**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility did not ensure Residents (R) that were assessed to be at risk for the development of pressure injuries or residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 4 (R373, R64, R223, R67) of 6 Residents reviewed for pressure injuries. * R373 was assessed to be at high risk for the development of pressure injures. R373's care plan did not include person centered interventions to prevent the development of pressure injures based on R373's risk assessment. R373 developed a facility acquired stage lll pressure ulcer to the left buttock on 10/04/2022 and there were no wound care treatment orders implemented until 10/11/2022. * R64 was admitted to the facility on [DATE] with a community acquired deep tissue injury to the right heel, which was not comprehensively assessed, nor was there a treatment ordered until 9/13/2022. * R223 was admitted on [DATE] and noted to have an open area on buttock crease with zinc applied. On 10/1/22, there was no comprehensive assessment of the open area on the buttock crease other than measurements. There was no staging of the pressure injury, no description of the wound bed, whether there was drainage, and no description of the periwound. Three days later on 10/4/22 a wound assessment documents gluteal crease pressure injury is Unstageable - Slough and/or Eschar. Measurements in centimeters are for length 1.93, width 0.81, and depth 0.2. 75% slough with a new treatment order to cleanse with 1/4 dakins followed by skin prep followed by santyl, followed by bordered gauze daily. On 10/6/22 the wound assessment is documented as - coccyx: Unstageable pressure wound measures 1.0 x 0.5 x 0.2 cm. R223 was on a mattress appropriate for a for a stage I (1) or II (2) pressure wound until 10/06/22 even though R223 was noted to have an unstageable PI on 10/4/22. On 10/6/22, the facility implemented the use of an air mattress. On 10/6/22, the air mattress was not on while R223 was in bed at 2:07 pm, 3:06 pm, and at 3:17 pm. The air mattress was turned on at 3:50 pm. The facility had no information on R223's wheelchair cushion as to whether the cushion was appropriate for an unstageable PI. R223's care plan did not address the offloading of R223's heels. R223 was observed on 10/5, 10/6, and 10/10/22 to have their heels directly on the mattress and not floated. R223 was observed to have his feet/balls of his feet pressing against the foot board. * R67 was admitted on [DATE] with diagnoses that included a left tibia fracture with an immobilizer in place. On 9/29/22, R67 developed an area to the left thigh and an area to the left lower extremity related to the immobilizer. A nursing order was written on 9/29/22 to inspect skin under brace to left leg every shift. This had not been an order upon admission on [DATE] even though R67 had been wearing the immobilizer brace since admission. R67's wound to the left lateral thigh, caused by the brace, was not comprehensively assessed. There was no evidence that the physician was notified and that an order for treatment was obtained. Further review of the plan of care showed that it was not updated to list interventions to prevent further skin breakdown. As of the time of exit on 10/11/22, the facility had not comprehensively assessed the open area to R67's left lower leg that was first observed on 9/29/22. The facility did not obtain a treatment order for the area, nor did they update the plan of care with interventions to prevent further skin breakdown. Example 1 involving R373 rises to a scope and severity level of G (harm/isolated). Findings include: The facility policy titled, Wound Care Policies and Procedure, with the subject, Pressure Ulcers and an email revision date of 03/23/2017 states: . 1. Evaluate the pressure ulcer initially for location; stage (see specific policy), size (in cm's (centimeter)), sinus tracts, undermining, exudate (type, odors), necrotic tissue, and the presence and or absence of granulation tissue and epithelialization. .Suspected Deep Tissue Injury: Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue .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 ulcer. .Stage lll: Full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present . 