**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to perform comprehensive skin assessments and implement interventions to promote healing and reduce the risk for further pressure ulcer development for 1 of 1 resident (R100) reviewed for pressure ulcers. This resulted in harm for R100. Findings include: 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. 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 (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) 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. R100's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not reject care, was dependent on staff for toileting, had lower extremity range of motion impairment on one side, required substantial assistance with bathing and showering, was independent with rolling left and right, had an indwelling catheter, was always incontinent of bowel, had a stage one or greater pressure ulcer, was at risk of developing pressure ulcers, had one stage one pressure ulcer, did not have other skin problems which included moisture associated skin damage (MASD), open lesions other than ulcers, rashes, cuts, surgical wounds, burns, and skin tears. Skin treatments indicated R100 had a pressure reducing bed, application of a nonsurgical dressing other than to feet. R100's Face Sheet indicated R100 admitted to the facility on [DATE], and had the following diagnoses: multiple sclerosis (a condition affecting the central nervous system that can cause muscle weakness, vision changes, numbness, and memory issues), adult failure to thrive, major depressive disorder, type 2 diabetes mellitus, and neuromuscular dysfunction of the bladder. R100's care area assessment (CAA) dated 1/12/24 indicated R100 had multiple sclerosis, weakness, failure to thrive and staff assisted R100 with activities of daily living, transfers, mobility, and toileting. The CAA was edited on 1/18/24, and indicated R100 was admitted with redness to her peri area, and had a dressing to her coccyx on admission and 1/10/24 nursing note indicated a stage 1 pressure ulcer to the left heel. R100's care plan dated 1/7/24, indicated a self care deficit and R100 required 1 to 2 assist with bed mobility, bathing, and transfers. R100's care plan dated 1/7/24, indicated R100 was at risk for alteration of skin due to her disease process and her goal indicated she would not develop any skin alterations. R100's interventions were: barrier cream applied to dry areas as needed. The care plan was later revised on 2/14/24, to include the following interventions: Braden skin risk evaluations completed on admission and every week for four weeks, then quarterly, annually, and with any significant change, nursing assistants to observe skin and report any abnormalities to the nurse, air mattress placed on the bed, heel protectors in place to protect heels while in bed, may choose to have the head of bed at the lowest elevation as possible to reduce the pressure on bottom, may refuse treatments and interventions, will allow therapy to see as appropriate to assist in wound healing, will be involved in the treatment process, will be monitored for properly fitting footwear and pressure reduction to heels. Will have a podiatrist as appropriate see me if issues, will be reminded to reposition every 2 hours, will have assistance in repositioning every two hours to offload the pressure areas, will maintain good skin hygiene and skin will be moisturized if I have dry skin as needed, my elimination of waste will be addressed in the toileting section of the care plan, my heels will be floated while in bed, my labs and weight will be monitored as ordered, my pain will be controlled as ordered, pressure redistributing mattress is in place on my bed and I have a cushion for my chair, proper notifications will be made if my wounds change, the staff will provide me with adequate nutrition and hydration. Nutritional supplements and vitamins as ordered, the staff will use a lift sheet to move me in bed as needed. R100's care plan dated 2/13/24, indicated R100 had a nutrition goal R100's skin would improve and or heal and approaches included honoring likes and dislikes, and supplements as ordered. R100's care sheet indicated R100 had an air mattress, report skin findings to the nurse, required assist of 1 for bed mobility, was to be turned and repositioned in bed as tolerated and had a buttocks wound. R100's physician orders indicated the following orders: • 1/6/24: Wound care: change dressing every Monday, Wednesday, Friday, and as needed for drainage and saturation. Gently remove previous dressing. Hold skin down as you remove the dressing to prevent further skin tearing and or soak off with NS. Cleanse with wound cleanser; pat skin