**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R32 was admitted to the facility on [DATE] with diagnoses which includes fracture of T11-T12 vertebra, chronic kidney disease (characterized by progressive damage and loss of kidney function), congestive heart failure (heart doesn't pump enough blood to meet the body's needs), morbid obesity, anxiety disorder and depression. R32's hospital Discharge summary dated [DATE] includes under discharge diagnoses pressure injury. Under hospital course pressure injury wound care consulted. R32's nurses note dated 4/18/25 at 15:18 (3:18 p.m.) and written by Licensed Practical Nurse (LPN)-W documents New admit head to toe: Resident was brought into facility from [hospital's initials] for rehabilitation around 1230. Resident was in care of [Name] ambulance and transferred from cot to bed and positioned to comfort. Vitals were obtained BP (blood pressure) 129/62, HR (heart rate) 59, spo2 (peripheral oxygen saturation) 94, temp (temperature) 97.4, RR (respiratory rate) 18. Resident had complaints of pain in her upper and lower back from compressions and fractures, no other pain noted at this time. scalp was dry with no signs of bruises or abrasions, ears appeared clear and able to hear and understand directions. Eyes were tracking however, resident stated that she is legal blind which per her definition she cannot see straight ahead but that she can see outlines and fuzzy shapes. face is free from cuts or bruises, neck is able to freely move in all direction with no pain. Resident has bruise on left arm purple and yellow of color ROM (range of motion) present in both arms. chest raises and fall evenly with inhalation and exhalation, lungs sound are clear bilateral, no apparent bruises or abrasions noted. abdomen is soft, bowel sounds normoactive in all 4 quadrants. left left side has multiple bruise location, (1)left side of buttocks, (2) left lateral thigh (3) left side calf. all are a bluish/yellow color. ROM is present bilateral legs but stiff no pain. Back had a lidocaine patch on upper midline, no abrasions or bruising noted under or around the patch. back is clear of all bruising and abrasions. abrasion on left buttock roughly 10 cm long by 1cm wide with no active bleeding at this time. abrasion on right buttock roughly 5cm long by 1cm wide with no active bleeding at this time. resident remained in bed and left in a comfortable position with call light and bed controls within reach. R32's admission/readmission assessment dated [DATE] completed by LPN-W for the skin section under details/comments documents (1) left buttock abrasion 10cm (centimeter) by 1cm. (2) right buttock abrasion 5cm by 1cm. (3) left upper arm bruising. (4) left hip bruising. (5) left thigh bruising. (6) left lower calf bruising. Surveyor noted there is no Registered Nurse (RN) assessment of R32's buttocks until 4/23/25, 5 days after admission. R32's Braden assessment dated [DATE] has a score of 14 which indicates moderate risk. R32's potential for impairment to skin integrity care plan initiated 4/18/25 & revised 5/15/25 documents the following interventions: Low air loss mattress to bed. Check function q (every) shift. Settings to resident weight or resident comfort. Initiated 4/24/25 & revised 5/15/25. Encourage good nutrition and hydration in order to promote healthier skin. Initiated 4/18/25. Encourage me to elevate my heels. Initiated 4/28/25. Encourage me to offload my heels. Initiated 4/28/25. Encourage/assist me with reposition as needed. Initiated 4/24/25. Keep my linen dry, clean, and free of wrinkles. Initiated 4/28/25. My skin will be assessed on a weekly basis on my scheduled bath day and document findings on a weekly skin assessment. Initiated 4/24/25. Report any skin redness/impaired integrity areas to my nurse. Initiated 4/24/25. Use draw sheet or lifting device to move resident. Initiated 4/28/25. Use barrier cream to prevent skin impairment issues, as needed. Initiated 4/28/25. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Initiated 4/28/25. R32's modification of admission MDS (minimum data set) with an assessment reference date of 4/20/25 has a BIMS (brief interview mental status) score of 6 which indicate severe impairment. R32 is assessed as not having any behavior including refusal of cares. R32 is assessed as requiring partial/moderate assistance for toileting hygiene, supervision/touching assistance for roll left & right, and dependent for chair/bed to chair transfer. R32 is assessed as always incontinent of urine and bowel. R32 is at risk for pressure injury development and has two unstageable slough and/or eschar pressure injuries which were present on admission. R32's pressure injury CAA (care area assessment) dated 4/28/25 under analysis of findings for nature of problem/condition documents Resident has 2 unstageable due to necrosis pressure injuries. Resident has a pressure relieving mattress and cushion to her manual wheelchair. Under care plan considerations documents Resident's pressure ulcers will improve with treatments. Advanced Practice Nurse Prescriber (APNP)-BB initial visit dated 4/22/25 does not address R32's pressure injuries. On 4/23/25 R32 was seen during wound rounds by Wound Nurse/Registered Nurse (WN/RN)-J and Wound Doctor (WD)-CC. This assessment is 5 days after R32 was admitted to the facility. WD-CC initial wound evaluation dated 4/23/25 documents for the left buttock etiology as pressure, Stage is Unstageable Necrosis, wound size for length is 8 cm (centimeters), width 9 cm, and depth is 0.1 cm. Thick adherent devitalized necrotic tissue is 40 % and intact normal color skin is 60%. The right buttock etiology is pressure and stage is unstageable necrosis. Wound size for length is 8 cm, width is 2 cm and depth is 0.1 cm. Thick adherent devitalized necrotic tissue is 30% and granulation tissue is 70%. Surveyor noted weekly assessments of R32's right and left buttock. R32's right buttock pressure injury resolved on 5/7/25 and the left buttock pressure injury resolved on 5/14/25. R32's weight on 5/18/25 was 220.5 pounds, on 5/19/25 221.5 pounds, and on 5/20/25 224.3 pounds. On 5/18/25, at 11:18 a.m., Surveyor observed R32's air mattress is set at 340 pounds. On 5/19/25, at 6:59 a.m., Surveyor observed R32 in bed on the right side. R32 has a comforter covering her head down to her feet. R32's air mattress is set at 340 pounds. On 5/19/25, 1:58 p.m., Surveyor observed Certified Nursing Assistant (CNA)-X provide incontinence cares to R32 who was incontinent of bowel. Surveyor observed the air mattress is set at 340 pounds. After CNA-X was finished with providing incontinence cares, a new incontinence product was placed on R32 and R32 was covered with bedding. The head of R32's bed was elevated, the call light was placed in reach and R32's bed was lowered. Surveyor observed R32's heels are resting directly on the mattress and are not being off loaded nor did CNA-X speak with R32 about offloading her heels. On 5/20/25, at 6:52 a.m., Surveyor observed R32 in bed on her back with the head of the bed elevated. R32 is wearing black gripper socks and R32's heels are resting directly on the mattress. R32's air mattress is set at 340 pounds. On 5/20/25, at 8:32 a.m., Surveyor observed R32 asleep in bed on the right side. R32 is now covered with an additional white blanket and R32's heels are not being offloaded. On 5/21/25, at 7:06 a.m., Surveyor observed R32 awake in bed on her back. Surveyor observed R32's heels are not being offloaded and the air mattress is set at 340 pounds. On 5/21/25 at 7:09 a.m. Surveyor asked R32 if staff has spoken to her about keeping her heels off the mattress. R32 replied no. On 5/21/25, at 12:29 p.m., Surveyor asked Wound Nurse/Registered Nurse (WN/RN)-J when a resident is admitted who assesses the residents skin. WN/RN-J informed Surveyor the admitting nurse. Surveyor asked WN/RN-J when would she or another RN assess the skin. WN/RN-J informed Surveyor she could be a second set of eyes if the nurse requests and then they do their weekly wound rounds with the doctor on Wednesday. Surveyor asked WN/RN-J if a resident comes in with a pressure injury on Saturday when would she assess the area. WN/RN-J informed Surveyor if the nurse wanted her to see it she would see it. Surveyor asked WN/RN-J when would she do an assessment. WN/RN-J replied Wednesday. Surveyor informed WN/RN-J of the concern that R32 pressure injuries were not assessed until 5 days later. WN/RN-J replied that's not how her role is. On 5/21/25, at 12:35 p.m., Surveyor asked Licensed Practical Nurse/Unit Manager (LPN/UM)-E how the air mattress should be set. LPN/UM-E informed Surveyor by the residents weight. Surveyor then asked LPN/UM-E to accompany Surveyor to R32's room where Surveyor showed LPN/UM-E R32's air mattress was set at 340 pounds and on May 20th R32 weight was 224.3 pounds. LPN/UM-E informed Surveyor it can be set for the resident's comfort. Surveyor informed LPN/UM-E of the observations of R32's heels not being offloaded or asking R32 to offload her heels. 