1.) R373 was admitted to the facility on [DATE] with diagnoses that include, nondisplaced fracture of fifth cervical vertebra, subsequent encounter for fracture with routine healing, abnormal posture, muscle weakness, and depression. R373's admission MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 9/27/2022, documents R373 has a BIMS (Brief Interview for Mental Status) score of 14, indicating R373 is cognitively intact for daily decision making; a PHQ-9 (Patient Health Questionnaire) score of 16, indicating moderately severe depressive symptoms; requires extensive assist of 2 plus staff for bed mobility, is totally dependent on 2 plus staff for dressing, toilet use, and personal hygiene, and totally dependent on one staff person for eating, frequently incontinent of bowel and bladder; and is at risk for pressure ulcers, but did not have any pressure injuries documented upon admission. R373's CAAs (Care Area Assessment) related to skin breakdown documents, at risk for pressure injuries as evidenced by needing extensive assistance for bed mobility and incontinent of bowel and bladder. Staff will apply barrier cream to buttocks and peri area with cares to prevent skin breakdown. Goal is to be free from skin breakdown. Care plan will address to avoid complications and minimize risk and improve skin integrity. Staff will continue to assess skin condition with ADL (Activities of Daily Living) cares daily and report any abnormalities. Staff will continue to encourage and assist turning and repositioning regularly. R373's Braden scale assessment dated [DATE], documents a score of 12, indicating R373 is at high risk for the development of pressure ulcers. R373's care plan documents, Alteration in skin integrity related to bruises and scab on left elbow, initiated on 9/20/2022; interventions include: Assess/Monitor/Document and communicate with nurse signs and symptoms of itching, skin bleeding, blisters, broken/cracked skin . Assist with change of position every 2-3 hours . Check and change upon rising, before and after meals, at hour of sleep and with night shift rounds . Provide peri cares followed by moisture barriers as needed The above interventions were initiated on 09/20/2022. The care plan did not include person centered preventative interventions based on an assessment such as a pressure reducing mattress or speciality wheelchair cushion. Surveyor did not locate any other pressure ulcer care plan interventions until 10/4/2022 when R373 was seen by the wound care Nurse Practitioner (NP) and a wound to the left buttock was identified and assessed. The left buttock wound was assessed as a Stage III, measuring 1.43 cm (centimeters) by 1.76 cm with 100% granulation tissue. A treatment of zinc was ordered by the wound NP. On 10/4/22, R373's care plan was updated to include the following: Alteration in skin integrity related to abrasion to left buttock due to shearing. The interventions include all of the same interventions as the 9/20/22 alteration in skin integrity care plan with a newly added intervention of: treatment as per MD (Medical Doctor) order. Surveyor notes there were no new preventative interventions put in to place to address the assessed cause of the pressure injury as related to shearing. On 10/5/22, at 9:33 AM, Surveyor observed R373 lying in bed on back with pillows underneath bilateral arms. Heel riser boots were observed in place to bilateral lower extremities. R373 was lying on an air mattress. R373 told Surveyor, I have a decubitis ulcer on my rear end. It is small, maybe the size of a dime or quarter. R373 told Surveyor the ulcer was acquired at the facility. R373 stated she thought the staff cleaned the area good and put some type of cream on the area. Surveyor reviewed R373's medical record. On 10/4/22, at 13:24 (1:24 pm), LPN (Licensed Practical Nurse) M documented in R373's medical record, Resident seen by wound care team and wound care NP (Nurse Practitioner) for assessment of left buttock. Wound bed granulated with edges attached. Scant amount of serous drainage with no odor. Peri wound erythematous. New order to apply zinc TID (three times a day). On 10/4/2022, at 13:23PM (1:23 pm), LPN M documents R373's wound measurements: Length - head to toe direction (centimeters) 1.43 Width - side to side direction (centimeters) 1.76 Stage: Stage III Tissue Type: Granulation Tissue Percent of wound covered by granulation tissue: 100% Wound edges/margins: Edge attached to base Skin surrounding wound: Assess within 4 cm of wound edge Erythema (redness)/blanchable Comments: