**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, family interview, staff interview, review of the facility therapy to nursing communication form and review of facility policy, the facility failed to provide adequate staff assistance during transfers to prevent falls. This resulted in actual harm on 01/15/25 at approximately 12:25 P.M. to Resident #100 when Certified Nursing Assistant (CNA) #20 completed a hands-on transfer of the resident from the wheelchair to the bed without the assistance of additional staff. Resident #100 sustained a fall to the floor during the transfer, resulting in a left femur fracture. This affected one resident (#100) of three residents reviewed for falls. The facility census was 84. Findings include: Review of the medical record for Resident #100 revealed an admission date of 01/13/25. Diagnoses included cerebral infarction (stroke), spastic hemiplegia (causes muscle tightness and involuntary contractions on one side of the body), diabetes mellitus, epilepsy, seizures, depression, anxiety, foot drop (difficulty lifting the front part of the foot), and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #100 revealed no information for this resident due to the length of stay in the facility. Review of the care plan, dated 01/14/25, revealed Resident #100 had an activities of daily living (ADLs) self-performance deficit and required staff assistance related to hemiplegia, foot drop, cerebral infarction, and overall medical condition. Interventions included total staff dependence with transfers and the resident required the assistance of one or more staff with transfers. Review of the facility Therapy to Nursing Communication Form, dated 01/14/25 and completed by Physical Therapy Assistant (PTA) #40, revealed Resident #100 had left-sided hemiplegia due to a previous cerebral infarction and was evaluated to need two staff assistance for all transfers. Further review revealed Licensed Practical Nurse (LPN) #10 acknowledged the communication on 01/14/25. Review of a nursing progress note, dated 01/15/25 at 12:35 P.M., revealed LPN #30 immediately responded to the room of Resident #100 after hearing her screaming in pain. Upon arrival, she witnessed CNA #20 and Resident #100 both on the floor, after an attempted transfer. Further review revealed Resident #100 was screaming in excruciating left hip pain. LPN #30 documented she was unable to complete an assessment due to the position of both CNA #20 and Resident #100. In addition, the note documented Resident #100 stated that during the transfer, both of their legs (Resident #100 and CNA #20) had gotten tangled, causing them both to fall to the floor. Review of a nursing progress note, dated 01/15/25 at 4:25 P.M., revealed Resident #100's father reported to LPN #30 via telephone correspondence that the resident had a fractured left hip and would be awaiting an orthopedic consultation at the hospital. Review of the Fall Investigation note for Resident #100, dated 01/16/25, revealed Resident #100 had a fall with major injury related to staff assisting the resident and both falling to the floor when the resident's legs became entangled with CNA #20. It further stated the resident's left lower extremity range of motion was abnormal, as she was unable to move it due to extreme pain. Review of CNA #20's written statement, dated 01/16/25, revealed Resident #100 wanted to get into her bed from her wheelchair. Their legs became tangled during the transfer, which caused both of them to fall. Interview on 02/22/25 at 8:24 A.M. with Resident #100's family member revealed the resident sustained a fractured left hip, requiring the placement of a metal rod in her left leg, as a result of the fall on 01/15/25. He further added that the resident transferred to another facility following her hospitalization. A telephone interview on 02/22/25 at 10:40 A.M. with CNA #20 revealed she was seven months pregnant at the time of the incident with Resident #100. CNA #20 stated she was informed Resident #100 was a one-person staff assist for transfers, but did not confirm this information. CNA #20 stated during Resident #100's transfer, their legs become entangled, causing both of them to fall to the floor. She verified she was the only staff member in the room at the time of the fall and further confirmed Resident #100 began screaming in pain after the fall to the floor. CNA #20 denied knowledge of the therapy communication form, completed on 01/14/25, which indicated Resident #100 was to be a two-person staff assist with transfers. An interview on 02/22/25 at 11:50 A.M. with LPN #30 revealed she had responded to Resident #100's room on 01/15/25 when she heard the resident screaming in pain. LPN #30 verified Resident #100 had fallen after CNA #20 attempted to transfer her alone. An interview on 02/22/25 at 12:10 P.M. with the Director of Nursing (DON) confirmed the therapy communication form completed on 01/14/25 indicated Resident #100 required two-person staff assistance with transfers due to her medical conditions. The DON verified Resident #100's fall occurred after this assessment had been completed and acknowledged by LPN #10 and only one staff (CNA #20) assisted with the resident's transfer at the time of the fall on 01/15/25. The DON further confirmed the facility received report