3.) R64's diagnoses includes dementia, mild protein calorie malnutrition, spinal stenosis (space inside the bones of spine get too small putting pressure on the spinal cord), hypertension (high blood pressure) and anxiety disorder. R64 receives hospice services. R64's alteration in skin integrity care plan initiated 11/28/24 & revised 5/15/25 documents the following interventions: 1/18/25 assessed brief size and tightness noted to be tight - sized up one size. Encourage resident to communicate any discomfort related to brief tightness & sizing. Initiated 1/30/25. Apply an alternating pressure mattress to the bed, check function every shift for proper inflation. Initiated & revised 12/26/24. Offered offloading boots, but declines. Initiated 12/26/24. Will continue to encourage all cares, treatments and interventions. Initiated 5/9/25. Administer treatments as ordered and monitor for effectiveness. Initiated 11/28/24. Apply barrier cream after incontinence. Initiated 11/28/24. Braden assessment on admission and per policy. Initiated 11/28/24. Encourage adequate hydration. Initiated 11/28/24. Encourage to float heels when in bed. Initiated 11/28/24. Monitor/document/report to MD (medical doctor) PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size, stage initiated 11/28/24. Notify MD for new orders, administer treatments as ordered, inform family initiated 11/28/24. Skin inspection: requires a skin inspection weekly and with cares. Observe for redness, open areas, scratches, blisters, cuts, bruises. Report to nurse/MD initiated 11/28/24. Update MD s/sx of infection or deterioration of wound/skin initiated 11/28/24. R64's pressure injury CAA (care area assessment) dated 1/9/25 under analysis of findings for nature of problem documents Resident has skin prep applied to left ankle scab. The quarterly MDS (minimum data set) with an assessment reference date of 4/1/25 has BIMS (brief interview mental status) score of 5 which indicates severe cognitive impairment. R64 is dependent for toileting hygiene, roll left & right, and chair/chair to bed transfer. R64 is assessed as always incontinent of bowel and bladder. R64 is at risk for pressure injury development and does not have any pressure injuries. Hospice care is marked yes. R64's hospice aide visit note dated 4/30/25 documents There is an open area to her right buttocks. The only cream available was some anti fungal cream. Nurse [Name] was aware. She stated she will call the [hospice name] nurse. I informed her I will also send her a message. Surveyor noted there is no assessment of R64's right buttocks open area until 5/7/25. R64's weight on 5/2/25 was 93.7 pounds. R64's Braden assessment dated [DATE] has a score of 12 which indicates high risk. The physician orders dated 5/7/25 documents Wound Care: right buttocks - Cleanse with wound cleanser and pat dry. Apply xeroform f/b (followed by) bordered foam daily and as needed. In the evening for wound care and as needed for wound care. The nurses note dated 5/9/25, at 10:44 a.m., documents IDT (interdisciplinary team) met and discussed: 5-7-25 1000 (10:00 a.m.). Resident was assessed on wound rounds by wound MD due to a report of an open area to resident's bottom. A 1cm (centimeter) x (times) 1 cm red and open area was noted to resident's right buttocks. The area is blanchable with light serious drainage. There is no pain at the site, but resident has generalized pain being controlled by comfort meds due to being on hospice. Wound MD gave treatment orders. Husband was in the room and updated on POC (plan of care). Hospice aware. NP (nurse practitioner) updated via Hucu (health communication platform) also. Daughter also aware. Resident has an air mattress. Intake is poor to fair and been generally declining (hospice). All prior interventions are in place. Encouraging intake and to turn and reposition, due to chronic pain and frail state resident is resistive and does not like to be bothered but with accept cares. She does cry out often, pain managed. MASD (moisture-associated skin damage) to buttock due incontinence, enc (encourage) to be check and changed as tolerated. Treatment as ordered to optimize wound healing but due to state of resident it maybe unavoidable as resident