dry. Protect and treat apply sacral Mepilex silicone foam dressing. Pressure injury prevention: turn and reposition every 2 hours; right and left turns avoid the back. • 1/8/24: nystatin powder; 100000 unit/gram; apply topically to groin twice daily • 1/9/24: heel pressure relief/floating heels with pillows, boot air fluidized heel aldt std/Z flex heel boot or comparable off loading product. Chair interventions: pressure redistribution seat cushion in place. Keep HOB/Recliner less than 30 degrees, knee [NAME] elevated on bed unless contraindicated by medical condition. Assess skin under all tubes and devices every shift. • 1/9/24: Shower day on Friday a.m., assess skin and document in nursing notes. If any skin concerns noted open an event and notify the physician and family per facility protocol. • 1/10/24: Wound care left heel stage one: apply skin prep and allow to dry daily. • 1/10/24: Braden score 15: assist with turn and repositioning every 2 hours. • 1/11/24: Glucerna 8 ounces daily at bedtime • 1/26/24: Activity: up in the wheelchair for not more than 2 hours twice a day • 1/10/24: blue boots bilateral feet on at all times except cares. • 1/26/24: sacral wound care use Medihoney and foam dressing every day. • 1/30/24: Measure wound to buttocks weekly and document in the progress notes. R100's telephone order dated 1/26/24 from nurse practitioner (NP)-C indicated orders for an occupational therapy evaluation (OT) for a Roho cushion, change bed to an air mattress, up in the wheelchair not more than 2 hours, sacrum wound care use Medihoney foam dressing daily. R100's Hospital admission History and Physical form dated 12/27/23, indicated under the heading, Assessment/Plan R100 had a decubitus ulcer that was present on admission. R100's Hospital documents dated 1/6/24 indicated R100's heels were floated off the end of pillows or with heel offloading boots, additionally R100 was out of bed for meals and turned and repositioned every two hours left to right avoiding the back on 1/5/24. Additionally, R100's groin was reddened from a yeast infection. Additionally a note on page (372 of 430) indicated a perineum bilateral pressure injury and surrounding skin was intact, and had a foam dressing, the wound base was open and had a red/pink base. Additionally, on page 373 of 430 had moisture associated dermatitis to skin folds on bilateral legs that were cleansed and a topical product was applied. The progress notes indicated R100 had a bilateral pressure injury to the perineum and bilateral leg moisture associated dermatitis. R100's After Visit Summary 12/27/23, to 1/6/24, indicated care instructions to change coccyx dressing every Monday, Wednesday, and Friday and as needed for drainage saturation. Gently remove previous dressing. Hold skin down as you remove the dressing to prevent further skin tearing and or soak off with normal saline. Cleanse with wound cleanser. Pat skin dry. Protect and treat apply sacral Mepilex silicone foam dressing. Pressure injury interventions included: turn and reposition every 2 hours right/left turns, avoid back, heel pressure relief floating heels with pillows, boot air fluidized heel adlt Std Z flex heel boot or comparable off-loading product, chair interventions; pressure redistribution seat cushion in place, keep head of bed and recliner less than 30 degrees, knee [NAME] elevated on bed unless contraindicated by medical condition, assess skin under all tubes and devices every shift. R100's certified wound ostomy continence nurse (CWOCN) note dated 12/28/23, (page 31 of 430) indicated R100's coccyx was reddened and non blanchable and had shallow ulcers to the right and left buttocks that measured 1 cm each. Further, the note indicated orders for pressure injury prevention, wound and skin care were on the chart, and a sacral Mepilex was ordered for R100. R100's medication administration record (MAR) dated 2/1/24 to 2/13/24 indicated R100 was to have 8 ounces of Glucerna (a nutritional supplement for people with diabetes) daily at bedtime starting on 1/11/24, however, R100 refused the Glucerna 12 times. Additionally, R100 refused the Glucerna 13 times according to the MAR dated 1/11/24 to 1/31/24. R100's dietician progress note dated 2/13/24, indicated R100 was on a consistent carbohydrate diet with intake of 76-100% for 9 of 13 meals monitored since 1/30/24 and R100 received a Glucerna supplement every day at bedtime to provide nutrition in addition to balanced diet including protein at three meals daily to promote healing of open areas and R100's weight, intake, and skin integrity was monitored. R100's breakfast, lunch intake percentages from 1/6/24, to 2/13/24, indicated the breakfast meal was documented 9 times; 6 times R100 