from the father of Resident #100 on 01/15/25 that the resident's left hip was fractured and required surgical intervention. The DON revealed the facility did not have hospital records related to the incident because the resident did not return to the facility. Review of the facility policy titled, Falls, dated September 2021, revealed, 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. Review of the undated facility policy titled, Activities of Daily Living (ADLs), revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation). The deficiency was corrected on 02/17/25 when the facility implemented the following corrective actions: • On 01/15/25 at approximately 12:25 P.M., LPN #30 assessed Resident #100, who was noted with pain and abnormal range of motion (ROM). Resident #100 was transferred to the hospital for further evaluation and treatment. • On 01/15/25, the DON or designee updated Resident #100's plan of care to include assistance of two-staff with transfers. • On 01/15/25, the DON or designee re-assessed Resident #100's fall risk and determined the resident remained at low risk for falls. • On 01/15/25, the DON or designee educated all licensed nursing staff on ensuring communication between therapy and matched the resident's care plan and [NAME] (system for organizing resident information). Review of the nursing in-service sign in sheets confirmed the education was provided. • On 01/21/25, the DON or designee reviewed the therapy evaluations for all residents to ensure the level of assistance recommended by the therapy department matched the resident's care plan and [NAME]. No discrepancies were identified. • Beginning on 01/24/25, the DON or designee will audit four residents weekly for four weeks to ensure therapy recommendations for assistance with transfers were communicated to the nursing department and matched the resident's care plan and [NAME]. The audits will be reviewed weekly by the Quality Assurance and Performance Improvement (QAPI) committee for trends and recommendations. • Telephone interview on 02/25/25 at 12:00 P.M. with LPN #10, LPN #110, and Registered Nurse (RN) #100 confirmed the facility provided mandatory education on ensuring therapy recommendations were properly communicated and documented. In addition, education was provided on proper transfers and utilizing the required staff assistance level identified for each resident. • Review of the facility audits from 01/24/25 through 02/17/25 revealed there were no further concerns identified. • Review of two (#12 and #74) additional open resident records revealed no related concerns. This deficiency represents non-compliance investigated under Complaint Number OH00162046.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, review of the facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin, failed to timely identify a resident's pressure ulcer until it reached an advanced stage, and failed to ensure pressure ulcer prevention interventions were in place. This resulted in Actual Harm to Resident #67 who was at risk for pressure ulcers and the facility found Resident #67's pressure ulcer as an unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) to her coccyx and did not accurately assess the wound upon identification of the wound. This affected two (Residents #59 and #67) of three residents reviewed for pressure ulcers. The facility identified seven residents with pressure ulcers. The facility census was 81. Findings include: 1) Review of the medical record for Resident #67 revealed an admission date of 07/16/22. Diagnoses included pancreatitis, congestive heart failure (CHF), heart disease, atrial fibrillation, and major depressive disorder. Review of the care plan dated 12/20/22 revealed Resident #67 was at risk for impaired skin integrity related to edema, confined to a chair all or most of the time, impaired cognition, incontinent of bladder, incontinent of bowel, and slides down in bed. Interventions included the following: dietary supplement(s) as ordered, encourage good nutrition and hydration, assist as needed, encourage the resident to reposition self if able, notify physician of any new areas of impaired skin integrity, and a pressure reduction mattress to bed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #67 was at risk for the development of pressure ulcers. Review of the medical record revealed there were no skin issues identified until 02/03/23. The nursing progress note dated 02/03/23 revealed Resident #67 had a new wound to her coccyx which the nurse classified as a stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough). The wound evaluation for Resident #67 dated 02/03/23 revealed the pressure ulcer to the resident's coccyx was 100% covered in slough and measured 1.0 cm in length by 0.6 cm in width by 0.2 cm in depth. The progress note did not classify the pressure ulcer correctly due to the wound evaluation stated there was 100% slough present in the wound. Review of the physician's orders dated 02/03/23 revealed to cleanse the wound with normal saline, pat dry, apply thin layer of Medihoney. Apply calcium alginate (cut to fit wound bed). Cover with foam dressing on day shift every other day. Review of the wound NP note for Resident #67 dated 02/07/23 revealed the pressure ulcer to the resident's coccyx was classified