declines. Will continue to encourage all cares, treatments and interventions. All parties aware. On 5/18/25, at 1:09 p.m. Surveyor observed R64 in bed on her back with her eyes closed and the head of the bed elevated. There is a pillow under R64's right and left upper side and under R64's left arm. R64's heels are not being offloaded. The nurses note dated 5/19/25, at 21:26 (9:26 p.m.) and written by LPN-DD documents Resident area on right buttock is purple in color and skin intact. TX (treatment) was changed, no issues noted, continue monitoring. Surveyor did not note any change in treatment in R64's physician orders or on the May 2025 treatment administration record. There is no RN assessment of this area. The Braden assessment dated [DATE] has a score of 12 which indicates high risk. On 5/20/25, at 6:58 a.m., Surveyor observed R64 asleep in bed on her back. Surveyor observed R64's heels are not being offloaded. On 5/20/25, at 9:15 a.m., Surveyor observed Certified Nursing Assistant (CNA)-Z and CNA-AA in R64's room with gloves on. CNA-Z asked R64 if she could change her top. CNA-Z removed the pillow under R64's left upper arm. CNA-Z informed she would be gentle & removed R64's top, placed deodorant on and placed an undershirt and sweater on R64. CNA-AA informed R64 they were going to lay her head back and lowered the head of the bed. CNA-Z informed R64 they were going to check her brief and they would be fast. R64's incontinence product was unfastened. CNA-Z stated it's dry in the front and washed R64's frontal perineal area. CNA-Z then stated to R64 they were going to turn her towards CNA-AA and R64 was placed on her side. Surveyor observed there is a dressing on R64's sacrum dated 5/19/24 but there is no dressing on R64's right buttocks according to physician orders. CNA-Z washed R64's buttocks, placed an incontinence product under R64 & applied barrier cream on R64's buttocks. CNA-Z removed her gloves, washed her hand and left R64's room. CNA-Z returned with a draw sheet and R64 was positioned side to side to remove the incontinence product, straighten & fasten the new incontinence product and straighten the draw sheet. CNA-Z and CNA-AA positioned R64 up in bed and CNA-Z placed a pillow under R64's lower leg. Surveyor observed although CNA-Z placed a pillow under R64's lower legs, R64's heels were resting directly on the pillow and were not being offloaded. R64 was covered with bedding and CNA-Z & CNA-AA removed their gloves and washed their hands. On 5/20/25, at 10:26 a.m. Surveyor observed R64 continues to be in bed on her back with the head of the bed elevated. R64's heels are not being offloaded. On 5/20/25, at 12:55 p.m., Surveyor observed Licensed Practical Nurse (LPN)-W and CNA-Z enter R64's room. Surveyor observed R64 is in bed with the head of the bed elevated & a pillow under R64's left shoulder. LPN-W informed R64 they were going to roll her on the side, it's going to hurt a little bit but that's why they have her the medication. LPN-W washed his hands and placed gloves on. CNA-Z wearing gloves removed the bedding and the pillow under R64's lower legs. Surveyor observed R64's heels had been resting directly on the pillow. CNA-Z unfastened R64's incontinence product and washed R64's frontal perineal area. CNA-Z & LPN-W positioned R64 on the right side. LPN-W removed the incontinence product and the dressing from R64's sacrum area. After removing the dressing, LPN-W removed his gloves, washed his hands, and placed gloves on. LPN-W cleaned the sacrum area with wound cleaner, removed his gloves, washed his hands and placed gloves on. Surveyor observed a deep tissue injury on R64's sacrum area the approximate size of a dime. At 1:06 p.m. Infection Control/Registered Nurse (IC/RN)-T entered R64's room, washed her hands, and placed gloves on. IC/RN-T stated she's looking to see if its chronic. IC/RN-T removed her gloves, washed her hands and left R64's room. At 1:09 p.m., Surveyor asked LPN-W if he had seen R64's open area prior. LPN-W replied it's been a minute since he was on the unit. At 1:10 p.m., LPN-W placed xeroform over the deep tissue injury and covered the deep tissue injury with a foam dressing. Surveyor noted there is no dressing on R64's right buttock. LPN-W washed R64's buttocks, LPN-W & CNA-Z positioned R64 on the left side and LPN-W stated he was going to get [first name of Wound Nurse/Registered Nurse (WN/RN)-J. LPN-W removed his gloves & cleansed his hands and CNA-Z removed her gloves & washed her hands. On 5/20/25, at 1:28 p.m., LPN-W informed Surveyor at the moment there are 2 wounds on R64's bottom. The coccyx one on the right buttocks and other on center coccyx. LPN-W informed Surveyor he can't explain the center one on coccyx. LPN-W informed Surveyor the only thing he can think of they saw that (referring to Deep Tissue Injury) and though that the was the area. LPN-W informed Surveyor he knows people mislabel right & left but that's speculation. Surveyor stated to LPN-W there are no order for the deep tissue injury. LPN-W replied correct for that one. On 5/20/25, at 1:32 p.m. LPN-W removed the dressing from his pocket, opened treatment supplies and then left R64's room for gauze. On 5/20/25, at 1:37 p.m. LPN-W returned to R64's room with gauze, opened the gauze, moved the garbage can closer, washed his hands & placed gloves on. At 1:38 p.m. CNA-Z entered R64's room placed gloves on and informed R64 they were going to turn her to change the bandage on her bottom. On 5/20/25, at 1:39 p.m. WN/RN-J entered R64's room stating she's here to do a televisit. Surveyor noted Wound Doctor-CC was on the televisit. R64 was positioned on the left side, LPN-W removed the dressing and Wound Doctor-CC indicating coccyx more sacrum 1.5 by 1 DTI (deep tissue injury) and right buttocks doesn't look open any more, continue with barrier cream. On 5/20/25, at 1:44 p.m., CNA-Z who was wearing gloves positioned R64 on the side. LPN-W wash his hands, placed gloves on and sprayed wound cleanser on gauze and cleansed the deep tissue injury. LPN-W removed his gloves, washed his hands, and placed gloves on. LPN-W applied zinc oxide on R64's deep tissue injury & buttocks and R64 was positioned on her back. LPN-W removed his gloves and washed his hands. CNA-Z fastened the incontinence product, covered R64 with a blanket, removed her gloves and placed a pillow under R64's left arm. CNA-Z washed her hands, placed the over bed table across R64 and offered R64 a sip of water then left R64's room. At 1:54 p.m. CNA-Z returned to R64's room with a pillow case, placed the pillow in the pillow case and informed R64 she was going to lift her legs a little bit. CNA-Z placed the pillow under R64's lower legs. Surveyor observed R64's right heel is resting directly on the mattress and the left heel is on the pillow. R64's heels are not being offloaded. R64's nurses note dated 5/20/25 at 13:58 (1:58 p.m.) and written by WN/RN-J documents Nurse, [Name], reported to Writer that resident had a new wound to her sacral area. Writer assisted with completing a telemedicine visit with wound MD and resident. Wound MD was able to assess a 1.5cm x 1cm DTI to the sacrum and gave orders for barrier cream q (every) shift and as needed. Writer explained to husband who was in the room at time of assessment. Resident will be seen in person by wound MD on wound rounds. Wound MD also noted during assessment that the area to resident's right buttock is resolved. On 5/20/25, at 2:01 p.m. Surveyor informed WN/RN-J Surveyor has a concern R64's had a dressing over the deep tissue injury dated 5/19/25 and there is no documentation in R64's medical record regarding this pressure injury on the sacrum. Surveyor informed WN/RN-J R64 was suppose to have a dressing on the right buttocks but there was none. Surveyor asked WN/RN-J if there is any information regarding this. WN/RN-J informed Surveyor LPN-W came and said hey she (referring to R64) has a new area that had a dressing. WN/RN-J informed Surveyor Wound Doctor-CC will be here tomorrow. Surveyor asked WN/RN-J how the deep tissue injury developed. WN/RN-J replied just her end of life not wanting to move as much. R64's nurses note dated 5/20/25, at 15:22 (3:22 p.m.) and written by LPN-W documents Entered residents room to perform wound care on residents right buttocks. resident was informed of what was happening, rolled to residents left side dressing removed, washed and dried per order and while performing wound cares writer noted a new wound located about the sacrum/coccyx area. Wound care nurse, [Name], was notified who messaged wound care provider. left voice mail for [hospice name] RN, contacted daughter who has no concerns. management inform and added to the 24 hour board new vitals: 102/78, 97.5, 74HR (heart rate), 18 RR (respiratory rate) , 94% RA (room air). Change of condition added and resident will