New patient - left buttock Stage 3 New Rx (Prescription) : zinc paste TID Surveyor reviewed R373's current physician's orders and could not find an order for zinc paste ordered by the wound NP on 10/4/22. On 10/6/22, at 9:21 AM, R373 gave permission for Surveyor to observe morning cares with two CNAs (certified nursing assistants), CNA N and CNA G. On 10/6/22, at 9:26 AM, R373 was turned onto left side and CNA N wiped R373's buttocks with wipes. Surveyor noted a small, quarter sized open area to left buttock. The wound appeared superficial with no signs or symptoms of infection. At this time, Surveyor could see a thick white cream surrounding the wound, but no cream on the wound. The two CNAs continued cleaning R373's peri-area and at 9:28 AM, CNA N applied zinc paste to coat the wound. On 10/10/2022, at 13:35 (1:35 pm) Surveyor asked RN (Registered Nurse) H what the current treatment for R373's pressure wound consists of. RN H stated she was not certain what the current treatment was. During R373's medical record review, Surveyor noted CNA W documented on 9/21/22, 9/26/22, and 9/28/22 that R373 has redness to buttock. Surveyor could not locate any other documentation relating to R373 having redness to the buttocks, prior to the 10/4/22 wound documentation. On 10/11/22, at 2:04 PM, Surveyor interviewed LPN M who stated R373's wound was being treated with Zinc cream and there should have been an order under the treatments section of the EMR (Electronic Medical Record). Surveyor informed LPN M that Surveyor was unable to locate an order for the zinc paste in R373's medical record. LPN M also told Surveyor that R373 had been seen by the wound team, and a new treatment was in place. At this time LPN M did not have access to the Internet and was going to review R373's medical records and report back to Surveyor. On 10/11/22, at 2:36 PM, LPN M informed Surveyor there was no order for zinc paste for R373. Surveyor asked when LPN M was made aware of the wound and LPN M replied either on 10/4/22 or the day before. Surveyor expressed concerns there were no wound care orders on the EMAR (Electronic Medication Administration record) or ETAR (Electronic Treatment Administration Record) from 10/4/22, date the left buttock wound was identified, until 10/11/22 when Surveyor brought the concern to the facility's attention. LPN M informed Surveyor the wound is getting better and there is a treatment order in now. On 10/11/22, at 2:40 PM, Surveyor interviewed CNA W who stated R373 had redness to the buttocks since admission. Per CNA W, the redness was localized to the buttocks area and where the wound is currently located. CNA W thought the nurses were aware of the redness and a zinc paste was being used. On 10/11/22, at 2:42 PM, Surveyor asked RN H if R373 had skin issues on buttocks prior to the wound. RN H told Surveyor yes it has always been red since admission, but RN H was unsure of the measurements. RN H stated she thought staff was putting zinc paste on it. Surveyor reviewed R373's medical record and noted a new physician's order dated 10/11/22 which documented, R (right) buttocks wound treatment: cleanse with 1/2 strength Dakins f/b (followed by) skin prep to periwound and bordered gauze daily. Surveyor notes the new physician's order for treatment to the buttocks was ordered for the right buttock when the pressure injury was located on the left buttock. Surveyor also notes a new wound assessment, dated 10/11/22, documenting wound healing status as improving with measurements of 0.87 cm x 1.01 cm. The wound is documented as a stage lll with light drainage and 100% granulation tissue. On 10/11/22, Surveyor informed Nursing Home Administrator A, Director of Nursing B and Assistant Director of Nursing C of the concern there is no documentation of interventions put into place to prevent pressure injuries when R373 was assessed to be at high risk for the development of pressure injuries such as a pressure relieving mattress or wheelchair cushion. R373 developed a Stage III pressure injury to the left buttocks on 10/4/22 and R373's care plan was not updated to include new preventative interventions other than the order for zinc paste. The zinc paste was not added to R373's treatment administration record and was not documented as being completed 3 times per day as ordered on 10/4/22. The first treatment order that was documented as being completed was on 10/11/22 after Surveyor brought the concern to the facility's attention. 