ate 76-100%, once R100 ate 51-75%, and R100 ate 26-50% of breakfast twice. The lunch meal was documented 7 times; 6 times R100 ate 76-100%, and once ate 51 to 75%. R100's Skin Risk Observation with Braden Scale form dated 1/6/24, indicated R100 had the following risk factors for developing a pressure injury: an acute condition, chronic incontinence, diabetes, hypothyroidism, multiple sclerosis required assistance for rolling left and right, lying to sitting, sitting to lying, was always incontinent, had lesions and redness to the peri area, had an unhealed pressure injury that was a stage one or higher to the coccyx. The Braden scale score was 15 and indicated R100 was at risk for developing pressure ulcers. Skin and ulcer treatments included a pressure reducing device for the chair and a turning and repositioning program. Additionally, referral that may be appropriate indicated dietary, occupational therapy (OT), and physical therapy (PT). R100's Skin Risk Observation with Braden Scale form dated 2/9/24, indicated R100 had the following risk factors for developing a pressure injury: cardiovascular disease, decreased range of motion, diabetes, multiple sclerosis, catheter/oxygen/wound vac/ tubing, required partial to moderate assistance to roll left and right, dependent for lying to sitting, and sitting to lying, was always incontinent, had redness to the peri area, had limited mobility, unhealed pressure ulcers to the sacrum, and moisture associated skin damage (MASD). The Braden Scale score was 8, indicating R100 was at very high risk for developing a pressure ulcer. Skin and ulcer treatments included turning and repositioning, and pressure ulcer injury care and under the heading Indicate Care Plan Action Taken indicated to continue current care plan. Additionally, referrals that may be appropriate indicated OT and PT. R100's admission Clinical Documentation note dated 1/6/24, indicated R100 required extensive assistance with bed mobility, was totally dependent on staff for toileting. R100's facility admission Skin Condition/New Wound Assessment form dated January 7, no year, indicated a diagram with instructions to use the list below to identify (number/letter) on the diagram all skin or body concerns. Further, instructions indicated to document size, depth (in, cms), color and drainage. If an ulcer was present, indicate pressure or non-pressure. The list contained a handwritten circle around the numbers 1, 2, and 8. The number 1 listed Pressure next to number 1, the number 2 listed Reddened next to number 2, and number 8 listed wound next to number 8. The posterior (back) view of the diagram indicated a number 1, and a number 8 next to the coccyx region, and to the left of the coccyx region a circle with a number 1, and 8. On the anterior (front) of the diagram was a circle with the numbers 2, and 3 indicating a reddened bruise. Additionally, there was a circled area with a number 2 indicating a reddened area. Additionally, under a heading, Comments indicated the suprapubic site (below the umbilical region) was reddened, there was a small reddened bruise on the left side groin, and a dressing on coccyx and left buttock. The assessment contained no measurements. R100's Braden Scale for Prediction of Pressure Score Risk form dated 1/24/24, indicated a score of 11. The form included an interpretation of the scores and a score range of 10-12 indicated a high risk for development of a pressure ulcer. Interventions included a pressure reducing device for the chair and a pressure reducing device for the bed. Additionally, referrals that may be appropriate included activities, dietary, nursing rehab, and OT, and the care plan action indicated to continue with the current plan of care. R100's Skin Integrity Events that was recorded on 1/30/24, for 1/6/24, indicated R100 admitted with pressure/moisture associated wound to right and left buttocks. R100's transitional care unit (TCU) follow up note dated 1/15/24, indicated nurse practitioner (NP)-C saw R100 who was sitting up in the wheelchair and had fallen the previous Friday and sustained bruising to her back. The note indicated R100 had incontinence associated dermatitis to her bottom and received topical treatment. R100's TCU follow up note dated 1/18/24, indicated R100 had incontinence associated dermatitis to her bottom, and had fallen with bruising to R100's back. R100's TCU follow up note dated 1/23/24, indicated R100 was sitting up in the wheelchair on this day's visit. The note indicated R100 had bruising to the back, and had incontinence associated dermatitis and planned to continue topical treatment. R100's TCU follow up note dated 1/25/24, indicated R100 was sitting up in the wheelchair and had