continue to be monitored. R64's nurses note dated 5/20/25 at 17:45 (5:45 p.m.) and written by Director of Nursing (DON)-B documents Discussed risks vs benefits with resident and POA r/t (related to) to refusing to turn/reposition, refusing cares, refusing wound treatment, refusing showers, poor intake r/t skin prevention and wound healing. Surveyor did not note a refusal care plan. On 5/21/25, at 7:12 a.m. Surveyor observed R64 awake in bed on her back with the head of the bed elevated. There is a pillow under R64's left shoulder and Surveyor observed R64's heels are not being offloaded. On 5/21/24, at 9:40 a.m., Surveyor observed R64 in bed awake on her back with the head of the bed elevated. Surveyor observed there are two pillows under R64's knees but R64's heels are resting directly on the mattress and are not being offloaded. R50 informed Surveyor hospice just left R64. On 5/21/25, at 9:46 a.m., Surveyor informed CNA-Z Surveyor noted R64 refused to wear pressure relieving boots but wondered if R64 allows her heels to be offloaded. CNA-Z replied yes, like yesterday I put a pillow. On 5/21/25, at 10:15 a.m. Surveyor informed WN/RN-J Surveyor had noted a hospice aide note dated 4/30/25 which documented an open area on the right buttocks and the nurse was aware. WN/RN-J informed Surveyor she was not aware of the right buttocks until 5/7/25. Surveyor asked what should have happened. WN/RN-J informed Surveyor our nurse should of done a skin check list on it. Surveyor informed WN/RN-J Surveyor was not able to locate this on 4/30/25. Surveyor also informed WN/RN-J of R64's heels not being offloaded. 4.) R49 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus with diabetic chronic kidney disease and polyneuropathy, chronic diastolic heart failure, end stage renal disease, pressure ulcer of the sacral region, and dependence on renal dialyses. R49's admission minimum data set (MDS) dated [DATE] indicated R49 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13 and the facility assessed R49 needing minimal assistance with hygiene and repositioning. R49 did not have upper or lower extremity impairment and was occasionally incontinent of bowel and bladder. R49 was admitted to the facility with a stage 4 sacral wound, in the admission MDS the facility documented 1 unstageable pressure injury on the sacrum due to presence of slough or eschar. The facility assessed R49 on 1/10/2025 to be a low risk for pressure injury development with a Braden score of 18. On 1/10/2025, at 14:43 (2:43 PM) in the progress notes nursing documented (R49) admitted to the facility Admitting diagnoses of sacral wound and treatment in place. Surveyor reviewed R49's admission skin assessment documented on 1/10/2025 with the following: -Sacral wound is 4.5cm X 2.0cm X 1.0cm (length X width X depth) 1.0cm tunneling at 6 o'clock. Surveyor noted that there was not a comprehensive assessment completed to describe what R49's sacral wound looked like if there was drainage, or description of the wound bed or surrounding tissue. On 1/15/2025 the wound doctor completed an initial visit with R49 and documented the following: - Unstageable (due to necrosis) coccyx, full thickness . - 2.5cm X 2.5cm X 1cm, moderate serous (clear, thin, watery fluid) drainage, 30% slough, 70% granulation tissue. - debridement procedure to remove necrotic tissue and establish margins and viable tissue performed. R49's continues to get weekly wound assessments with the wound doctor with the most recent assessement documents: - Stage 4 pressure injury coccyx, full thickness . - 2.5cm X 2.5cm X 0.8cm, moderate serous drainage, 10% slough, 90% granulation tissue . On 5/20/2025, at 1:50 PM, Surveyor interviewed wound nurse (WN)-J who stated a head to toe assessment is required within at least 24 hours of admission. WN-J stated that nursing staff should do a full comprehensive assessment of any areas of concern which includes, wound measurements, staging, description of the wound bed and surrounding skin. Surveyor shared concern that a comprehensive assessment for R49's sacral pressure injury could not be located. WN-J looked through R49's medical record and agreed that a comprehensive assessment could not be located when R49 admitted into the facility on 1/10/2025. WN-J stated that nursing documented R49's sacral wound measurements but did not include a comprehensive assessment that detailed R49's sacral wound to include wound