2.) R64 was admitted to the facility on [DATE] with diagnoses that include, end stage renal disease, on dialysis; unsteadiness on feet, long term use of anticoagulants, and type two diabetes mellitus with diabetic neuropathy. R64's admission MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 9/14/2022, documents R64 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R64 is cognitively intact for daily decision making; is at risk for pressure ulcers and has one stage three pressure ulcer that was present upon admission. R64's care plan titled, At risk for skin breakdown related to dialysis three days per week with prolonged sitting during this time, weakness, actual skin breakdown noted upon admission, shearing, incontinence of bladder, pain, obesity, HERD (end stage renal disease), lower extremity cellulitis and DM (diabetes mellitus), has a start date of 09/07/2022 and has interventions that include: Assess resident skin daily during bathing; Bilateral tubigrips; Diabetic foot checks daily; Use low air loss mattress for pressure reduction when resident is in bed. Surveyor notes all of the interventions for R64's skin breakdown care plan were initiated on 09/07/2022. Surveyor reviewed R64's medical record and notes documentation from [name of hospital] upon discharge, dated 9/07/2022 which documents, Community acquired: deep tissue pressure injury to right heel. On 9/8/22, at 1:15 AM, R 64's medical record documents: Skin check done. Resident right hand 2nd fingernail has come off. Dry skin noted to cuticle area. Blister that has popped is now dark skin which includes entire pad of finger. Dry flaky skin extends around entire area from pad of finger up around to nail bed. Right hand 3rd fingernail has come off and is slightly red around cuticle. Left anterior shin has 2.5 cm (centimeter) x (by) 1.5 cm superficial wound. Fresh bleeding noted. Resident also has a 2 cm x 3.5 cm bright to right antecubital space, a 6 x 6 cm bruise to right mid inner forearm from IVs (Intravenous therapy). Has a 9 cm x 4 cm faint black bruise to right back of hand. Has a 1 cm x 2.5 cm red area from cardiac monitors to left back rib area, Has bruises to abdomen from injections. Resident right foot 2nd toe missing r/t (related to) hx (history) of amputation. Has 1 cm blister behind right inner knee, Has a 5 cm x 7 cm faint bruise to right knee lateral. Has a 7.5 cm x 1.5 cm old blister area which is dark red in color under left anterior knee. Has a 4 cm x 3 cm scab to left 4th toe. 5th pinky toe amputated and well healed. Surveyor notes the 9/8/22 skin check does not document the presence of the right heel deep tissue pressure injury that was documented on R64's hospital discharge paperwork on 9/7/22. R64's admission physician orders, dated 9/07/2022 included: Diabetic foot checks every noc (night shift). Special Instructions: Check skin breakdown on feet every night. Surveyor was unable to locate documentation of a right heel, deep tissue injury documented during diabetic foot checks every night. On 9/13/2022, at 12:29 PM, LPN (Licensed Practical Nurse)-M documents in a progress note: Resident seen by wound care team and wound care NP (Nurse Practitioner) for assessment of left shin and right heel .Right heel wound bed with granulation and eschar. Edges attached. New order to cleanse with NS (Normal Saline). Apply iodosorb f/b (followed by) bordered gauze 3x (times)/week. On 9/13/2022, LPN-M documents in wound management progress notes: Date/Time Observed: 9/13/2022, at 13:57 PM (1:57 PM), New patient- right posterior heel Stage 3 . Length - head to toe direction (centimeters) 1.1 Width - side to side direction (centimeters) 1.32 . Tissue Type: Granulation Tissue Percent of wound covered by granulation tissue: 75% Percent of wound covered by eschar tissue: 25% . Present on admission/re-entry: Yes . R64 has an active physician's order with a start date of 9/13/2022 which documents, Right posterior heel treatment: Cleanse with NS f/b iodosorb f/b bordered gauze 3x/week and PRN(as needed) for soiling/saturation. Once A Day on Tue (Tuesday), Thu (Thursday), Sat (Saturday). Surveyor was unable to locate physician's orders or wound documentation related to the right heel deep tissue injury prior to 9/13/2022. On 10/11/22, at 1:40 PM, Surveyor interviewed LPN-M, who stated she works with