound consult note dated 9/26/24, indicated a stage one pressure ulcer to the left heel and R33 weighed 219 pounds. Further, R33 was alert and oriented and was able to make his needs known. NP-A encouraged aggressive offloading and repositioning, good diabetes control and proper nutrition and hydration. The heading, Plan indicated R33 had multiple comorbidities that affected wound healing and wound progression including diabetes mellitus type two, limited mobility, muscle weakness, and risk for malnutrition. Additionally, the note indicated R33 was at risk for malnutrition and suggested supplementation with Glucerna or equivalent per facility protocol, Juven or Prosource 30 milliliters by mouth twice daily, and suggested following a dietician as needed. Additionally, under the heading, Plan, R33 required skin prep to the heel and allow to dry, boots and float heels freely and offload and reposition. The current diagnoses portion of R33's note indicated R33 had unspecified protein-calorie malnutrition. R33's NP-A wound consult note dated 10/2/24, indicated a stage one pressure ulcer to the left heel and R33 weighed 219 pounds. The note indicated R33 had an intact blood blister on the left heel. The heading, Plan indicated R33 had multiple comorbidities that affected wound healing and wound progression including diabetes mellitus type two, limited mobility, muscle weakness, and risk for malnutrition. Additionally, the note indicated R33 was at risk for malnutrition and suggested supplementation with Glucerna or equivalent per facility protocol, Juven or Prosource 30 milliliters by mouth twice daily, and suggested following a dietician as needed. Additionally, under the heading, Plan, R33 required skin prep to the heel and allow to dry, boots and float heels freely and offload and reposition. The current diagnoses portion of R33's note indicated R33 had unspecified protein-calorie malnutrition. R33's NP-A wound consult note dated 10/10/24, indicated a stage one pressure ulcer to the left heel and R33 weighed 219 pounds. The note indicated the blister was getting smaller and the wound edges remained eschar. The heading, Plan indicated R33 had multiple comorbidities that affected wound healing and wound progression including diabetes mellitus type two, limited mobility, muscle weakness, and risk for malnutrition. Additionally, the note indicated R33 was at risk for malnutrition and suggested supplementation with Glucerna or equivalent per facility protocol, Juven or Prosource 30 milliliters by mouth twice daily, and suggested following a dietician as needed. Additionally, under the heading, Plan, R33 required skin prep to the heel and allow to dry, boots and float heels freely and offload and reposition. The current diagnoses portion of R33's note indicated R33 had unspecified protein-calorie malnutrition. During interview and observation on 10/21/24 between 6:32 p.m., and 6:39 p.m., R33 stated he had a smaller bed prior to this date and his foot used to touched the foot board and stated had received an air mattress today. R33 had a heel flotation cushion in bed under his legs, but the left heel was still touching the mattress. R33 had dryness around the left heel with flaking dry skin and a round blackened area was observed on the back of R33's left heel approximately the size of a tennis ball. R33 stated they put ointment on the area and tried to put a boot on his feet but stated it rubbed and told staff he did not want the boot because it was hurting his heel. During interview and observation between 10/22/24 at 10:01 a.m., and 10:07 a.m., R33 continued to have a thick blackened area to the left heel and when R33 was relaxed, the foot touched the bed. R33 had a heel flotation cushion positioned under the left leg. Additionally, R33 had a low air loss APM 48 inch air mattress that indicated was from Integra Healthcare. The weight setting indicated all green lights were lit including up to 660 to 750 pounds. A green light was located on alternate and a 10 minute cycle. R33 stated he was 6 feet, 3 inches tall and weighed about 215 pounds. During observation 10/23/24 between 8:19 a.m., and 8:23 a.m., NA-D brought R33 his breakfast and took off the cover on R33's plate, and R33 had a small scoop of eggs and toast with no other items on the breakfast tray. R33's meal ticket indicated R33 required a regular diet with large portions. At 8:23 a.m., NA-A entered R33's room and asked R33 if he was going to eat his breakfast and R33 stated he was not. NA-A asked R33 why he was not going to eat and R33 stated because he had no meat on his tray. NA-A repeated that R33 stated no meat and walked out of the room. NA-A did not offer repositioning and did not offer to provide meat. During interview on 10/23/24 at 8:27 a.m., NA-A stated residents don't receive meat every day and did not know if residents could get meat if they asked for it and stated she would get on the phone and ask the kitchen. NA-A further stated R33 wasn't going to eat because there was no meat and he didn't ask for meat. After inquiry, NA-A went into R33's room and asked R33 what he would like and stated she would let them know R33 wanted sausage every day. During interview on 10/23/24 from 8:31 a.m., to 8:38 a.m., LPN-A stated she would have expected the NA to offer an alternative per R33's preference after resident stated there was no meat. When asked what was on R33's plate, LPN-A stated R33 had a scoop of eggs and 2 pieces of toast. At 8:34 a.m., LPN-A unplugged R33's bed and plugged the bed into another outlet behind the bedside table and brought the breakfast out of the room. LPN-A did not look at the settings on the bed, and then called and asked kitchen to bring up a peanut butter and jelly sandwich. At 8:37 a.m., staff brought sausage to R33. At 8:38 a.m., NA-A brought R33's plate into the nursing station to warm up the meal in the microwave. During interview on 10/23/24 at 8:40 a.m., the dietary director (DD) stated R33's plate looked a bit light when asked about the large portions. NA-A told DD she just mashed the eggs up to warm them and told DD there was only one scoop