incontinence associated dermatitis. R100's TCU note dated 1/31/24, indicated incontinence associated dermatitis. R100's TCU note dated 2/1/24, indicated R100 had fallen from a lift at the TCU and x-rays were obtained with no acute injury. Additionally, the note indicated R100 had a coccyx ulcer and per reports had moderate slough and eschar. Additionally, the note indicated R100 had incontinence associated dermatitis. R100's TCU follow up note dated 2/13/24, indicated R100 was sitting up in the wheelchair eating lunch and had an appointment 2/15/24 with vascular service to debride her coccyx wound and continued with the Medihoney dressing changes. During exam, R100 was lying in bed and the wound was documented as a deep tissue injury (DTI) to coccyx that was now unstageable. The note also indicated R100 had admitted to the facility with IAD (incontinence associated dermatitis). The note further indicated R100 slipped in the bathroom that resulted in a DTI to the coccyx and over time the area developed into thick eschar. The note indicated the area measured 7 cm by 6 cm by 2 cm of thick eschar, with no peri wound redness. Additionally, there were four areas to the peri wound with granulation present. R100's emergency department (ED) note dated 2/11/24, indicated R100 was seen for evaluation of a worsening sacral wound and had a CT scan that showed possible cellulitis of the sacral wound, and recommended follow up with the wound clinic. R100's After Visit Summary note dated 2/15/24, indicated new orders to cleanse the buttock wound(s) with normal saline, pat dry with non-sterile gauze, pack wounds with aquacel AG (used for wounds with moderate to heavy drainage) cover with Mepilex. Additionally, the note indicated to offer a supplement three times daily. R100's wound clinic note dated 2/15/24, indicated R100 reported the wound had been present since 10/2023. The note further indicated the wound bed contained necrotic material and the surrounding wound had healthy intact skin. Additionally, the wound had necrotic muscle and was a fairly deep stage four pressure ulcer. The wound pre debridement measurements were 7 cm (centimeters) long by 6.5 cm wide and 1.8 cm deep and total 56 square cm. Further, the note indicated the most important thing to do to support healing was to keep pressure off the wound, R100 should be repositioned every 2 hours around the clock while in bed. Additionally, the physician explained to R100 the importance of protein intake to wound healing and increasing protein intake will speed wound healing and to further speed wound heeling encouraged R100 to take a protein supplement. Further, R100 should only be in the wheelchair for 3 hours a day and R100 needed to reposition themselves every 15-20 minutes while there are in the wheelchair. R100's Wound Management form indicated there were no wound types identified for the resident. R100's nursing progress notes were reviewed from 1/6/24, to 2/14/24, and indicated the following: • No progress note was entered on 1/6/24. • 1/8/24 perineal care was completed and there was redness noted on R100's sacrum and cream per order and foam dressing endorsed. The documentation lacked any measurement of the reddened area. • 1/9/24 perineal cares were completed and nystatin was applied on redness, and [NAME] was applied on the sacrum and the foam dressing was changed. The documentation lacked any measurement of the reddened area to the sacrum. • 1/10/24 R100 complained of pain to the left heel which was offloaded with a pillow and blanchable redness was observed on the left heel. Nystatin was applied on the groin. The note indicated negative moisture positive redness and peeling skin was noted on the groin. Additionally R100's sacrum was still red and [NAME] was applied along with a foam dressing. The documentation lacked any measurement of the reddened area to the sacrum. • 1/10/24 R100 had a left heel stage 1 ulcer and orders were received to apply skin prep and allow to dry and blue boots both feet at all times except for cares. The documentation lacked a skin assessment of the left heel including measurements. • 1/12/24: R100 had a witnessed fall with staff and was lowered to the ground without injuries, the note indicated R100's legs got weak during a transfer with a [NAME] lift and it was recommended to change to a Hoyer for safety. • 1/13/24: R100 had a bruise on her right buttocks and the site was red with a closed bruise on the redness. The site was covered with a foam protective dressing. The red site was measured at 13 cm by 10 cm. • 1/14/24: R100 had [NAME] on her buttocks, and had bruises on the redness of the sacrum area. Further, the redness on the left heel was prepped and a foam dressing was