the facility wound NP once a week and she documents the wound findings in the resident's charts. For an admission, LPN-M stated the admitting nurse should measure the wound, note what color the wound is, describe the wound bed and document the findings in a progress note and under the wound management tab in the resident's electronic chart. LPN-M stated, if a resident is admitted with a wound, the admitting nurse would use the wound care orders from the hospital until the resident is seen during wound rounds which happens on Tuesdays. LPN-M informed Surveyor the admitting nurse would do the wound assessment even if it is not always an RN (Registered Nurse). LPN-M stated, the ADON (Assistant Director of Nursing) and the DON (Director of Nursing) do not get involved with wound assessments, but sometimes the facility NP will assess a wound and prescribe a treatment, if needed. LPN-M informed Surveyor R64's right heel wound was not documented in the admission skin check, but R64 did admit with that wound. Surveyor expressed concerns regarding no wound assessment for R64's right heel deep tissue injury from admission on [DATE] until 9/13/2022. Surveyor asked LPN-M if any treatments were ordered for R64's right heel prior to 9/13/2022. LPN-M did not have access to the Internet at that time and told Surveyor she would check R64's medical records and get back to surveyor. On 10/11/22, at 2:04 PM, LPN-M informed Surveyor there were no treatment orders for R64's right heel deep tissue injury prior to 9/13/2022, but the wound is getting better. On 10/11/2022, at 7:16 am, Surveyor observed R64's right heel wound. RN-V removed R64's sock and Surveyor observed there was no dressing covering the right heel deep tissue injury. R64 stated the dressing must have come off but could not remember when. Wound care was preformed by RN-V per professional standards of practice. Surveyor noted the wound appeared superficial, did not have drainage and had no signs or symptoms of infections. R64 did not have signs of pain during the wound care, and R64 stated, I feel nothing on that foot. Surveyor reviewed R64's wound assessments which documented the right heel deep tissue injury had decreased in size from 1.1 cm x 1.32 cm on 9/13/2022 to 0.94 cm x 1.14 cm on 10/11/2022. However, Surveyor cannot ascertain if the wound worsened or progressed from admission on [DATE] until the first assessment of the area on 9/13/22 because there is no documentation of the right heel deep tissue injury until 9/13/2022. 3. R223 was admitted to the facility on [DATE] with diagnoses which includes dementia, anxiety, hypertension and benign neoplasm of meninges. The nurses note dated 10/1/22 documents Res (Resident) admitted to room [number] at 1400 (2:00 p.m.) via [name of] Ambulance. Res oriented to room, call light, TV remote, meal times, shower day, and staff. Res is A&O x (times) 2-3 (alert and orientated times two to three), occasional forgetfulness. Makes needs known. Understands and able to use call light. Denies dizziness. Speech clear, slow to respond. admitted to facility for strengthening following hospitalization r/t (related to) bilateral PE (pulmonary embolism), also has hx (history of) of BPH (benign prostatic hyperplasia), dementia, HTN (hypertension), heart failure, hyperlipidemia, meningoma with frontal craniotomy. LCTA (lungs clear to ausciltation)/diminished in the bases. Denies SOB (shortness of breath), but appears SOB when talking. POX (pulse oximetry) 97% 2L (liters). No coughing noted. HOB (head of bed) elevated. Covid test negative. Abdomen soft/nontender. BS (bowel sounds) active x 4. Appetite good. Able to feed self general diet. Oral mucosa pink and moist. Skin turgor WNL (within normal limits). Fluids encouraged. No s/sx (signs/symptoms) of dehydration. Continent of B&B (bowel and bladder). No c/o (complaint of) pain. 1 assist with walker for transfers. Skin assessment: bruises: 1.5 x 1.5 cm (centimeter) RAC (right antecubital), greenish, LAC (left antecubital) 0.5 x 0.5cm reddish, 5 x 5cm top of left hand greenish. 