of eggs on the plate for R33. During interview and observation on 10/23/24 at 8:45 a.m., LPN-A viewed R33's air mattress settings, verified they were set for 660 to 750 pounds, and stated the weight setting was incorrect. NPN-A asked R33 how much R33 weighed, readjusted the settings, and stated she would be back to double check after verifying R33's weight. During interview on 10/23/24 at 8:54 a.m., the dietician stated she worked at the facility one day a week and completed all high risk documentation. The dietician stated residents at high risk included residents with weight loss, tube feedings, and wounds, and she could run reports for wounds and if staff reached out with concerns. The dietician further stated if a resident had a wound and had a good appetite, she may do double proteins if they were not malnourished, looked at protein intake, and stated if supplements were needed she would make a progress note or put an order in the chart. The dietician stated she was alerted if a resident had a wound right away and expected staff to inform her right away. The dietician stated R33's appetite was good and his weight was stable and would expect large portions, and stated R33 was educated if he wanted larger portions could let staff know. She further stated R33 only had a stage one pressure ulcer, but if he had more than a stage one pressure ulcer, R33 would definitely need more protein. When asked about R33's weights, the dietician stated R33's weights were stable for the last two months at 217 to 219 pounds and prior to that was 230 pounds upon admission. The dietician stated R33 was not triggering for significant weight loss for some reason and could not identify why R33 lost weight. The dietician further stated R33's appetite was variable and he had been eating 100%, and stated a double protein would be a double scoop of the eggs, and she could talk with dietary staff about resident not receiving double proteins. During interview on 10/23/24 at 9:53 a.m., LPN-A stated R33 would be on their wound rounds on 10/24/24. During interview on 10/23/24 at 1:31 p.m., family member (FM)-B stated R33's mattress was changed but was not sure when because the facility did not communicate well regarding R33's care. FM-B further stated the facility never informed FM-B when R33 developed a pressure ulcer. FM-B stated R33 was a bigger man and needed a bigger bed, and at first the facility was not supplying a longer bed. FM-B stated R33 was 6 feet, 5 inches tall and asked about R33 having a bigger bed after R33 developed a pressure ulcer. FM-B stated she would door dash food for R33 and stated R33 was a bigger man and wanted double portions, but the facility provided traditional portion sizes, and added R33 had diabetes and stated they should be extra cautious with R33's food due to blood flow so his foot would not be amputated. During interview on 10/23/24 at 2:04 p.m., LPN-A stated NP-A was conducting wound rounds on 10/24/24. LPN-A refused to allow visualization of wound images in the electronic medical record (EMR). LPN-A stated wounds were documented under the Forms tab in the EMR and stated the first pictures taken were on 9/19/24, and she was notified on 9/19/24, R33 had a pressure ulcer, added him to the list for wound rounds, and he was seen the same day. LPN-A further stated the provider stated the wound was a pressure ulcer, but did not tell LPN-A what caused it. LPN-A stated R33 was at risk for pressure ulcer development prior to R33 developing a pressure ulcer. LPN-A stated interventions in place to prevent pressure ulcers included monitoring skin during daily cares, and all beds had pressure redistribution mattresses and cushions on all beds. LPN-A stated the air mattress was provided after R33 developed the wound but could not state when R33 received an air mattress, and stated they contracted with Integra. LPN-A stated R33's wound started as a stage one pressure ulcer and if the NP documented R33 had a blister, she would defer to the NP's documentation and stated categorizing and labeling wounds was left up to the NP wound care providers. During interview with the DON and administrator on 10/24/24 at 7:50 a.m., and 8:00 a.m., the DON stated the wound provider took all the wound pictures and filled out and documented on the form under skin and wound evaluation. The DON further stated, under the miscellaneous tabs, the NP uploaded the individualized wound notes and the DON completed a skin and wound note weekly in the progress notes and stated R33 had wound notes on 9/26/24, 10/2/24, 10/10/24, and 10/17/24. DON stated they provided R33 with an air mattress on 10/21/24. The administrator added R33 felt the mattress was too firm and had less to do with R33's skin. They were comfortable with leaving R33 with interventions for grab bars and floating heels, and stated R33 was non compliant with boots and preferred pillows for interventions because the boots were uncomfortable. At 8:00 a.m., the administrator stated they switched to Integra and did not have a user manual for the air mattress. The DON stated their root cause analysis found R33 got the pressure ulcer from being stationary in bed and R33 lays flat on his back in bed with his heels on the mattress. During interview on 10/24/24 at 8:05 a.m., LPN-G stated they measured residents with a tape measure while the resident was in bed. During interview on 10/24/24 at 8:13 a.m., the dietician stated R33 was not on any supplements and stated she should have written protein and not meat and corrected the ticket because the meal ticket indicated double something. When asked about a handbook they utilized for wound treatment guidelines, the dietician stated they treated residents individually and depending on whether a wound was healing or what stage it was, a resident may not need an additional protein. She added it was very individualized and stated that obviously, if a wound was a stage three or stage four she would put in Prosource. The dietician stated she was just going to go in and visit with R33 at this time. During interview on 10/24/24 at 8:42 a.m., the general manager ([TRUNCATED]