as an unstageable pressure ulcer and measured 1.0 cm in length by 1.6 cm in width by 0.4 cm in depth with a moderate amount of drainage and 100% slough to the wound bed. NP orders included to offload resident's heels per the facility protocol. The wound NP changed the treatment to cleanse the coccyx wound with a wound cleanser, pat dry, apply triad to wound bed and cover with foam dressing. Change daily on day shift and as needed. Review of the wound NP note for Resident #67 dated 02/28/23 revealed the unstageable pressure ulcer to resident's coccyx measured 1.6 cm in length by 1.1 cm in width by 0.5 cm in depth with a moderate amount of serosanguineous drainage noted which has no odor. The wound bed had 51-75% slough. Wound NP gave order again to offload heels per facility protocol. Observation on 03/06/23 at 9:41 A.M. revealed Resident #67 was resting on a pressure reduction mattress. Resident #67's heels were resting directly on the mattress and were not floated. Interview on 03/06/23 at 9:41 A.M. with Registered Nurse (RN) #545 confirmed Resident #67 had a pressure ulcer to her coccyx and she did not have any orders to float her heels or use any type of devices such as heel boots to relieve pressure to her heels. Interview on 03/06/23 at 2:38 P.M. with LPN #680 confirmed the nurse who identified the wound for Resident #67 had not correctly classified the wound when she called it a stage II pressure ulcer. LPN #680 confirmed the wound NP classified the wound as unstageable because of the presence of slough in the wound bed which was noted in the nurse's assessment on 02/03/23. LPN #680 further confirmed the wound for Resident #67 was not identified until it had reached an advanced stage. LPN #680 confirmed the resident was at risk for breakdown to her heels and her heels should be offloaded as recommended by the wound NP. LPN #680 confirmed Resident #67 had no orders to offload heels or use devices such as heel boots. Interview on 03/06/23 at 3:00 P.M. with the Director of Nursing (DON) confirmed Resident #67 did not have orders to offload heels, but she was at risk for further skin breakdown and should have interventions in place. The DON confirmed staff should inspect skin regularly during care and wounds should be identified before they reach an advanced stage. 2) Review of the medical record for Resident #59 revealed an admission date of 06/07/22. Diagnoses included protein calorie malnutrition, diabetes mellitus (DM), fracture of right femur, atherosclerotic heart disease, and acute kidney failure. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #59 was at high risk for the development of pressure ulcers. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) Resident #59 was coded as at risk for pressure ulcers and was coded for the presence of an unstageable pressure ulcer which was not present on admission. Review of the nurse progress note dated 12/31/22 revealed Resident #59 had a new pressure ulcer to the left heel. The nurse notified the nurse practitioner (NP) and initiated a treatment per standing orders. Review of the wound evaluation for Resident #59 dated 12/31/22 revealed the pressure ulcer to the resident's left heel measured five centimeters (cm) in length by 4.5 cm in width. The wound had no depth and no drainage. The nurse placed the wound evaluation in the facility wound care nurse's folder. The nurse classified the wound as a stage I pressure ulcer (skin is intact with red or discolored area). Review of the wound evaluation for Resident #59 dated 01/04/23 revealed the facility's wound care nurse, Licensed Practical Nurse (LPN) #680, assessed Resident #59's left heel wound. The resident's left heel measured 7.5 cm in length by 4.5 cm in width. LPN #680 classified the wound as a diabetic ulcer. Review of the wound NP note dated 01/05/23 revealed Resident #59 had a deep tissue injury (DTI) ulcer (Purple or [NAME] area of discolored intact skin due to damage of underlying soft tissue) to her left heel which measured 5.0 cm in length by 3.4 cm in width with no measurable depth. The wound was non-blanchable with deep red, maroon, and purple discoloration. Wound NP gave new orders for wound care which included to cleanse the wound with wound cleanser, pat dry, apply Betadine, and cover with border foam dressing once daily, offload heels per facility protocol. Review of the care plan, last updated 02/14/23, revealed Resident #59 had impaired skin integrity as evidenced by: pressure ulcer to the left heel related to confinement to a chair all or most of the time, impaired cognition, incontinent of bladder, incontinent of bowel, needs assistance with ADLs. Interventions included the following: assist the resident with turning and repositioning every two hours and as needed, skin inspection every seven days, notify nurse of any new areas of skin breakdown noted during bathing or daily care, notify physician or NP of noted worsening skin condition or any new areas of skin breakdown, float heels when in bed, and to have cushioned heel boots to bilateral feet. Review of the wound NP note for Resident #59 dated 02/28/23 revealed the wound to the left heel was now classified a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed.) which measured 2.2 cm in length by 0.9 cm in width by 0.3 cm in depth. There was a moderate