16 cm incision to forehead, sutures intact, no drainage noted. Open area to buttocks crease 2 cm x 0.5 cm, zinc applied. Res to participate in PT/OT (physical therapy/occupational) for strengthening. Wife here at this time. Pleasant with cares. The admission observation dated 10/1/22 under the skin section documents Skin temperature: Warm, Skin moisture: Dry, Skin color: Normal color, Petechiae present? No, Skin turgor: Normal, Alterations in skin? No, and Comments: see skin progress note and skin observation. The Focused Observation dated 10/1/22 under observation details for skin documents Skin temperature: Warm, Skin moisture: Dry, Skin color: Normal color, Petechiae present? No, Skin turgor: Normal, and Alterations in skin? Yes. Under Ulcer documents Location: coccyx, Length - head to toe direction (centimeters): 2, Width - hip to hip direction (centimeters): 0.5, Can depth be measured? No, and Proceed with wound care observation? No. Surveyor noted R223's coccyx pressure injury was not comprehensively assessed on 10/1/22 as the nurses note and focused observation only includes measurements and does not include the Stage of the pressure injury, description of the wound bed, whether there is drainage, and description of the periwound. The MD (medical doctor) order dated 10/1/22 documents Apply zinc barrier cream to buttocks TID (three times a day) and PRN (as needed). The Braden assessment dated [DATE] has a score of 18 which indicates at risk. The baseline care plan dated 10/3/22 under approach for skin integrity is checked for at risk & pressure ulcers. Complete skin checks is checked. The wound assessment dated [DATE] documents for R223's gluteal crease pressure injury for the Stage is Unstageable - Slough and/or Eschar. Measurements in centimeters are for length 1.93, width, 0.81 and depth 0.2. Exudate amount is light and exudate color and consistency is documented as serous (clear, amber, thin, and watery). The tissue type is documented as slough. The percent of wound covered by granulation tissue is documented as 25 and the percent of wound covered by slough tissue is 75. Under comments documents New patient - unstageable pressure ulcer to gluteal crease New Rx (prescription)- skin prep, Santyl then bordered gauze, change daily. Surveyor noted this comprehensive assessment is 3 days after R223 was admitted to the Facility. The nurses note dated 10/4/22 documents Resident seen by wound care team and wound care NP (nurse practitioner) for assessment of gluteal fold. Wound bed with granulation and slough, edges attached to base. Scant amount of serous drainage, no odor present. Periwound C/D/I (clean/dry/intact). New order to cleanse with 1/4 dakins f/b (followed by) SP (skin prep), f/b santyl, f/b bordered gauze daily. The physician order dated 10/4/22 documents Gluteal crease treatment: Cleanse with 1/4 strength dakins. Apply skin prep to periwound. Apply santyl to wound bed f/b (followed by) bordered gauze daily. Change PRN (as needed) for soiling/saturation. The pressure ulcer care plan with a start date of 10/5/22 has the following approaches all dated 10/5/22: * Assess pain (every) 4 hours and medicate prn (as needed) for dressing changes and wound rounds. * Avoid positioning directly on the trochanter. * Cleanse skin at the time of soiling. Avoid hot water, use mild cleansing agents. Use moisturizers on dry skin. Apply to skin while still damp from bathing. * CNA's (Certified Nursing Assistant) to inspect skin daily during bathing, especially over bony prominences LN (Licensed Nurse) to do skin check weekly. * Encourage foods high in protein and calories. * Minimize skin exposure to moisture from incontinence, perspiration, or wound drainage. Use barrier cream for skin protection. * Refer for nutritional assessment. * Reposition Q 2-3 hours. * Screen by OT/PT for rehab potential. * Use pressure relieving mattress support surface for bed. * Use turn sheets for positioning. * Wound care as ordered. See treatment record. * Wound team to evaluate wound(s), treatments and weekly healing. Surveyor noted there are no interventions regarding offloading R223's heels. On 10/5/22 at 12:02 p.m. Surveyor observed R223 sitting in a wheelchair in his room with a lunch tray on the over bed table in front of R223. Surveyor observed R223 has a cushion in his wheelchair. On 10/5/22 at 12:53 p.m. Surveyor observed R223 in bed on his back with the head of the bed elevated. R223's heels are on the mattress and R223's left foot is pressed against the foot board. On 10/5/22 at 1:31 p.m. Surveyor observed R223 continues to be in bed on his back. R223's heels continue not to be offloaded and R223's left foot continues to be pressing against the foot board. On 10/5/22 at 3:26 p.m. Surveyor