applied. The heel was not measured. • 1/15/24: R100 had bruises on the sacrum with bleeding and peeling skin, and left heel cares were completed. • 1/24/24: R100's heel ulcers were documented as assessed and redressed, however there was no documentation of measurements or the assessment. • 1/28/24: R100's sacral wound care was completed and slough was noted on the buttocks and was increased in size. The NP was updated who ordered Medihoney and a foam dressing, up in the wheelchair for no more than 2 hours, change bed to an air mattress, and an OT evaluation for a Roho cushion. The note lacked a wound assessment to include any measurements. • 1/31/24: R100's total surface area of the sacral wound was 13 by 12 cm and there was no assessment documented on the wound bed. Additionally the left heel pressure wound was red dry and intact, however there were no measurements. • 2/1/24: R100's progress note indicated 13.4 cm by 0.1 cm and wound bed was 30% eschar, 30% slough, and 10% superficial tissue loss, 20% non blanchable irregular edges. The periwound was documented as intact and blanchable and the note indicated R100 was admitted with area. The progress note did not identify the location of the wound. • 2/3/24: R100's dressing on sacrum was changed and the eschar measured 5 by 6 cm and the total surface of the wound was 12 by 10 cm. The documentation lacked information on R100's left heel. • 2/7/24: R100 had eschar that measured 5 by 6 cm and had a total surface area of 11 by 10 cm and the heel wound was documented as intact with no open areas. The documentation lacked a measurement of the left heel wound, and did not identify the location of the wound with eschar. • 2/8/24: R100 had an unstageable area on the sacrum and coccyx that measured 13.5 cm by 13.5 cm by 0.1 cm and the wound bed had 30% eschar, 30% clean non granulated tissue, 10% superficial tissue loss, 20% non blanchable irregular edges and the area of eschar measured 6 cm by 6.8 cm and was unable to determine depth of the wound due to the eschar. The documentation indicated that R100 was admitted with the area. Additionally, R100 had a DTI on the left heel that measured 1.5 cm by 1.8 cm in an L shape that was intact and the surrounding wound was intact and pink. Additionally, the note indicated R100 admitted with area. This was the first time R100's left heel wound had been measured. • 2/14/24: R100's sacrum wound had a total surface area of 13.3 by 12 cm and the open wound measured 5.4 by 5.6 cm. The wound had varying wound depth with the deepest measuring 0.9 cm. R100 had a 2nd wound documented at the bottom of the first that measured 1.5 cm by 0.9 cm by 0.5 cm in depth, and an open wound at 6 O' clock on the right bottom that measured 3.8 by 0.6 cm, a wound at 9 O' clock 1.6 by 1.1cm, at 8 O' clock 3 by 0.5 cm, and had left buttocks excoriation 0.3 by 0.3 cm. R100's left heel was intact and measured 1.1 cm by 0.4 cm. During interview and observation on 2/12/24 between 4:40 p.m., and 4:48 p.m., R100 was laying on her back in bed towards her right side. A pillow was under the left side of R100 and a family member stated R100's sore was on the right side of her buttocks. At 4:48 p.m., R100 stated the sore on her bottom started in October and didn't become worse until coming to the facility. During continuous observation on 2/13/24 from 1:44 p.m., to 2:07 p.m., R100 was in a wheelchair and there was a Reliant 450 full body lift located in the hallway. At 2:06 p.m., registered nurse (RN)-A brought the full body lift into R100's room and was awaiting assist and at 2:07 p.m., nursing assistant (NA)-B entered the room. RN-A and NA-B positioned R100 in bed on her back. During interview on 2/13/24 at 2:10 p.m., RN-A and NA-B assisted in providing perineal cares and at 2:22 p.m., boosted R100 up in bed, positioned her on her back and provided the call light. RN-A and NA-B did not offer to lie resident on her side. During interview on 2/13/24 at 2:25 p.m., RN-A stated R100 had a bed sore on her bottom and came with incontinence associated dermatitis and it worsened because of incontinence. RN-A stated they use Medihoney for the area because it helped debride the slough and R100 had an appointment on 2/15/24, for vascular to have the wound checked. RN-A stated R100 should be kept repositioned on her left and right side and verified R100 was not positioned on her right or left side and further stated the ulcer was all over her buttocks. Additionally, RN-A stated R100's bed sore could worsen being on her back. Further, RN-A stated wound measurements were documented in the progress notes and was not sure how often they were completed. During observation on 2/13/24 at 3:04 p.m., R100 stated she would be willing