amount of serosanguinous drainage noted which had no odor. The wound bed had 26-50 percent (%) slough. Wound NP gave order again to offload heels per facility protocol. Review of the monthly physician orders for March 2023 revealed Resident #59 had an order to float heels when in bed dated 06/17/22 and an order dated 06/24/22 for Resident #59 to have cushioned heel boots to bilateral feet. Review of the March 2023 Treatment Administration Record (TAR) for Resident #59 revealed the orders to float heels and wear cushioned heel boots were not included in TAR. Observation and interview on 03/06/23 at 9:45 A.M. with LPN #680 revealed Resident #59 was resting on a pressure reduction mattress. There was a dressing in place to the resident's left heel dated 03/05/23. Resident's heels were resting directly on the mattress and were not floated. LPN #680 confirmed Resident #59 had a stage III pressure ulcer to her left heel and the resident's left heel was resting directly on the mattress. LPN #680 confirmed Resident #59 was supposed to wear soft heel boots when she was in bed, and she wasn't sure why they were not in place. Observation of wound care with LPN #680 on 03/06/23 at 11:08 A.M. revealed Resident #59's heels were not floated. Resident #59 had a dime sized open wound to the left heel which had visible slough in the wound bed. Interview on 03/06/23 at 11:20 A.M. with LPN #680 confirmed Resident #59's heels were not floated. LPN #680 again confirmed Resident #59 was supposed to be wearing heel boots, but she couldn't find them. Interview on 03/06/23 at 2:38 P.M. with LPN #680 confirmed she first saw Resident #59's wound on 01/04/23 and it looked like a large purple fluid filled blister and she classified it as a diabetic ulcer. LPN #680 confirmed she was with the wound NP on 01/05/23 when the wound was reclassified as a deep tissue injury (DTI.) Interview on 03/06/23 at 3:00 P.M. with the Director of Nursing (DON) confirmed Resident #59 should be wearing heel boots or have her heels floated on pillows while in bed. Review of the undated facility's policy titled Pressure Reducing and Relieving Devices revealed the facility would implement appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. Review of the facility's undated policy titled Skin and Wound Program Best Practice revealed the facility would ensure staff conduct a head to toe inspection of resident's skin every seven to 10 days. Review of the NPUAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Review of the NPUAP guidelines dated 2014 page 115 revealed ideally, heels should be free of all pressure, a state sometimes called floating heels. Pressure can be relieved by elevating the lower leg and calf from the mattress by placing a pillow under the lower legs, or by using a heel suspension device that floats the heel. Consequently, the pressure will instead spread to the lower legs, and the heels will no longer be subjected to pressure. This deficiency represents non-compliance investigated under Complaint Number OH00140190.

Based on observation, medical record review, staff interview, review of the facility's policy and review of the information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure timely treatments, interventions, and assessments were done for a resident's pressure ulcers. This resulted in actual harm when Resident #226's pressure ulcers to his bilateral heels and sacrum deteriorated in condition and increased in size from the delay in treatment. This affected one (Resident #226) of two residents reviewed for pressure ulcers. The facility identified three residents with pressure ulcers. The facility census was 70. Findings include: Review of the medical record for Resident #226 revealed a re-admission date of 03/05/20. Diagnoses included dementia, anxiety, bipolar, hypertension and diabetes mellitus. Review of the nursing re-admission assessment, dated 03/05/20, revealed Resident #226 had two stage one pressure ulcers (intact skin with non-blanchable redness of a localized area) to the left and right buttocks and three unstageable pressure areas (full thickness tissue loss in which the base of the ulcer is covered by slough or eschar in the wound bed) to the left great toe and to the left and right heels. Review of the wound assessment, dated 03/05/20, revealed Resident #226 had an unstageable area to the left great toe upon re-admission described as reddened with no drainage and measured 1.2 centimeters (cm.) in length by 0.6 cm. in width. The resident had an unstageable area to her right heel described as dry with no drainage and measured 3.0 cm. in length by 1.4 cm. in width and had an unstageable area to her left heel described as dry with no drainage and measured 3.0 cm. in length by 2.0 cm. in width. The resident had a stage two pressure ulcer to his left buttock described as pink and dry with no drainage and measured 1.0 cm. in length by 0.6 cm. in width and 0.2 cm. in depth. There was a reddened area surrounding to her buttocks measuring 9.0 cm. by 2.0 cm. Review of the physician orders, dated March 2020, revealed on 03/05/20, there were orders to turn every two hours, house barrier ointment after each incontinent episode, and calmoseptine skin barrier to buttocks every shift for the pressure ulcer. On 03/06/20, there were orders to float the