observed R223 bed on his back with the head of the bed elevated watching TV. Surveyor observed R223 is wearing yellow gripper socks, R223's heels are resting directly on the mattress and the ball of R223's feet are pressing against the foot board. The nurses note dated 10/6/22 documents Wound assessment - coccyx: Unstageable pressure wound measures 1.0 x 0.5 x 0.2 cm, white center surrounded by granulation tissue, edges intact. No drainage or odor. Treatment applied per orders, skin prep to periwound f/b new bordered gauze dressing. Pillow to support R (right) hip placed for pressure relief to area, res lying toward L (left) side at 30 degrees. Heels firm with normal colored tissue. Pillow added to float heels. Spouse was present during treatment, stated notable improvement. On 10/6/22 at 7:31 a.m. Surveyor observed R223 in bed on his back with the head of the bed elevated. R223 is wearing glasses and oxygen via nasal cannula. Surveyor observed R223 heels are not being offloaded and the balls of R223's feet are pressing against the foot board. Surveyor asked R223 if staff have washed him up this morning. R223 replied not yet. Surveyor inquired about the treatment. R223 informed Surveyor it was already done. On 10/6/22 at 7:52 a.m. Surveyor observed R223 continues to be in bed on his back. R223's heels are not being offloaded. On 10/6/22 from 8:25 a.m. to 9:00 a.m. Surveyor observed morning cares for R223 with CNA (Certified Nursing Assistant)-G. During this observation at 8:20 a.m. Surveyor checked the cushion in R223's wheelchair which is black with gray. Surveyor did not note a brand name on the cushion. At 8:27 a.m. Surveyor observed R223 has direct supply panacea original mattress which is blue & gray on bed. On 10/6/22 at 9:47 a.m. Surveyor observed R223 in bed on his back with the head of the bed elevated. Surveyor observed R223's heels are not being offloaded. On 10/6/22 at 11:12 a.m. Surveyor observed R223 sitting in a wheelchair in the salon getting his hair cut. At 11:13 a.m. Surveyor observed CS (Central Supply)-S wheeling R223 out of the salon. Surveyor observed R223 has a cushion in the wheelchair. As CS-S was wheeling R223 by therapy, a therapist came out and asked R223 if he was up for therapy. Surveyor then observed R223 sitting in his wheelchair in the therapy department. On 10/6/22 at 11:20 a.m. Surveyor asked RN (Registered Nurse)-H asked if there is an admission nurse who would admit Residents. RN-H informed Surveyor there is someone that does the medications but she or who ever is working when a Resident arrives would do the admission. Surveyor inquired what happens when a Resident is admitted with a pressure injury. RN-H informed Surveyor that they usually look to see if there is a treatment and follow that same treatment. Surveyor asked RN-H if she stages the pressure injury. RN-H replied I don't. Surveyor asked RN-H if she measures the pressure injury. RN-H replied we measure it. Surveyor asked RN-H about the wound bed. RN-H informed Surveyor she describes it as best as she can on her wound note. Surveyor asked RN-H if she document the percentages of the wound bed. RN-H replied no. Surveyor asked RN-H after the initial note is completed who would assess the pressure injury next. RN-H informed Surveyor it would depend on what shift the treatment is on. RN-H explained there is a wound team on Tuesdays and that the wound NP (nurse practitioner) comes in with LPN (Licensed Practical Nurse)-M. Surveyor asked if the wound team consists of just the wound NP and LPN-M. RN-H replied usually just the two of them. Surveyor asked RN-H when R223 was admitted was there slough in the wound bed. RN-H informed Surveyor she doesn't recall and she's not good at describing the wound bed but told LPN-M right away. On 10/6/22 at 2:07 p.m. Surveyor observed R223 in bed on his back with the head of the bed elevated attempting to place batteries in his hearing aides. Surveyor observed R223's heels are on the mattress and both feet are against the foot board. Surveyor observed there is now an air mattress box at the foot board which is off. On 10/6/22 at 2:13 p.m. Surveyor asked RN-H if R223 received a new mattress today. RN-H replied I don't recall. On 10/6/22 at 3:06 p.m. Surveyor observed R223 in bed on his back with the head of the bed elevated high. R223's heels are not being offloaded and the balls of his feet are pressing [TRUNCATED]