staging, or description of the wound bed/ surrounding skin. WN-J agreed that a comprehensive assessment for R49's sacral wound was not documented until R49 saw the wound doctor on 1/15/2025. On 5/20/2025, at 2:23 PM, Surveyor interviewed licensed practical nurse unit manager (LPNUM)-F who stated if an area of concern for a resident was noted on admission nursing would do a comprehensive assessment that included measurements, describe what the area looked like, surrounding area, describe the length, width, depth, stage if applicable, etc. Surveyor shared concern that 49 did not have a comprehensive assessment for R49's sacral pressure injury when admitted to the facility on [DATE] until the wound doctor's initial visit on 1/15/2025. LPNUM-F stated there should have been more description of what R49's sacral wound looked like on 1/10/2025 when R49 was admitted to the facility. On 5/20/2025, at 3:19 PM, Surveyor interviewed nursing home administrator (NHA)-A, director of nursing (DON)-B, and regional consultant (RC)- I. Surveyor asked what the expectations of staff are when a resident is admitted to the facility with an area of concerns such as a pressure injury. DON-B stated that nursing staff are expected to document a skin and body assessment that includes a head to toe assessment, if an area of concern is identified nursing staff is to measure and describe the area. Surveyor shared concern that R49 did not have a comprehensive assessment documented for R49's sacral pressure injury. Surveyor shared that staff did not describe what the pressure injury looked like, surrounding tissue, or if drainage was present until R49's initial visit with the wound doctor on 1/15/2025. DON-B stated a description should have been completed on admission. No additional information was provided. Based on observation, interview, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 4 (R9, R32, R64, R49) of 8 residents reviewed for pressure injuries. * R9's unstageable pressure injury to the left posterior thigh reopened on 2/24/25. The facility states it is due to noncompliance with repositioning and offloading. Four Minimum Data Set (MDS) assessments were completed in 2025 and none document rejection of care or refusals by R9. R9 has an air mattress and no documentation for inflation setting guidance was found. The day after the pressure injury was discovered an intervention was added to the care plan related to refusals. The cushion in R9's wheelchair is not on the care plan or correct for R9's weight and type of pressure injury. 5/8/25 is the first documentation of a discussion with R9 regarding the risk and benefits of R9's noncompliance with wound care and interventions. After the weekly wound assessment on 2/26/25 was completed, two weeks are missed before the next comprehensive wound assessment. On all facility assessments the wound bed tissue type is selected but not the percentage of coverage over the wound. The wound has continued to increase to almost double the size from the time of discovery with no pertinent, new interventions attempted. * R32's hospital records state R32 admitted back to facility with 2 (unstageable) pressure ulcers. A Licensed Practical Nurse did the readmission assessment and noted abrasions with treatment of barrier cream. The wound was not comprehensively assessed until 5 days later. Surveyor made observations of R32's heels not being offloaded and the mattress setting was incorrect. * R64 has orders for a dressing to right buttocks due to MASD (Moisture Associated Skin Damage). Surveyor observed R64 had a dressing to sacrum area. Surveyor observed a nurse put dressing on a different area. When the dressing was removed, Surveyor observed a Deep Tissue Injury. Surveyor made observations of R64's heels not being offloaded. * R49 did not have a comprehensive assessment upon admission on [DATE] for a sacral wound until 1/15/25. Findings include: The facility's policy titled Pressure Injury Prevention and Management revised 2/2025, documents (in part): Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries . Policy Explanation and Compliance Guidelines .: 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk a. Licensed nurses will conduct a pressure injury risk assessment on all residents upon admission/readmission, weekly x (times) four weeks, then quarterly or whenever the condition changes significantly . c. Licensed nurses will conduct a full body skin