heels when in bed and a low air loss mattress for wound management when authorization approved. On 03/10/20, there were new orders for a low air loss mattress to the bed and to monitor both heels and apply skin prep every shift and leave open to air. There were no treatments for the heels upon readmission until five days later, on 03/10/20 and there were no treatments for the area to the left great toe. Review of the admission Minimum Data Set (MDS) assessment, dated 03/09/20, revealed Resident #226 had moderate cognitive deficits, had presence of stage two pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, and may present as an intact or open/ruptured blister) and two deep tissue injuries (classified as purple or maroon area of discolored intact skin due to damage of underlying soft tissue) that were all present upon readmission. The MDS assessment showed the resident had deteriorated to two stage two pressure ulcers versus the readmission nursing assessment and the initial wound assessment on 03/05/20, which stated two stage one pressure ulcers. Review of the treatment administration record (TAR), dated March 2020, revealed the nurses were not documenting any treatments or monitoring of any wound areas until 03/10/20. On 03/10/20, the nurse began to monitor both heels and apply skin prep every shift and began treatment of nystatin cream to buttocks every shift for wound healing. On 03/11/20, the nurse began to monitor the area to the left big toe and applied skin prep every shift for wound healing. Review of the certified nurse practitioner note, dated 03/10/20, revealed Resident #226 was admitted back to the facility with ulcerations to the bilateral heels and excoriation to the sacrum. He had unstageable areas to the left and right heels and a rash to the sacrum. There was no mention of an area to the left great toe. Review of the wound assessment, dated 03/10/20, revealed Resident #226 had unstageable area to the right heel described as necrotic tissue and black in color with measurements of 2.5 cm. in length by 4.5 cm. in width. The width had increased in size since the last measurement on 03/05/20 and now it was necrotic. The unstageable area to the left heel was described as necrotic and black in color and measured 3.0 cm. in length by 5.0 cm. width. The width was larger from 3.0 cm. on 03/05/20 and now was necrotic. The stage two pressure ulcer to the sacrum now had 25 percent slough to the wound bed. There were no measurements for the area to the left great toe. Observations on 03/10/20 at 9:47 A.M., at 3:32 P.M., and 5:51 P.M. of Resident #226 revealed he was resting in bed with his eyes closed. He had his feet laying directly on the bed and not elevated and there were no pillows to the foot of the bed or on the floor beside the bed. Interview and observation on 03/10/20 at 5:51 P.M. with Registered Nurse (RN) #130 verified Resident #226 did not have his feet elevated off his bed. He stated he may have kicked his pillows off. Observation of his heels with RN #130 revealed they were dark purple in color and his left great toe was reddish purple in color. He was laying on his bottom and there was no observation of his sacrum wound was done at this time. RN #130 stated he had just been in earlier to assess him and he needed to get him a different treatment and better positioning. Interview on 03/12/20 at 2:08 P.M. with the Director of Nursing (DON) stated Resident #226 had been sent out to the hospital that morning due to complications from his trach. He verified the treatments for his bilateral heels were not started until 03/10/20 because they were just to keep them elevated prior to the initiation of treatment because they were 'reabsorbing'. He verified there was no further documentation, treatment or assessment for the pressure ulcer to the left great toe stating he was under the understanding it was 'reabsorbing'. He verified the wound measurements for the pressure ulcers to his bilateral heels and sacrum had grown bigger and deteriorated in condition. He stated the nurse may have documented wrong upon admission because he was not a certified wound nurse. He verified the wound assessments for the bilateral heels were done on 03/10/20 and revealed they were necrotic, and the sacrum wound had the presence of slough. He stated he was seen by nurse practitioner on 03/10/20. Review of the facility's undated policy titled Best Practice Guidelines Skin Management Process Policy revealed residents identified having active skin issues will have a routine assessment and interdisciplinary team review and care plan implemented to maintain and or improve skin integrity. Review of the information from the NPUAP revealed a deep tissue pressure injury is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. 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, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage Three or Stage Four). Do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic, or dermatologic conditions. Further review of the NPUAP revealed staff should assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows and beneath medical devices, implement interventions to ensure that the heels are free from the bed and use heel offloading devices or polyurethane foam dressings on individuals at high-risk for heel ulcers.