to lie side to side. R100 had a pillow under her right side, but was still positioned on her back and the head of the bed was elevated about 30 degrees. R100 had a Journey wheelchair cushion in her wheelchair. During observation on 2/14/24 at 7:20 a.m., R100 was lying in bed on her back, her weight was shifted towards the right side but was mostly on her back and the head of the bed was elevated about 20 to 30 degrees. There was no pillow located under the left side of R100. During interview on 2/14/24 at 8:36 a.m., occupational therapist (OT)-F stated a Roho cushion was a gold standard for true pressure relief because it had air in its cells and were wonderful for wound management. OT-F stated if a resident had trouble with core stability, the cushion would be discouraged and in that case would use a foam cushion which still redistributes pressure, but the foam cushion gave more stability to feel secure in the chair. OT-F further stated the Roho worked well on the TCU. OT-F further stated if an order was to evaluate for a Roho, OT would document the evaluation and do a trial and error. The benefit of the doctor ordering a Roho is if we are not getting enough pressure relief from the redistribution mattress. OT-F stated an evaluation with an order should take place as soon as possible and a TCU patient was very easy to get to right away. OT-F stated R100 was on the TCU side. During interview on 2/14/24 at 9:18 a.m., the rehab director stated their OT was trained in wheelchair positioning and would initiate what they thought was appropriate with or without an order and would document. The rehab director reviewed the OT progress notes and did not locate any documentation of an OT evaluation for a Roho cushion. Further, the rehab director said when there is an order they are notified of the order by nursing staff and the therapist would address the order and would be in their documentation that they looked at the cushion and verified she did not see any documentation R100 was formally assessed for a Roho cushion. The rehab director stated the nurse manager or health unit coordinator would share with therapy anything new to address and stated she got the order and would get it to the appropriate person and was not aware of an order for a Roho cushion and stated she would look through her email. The rehab director also verified physical therapy would not be involved in the Roho cushion and stated if there was an order it would be emailed to her. During observation on 2/14/24 at 9:05 a.m., R100 still had a journey cushion in the wheelchair. RN-G stated R100 had a regular cushion not a Roho cushion. R100 also had a comfort curve cushion and RN-G stated that was not a Roho cushion, but later stated she would have to ask the nurse manager and verified the wheel chair cushion was a Journey wheelchair cushion and the cushion in R100's recliner was a Comfort Curve cushion. During interview on 2/14/24 at 9:11 a.m., OTR stated R100 did not have difficulty with core stability and when asked if R100 had been evaluated for a Roho cushion stated she thought R100 had a pressure relieving cushion on the chair and stated staff elevate the head of the bed for R100 to eat, but patients should not have the head of the bed elevated for a long period of time. During interview on 2/14/24 at 7:13 a.m., NA-B stated she looks on the care sheet to know what cares a resident requires and stated R100 never refused cares. NA-B further stated R100 was incontinent of stool and her dressing sometimes needed to be changed and stated R100 could not reposition herself and stated they reposition R100 off the area a little bit on the left side and right side. NA-B was not aware R100 had any issues with her heels. During interview on 2/14/24 at 9:37 a.m., the dietician (D)-I stated she monitors a appetites and their weights, and proteins, when a resident has a pressure ulcer. D-I stated if a resident had a stage 1 pressure ulcer she encouraged food and ensure and if a resident had a more serious ulcer, she reviews her supplements a resident may be interested in and added, it won't help if a resident refuses and stated she looks at the electronic medication administration record (EMAR). D-I further stated she looked at point of care to see what the NA's documented and stated they couldn't have an expectation that every single meal was documented, but stated the more documentation, the better. R-I stated Glucerna is made by the company that makes Ensure and is for people with diabetes and it was a protein to help with wounds. D-I stated if residents didn't like Glucerna, they had Arginaide which also helped with wound healing. D-I stated the nurses let her know if a resident was refusing [TRUNCATED]