**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R39) of 3 Residents reviewed for pressure injuries. The facility did not routinely assess R39's skin condition, did not implement or update care plans in response to skin changes, and did not evaluate the effectiveness of current care planned interventions and implement effective and timely interventions to prevent R39's pressure injury from becoming an infected stage 4 pressure injury that led to two weeks of hospitalization. * R39 was admitted to the facility on [DATE] with no skin impairment. R39 was assessed to be at risk for the development of pressure injuries. On 05/16/23, R39 developed a Deep Tissue Injury (DTI) to the left ischial tuberosity. The facility indicated on 5/16/23 they ordered/requested a Roho cushion for R39 however it was not immediately available. There is no indication that staff assessed the appropriateness of continuing to use R39's high density foam pommel cushion to ensure it would not be a contributing factor in possible deterioration of the wound until the Roho was obtained. The facility did not get a Roho cushion until 5/30/23. A care plan initiated on 5/16/23 said to encourage R39 to reposition every 2-3 hours. MDS dated [DATE] indicated, however, that R39 needed extensive assist of 2 for transfer and bed mobility and needed partial/moderate assistance to roll left to right. On 05/17/23, a nurse's progress note documents the DTI was opened and the facility updated the physician and received new treatment orders. During the following week, the facility indicated that ongoing assessments of the wound were taking place, as noted on the facility 24-hour boards. However, review of the facility 24 hour boards for the dates of 5/16-5/23/23 do not identify that staff routinely completed the 24-hour board information, and it is noted the 24-hour boards do not contain the information/details that would constitute an assessment of the wound. On 05/23/23 a nurse practitioner (NP) documented that the DTI was an open and unstageable pressure injury due to 80% slough. Review of the facility 24 hour board does not indicate a decline in the wound to an unstageable pressure injury or new treatment details. The 24-hour board entries for this date indicate the dressing is intact. On 5/23/23, the facility implemented new treatment orders but did not update/revise other areas of R39's care plan; R39 continued to sit on a high density foam pommel cushion on the wheelchair, and R39 did not have nutritional, incontinence, nor repositioning care plans updated or revised. On 5/23/2023, the Nurse Practitioner discussed the plan of care for diligent offloading and incontinence cares and cushion in wheelchair at all times while up, no longer than 2 hours at a time in wheelchair. The intervention up no longer than 2 hours at a time in wheelchair was not implemented until 06/15/23, after R39 returned from the hospital for treatment, debridement, and IV (intravenous) therapy for an infected pressure injury, returning to the facility with a Stage 4 pressure injury. Some staff indicated that R39 was noncompliant with repositioning. There is no care plan addressing noncompliance or alternatives. On 05/30/23, the pressure injury was assessed as having 70% necrotic tissue, heavy seropurulent drainage with moderate odor and the surrounding peri wound skin was assessed as black/blue/reddened and hot. On 05/30/23 the facility sent R39 to the hospital, and the hospital sent R39 back to the facility the same day with oral antibiotics. At the facility's request, R39 went to the wound clinic on 06/01/23. The wound clinic had R39 admitted to inpatient for Intravenous (IV) Antibiotics and surgical debridement of the ischial pressure injury. R39 was in the hospital from [DATE] to 06/14/23. R39 returned to the facility on [DATE], the left ischial pressure injury was a stage four and R39 had a wound vac. Since re-admission to the facility, R39 continues with the pressure injury. R39 developed a facility acquired, unstageable pressure injury requiring hospitalization, debridement, and IV antibiotic for infection. The facility failure to implement interventions to prevent R39's deep tissue injury from becoming an infected stage 4 pressure injury created a finding of Immediate Jeopardy that began on 05/23/23. Surveyor notified the Nursing Home Administrator of the Immediate Jeopardy on 10/05/23 at 3:08 PM. The Immediate Jeopardy was removed on 10/6/23, however, the deficient practice continues at a scope and severity level of D (potential for harm/isolated) as the facility continues to monitor their plan. Findings include: The facility policy, not dated, entitled, Etiology and Risk Factors for Pressure Injury, documented: Definition: Pressure Injury-A pressure injury is localized damage to the skin and/or underlying soft tissue over a bony prominence or related to a medical device or other devices. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense/prolonged pressure in combination with shear .A pressure injury is considered unavoidable if the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and revised the approaches as appropriate . Limit time in chairs: All residents at risk for skin breakdown should avoid long periods of sitting in a chair without being repositioned. A teachable resident should, be taught to shift his/her weight approximately every 15 minutes while sitting in a chair. According to AHRQ [sic] guidelines, the resident should be repositioned, shifting the points of pressure at least every hour or be placed back in bed . Resident Choice: When a resident refuses, evaluate the basis for the refusal and identify potential alternatives. On 10/3 through 10/5/23, Surveyor reviewed R39's medical record which included in part, the following; R39 was admitted to the facility on [DATE] and had diagnoses including, Left-sided Hemiparesis related to Cerebral Vascular accident, Peripheral Vascular Disease, and Diabetes Mellitus type 2. R39 smoked tobacco. R39's Braden Scale Assessment score on 01/24/23 was 18, indicating R39 was at risk for pressure injury development. Interventions initiated on 01/24/23 included: Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Turn and reposition as necessary. On 01/25/23, the care plan was updated to include: Float heels while in bed. R39's care plans also included (in part): R39's fall risk care plan, initiated 01/24/23, documented the following intervention, 1/31/23 pommel cushion for wheelchair. R39's Nutrition care plan, initiated 01/26/23 documented, Resident is at Risk for Maintaining Nutritional Status R/T (related to): S/P (Status Post) CVA (Cerebral Vascular Accident), Insulin .G (Gastrostomy) Tube was pulled on March 17 as no longer needed for Nutrition Support .Has Increased Cal + Protein Needs R/T DTI PI (Pressure Injury). Q [sic] June 2023 Wt Stable at 30 + 90d . Sept Q [sic] Wt stable @ 1,3,6 mo review and had the following intervention in part: Provide 8 oz (ounces) Ensure + 30 mls (mililiters) Prostat SF [sic]+ 8oz Water TID (three times a day). R39's admission Minimum Data Set (MDS) assessment dated , 01/31/23, assessed R39 to have a Brief Interview for Mental Status (BIMs) of 9, indicating R39 had moderate cognitive impairment. R39 had no pressure injuries upon admission but was assessed to be at risk for skin impairment r/t (related to) impaired mobility and incontinence and documented to follow current interventions listed in skin care plan. R39's Braden Scale Assessments scores on 02/1/23 was documented as 15 indicating at risk for the development of pressure injuries. R39's Bladder Incontinence care plan, initiated 02/06/23, documented, The resident has bladder incontinence r/t impaired mobility, and had the following interventions: Check and change every 2-3 hours and prn (as needed). Date Initiated: 01/27/2023 Clean peri-area with each incontinence episode, establish voiding patterns. Date Initiated: 02/06/2023 . R39's Bowel Incontinence care plan documented, The resident (R39) has bowel incontinence r/t impaired mobility. This care plan was initiated on 02/08/23 and had the following interventions, all initiated on 02/08/23: Call light kept within reach. Check and change every 2-3 hours and prn [as needed] Provide loose fitting, easy to remove clothing Provide pericare after each incontinent episode Staff will assist with incontinence care as needed . R39's Nutrition care plan was updated on 3/10/23 to include 3/10/23 .Provide 8 oz (ounces) Ensure + 30 mls (milliliters) Prostat SF [sic]+ 8oz Water TID (three times a day). 3/10/23 .Provide FROZEN NUTRITION TREAT on Lunch Tray. ***Give Shake when substitute needed . R39's Peripheral Vascular Disease care plan, initiated 03/22/23 documented the following intervention, Encourage resident to change position frequently, not sitting in one position for long periods of time. R39's quarterly MDS, dated [DATE], documented R39 had no pressure injuries but was at risk for pressure injury development and R39 should have a pressure reducing cushion and mattress; R39 was assessed as needing extensive assist of two staff for transfers and bed mobility. This MDS also indicates that R39 needed partial to moderate assistance rolling left to right. R39's Braden Scale Assessments score on 05/8/23 was documented as 16 indicating at risk for the development of pressure injuries. On 05/16/2023 at 12:05 PM a nursing progress note documented; It was reported to writer by CNA (Certified Nursing Assistant) that resident had an area of discoloration to left outer buttocks. Writer along with wound NP (nurse practitioner) assessed area. To the left ischial tuberosity there appears to be a DTI (deep tissue injury). CNA states that this morning the resident was sitting on the edge of the bed on mattress and upon grab bar calling out for help as she wanted to get in her w/c (wheelchair). Area may be bruising from sitting on outer edge of the grab bar but will consider to be a DTI. New orders received for site care. Resident will have application of air mattress. [R39's] weight is monitored weekly. Lab values also closely monitored by [NP-Q]. [R39] denies pain to the site and said [R39] did not know it was there. PMD (Primary Medical Doctor) updated as well as call placed to POA (Power of Attorney). Dietician updated. On 05/16/23 R39's Skin and Wound Evaluation form documented R39 had a Deep Tissue Injury that was In-House Acquired and measured 2.7 cm (centimeters) x (by) 1.8 cm. The wound bed was documented as 100% epithelial tissue, with no drainage, peri wound skin blanchable and there was an order for skin prep to the site. A resident Skin Impairment Data Collection sheet was provided to Surveyor that indicated the original date of area being noted was 5/16/23. This document indicated it was unwitnessed, but with a known origin, pressure area of (L) left ischial tuberosity. Pressure area 5/16/23. Location where impairment occurred was room. Skin preventative measures previously in place per plan of care checked is: preventative topical treatments, specialty alternating air mattress, protective boots. No anticoagulants. Immediate intervention put in place indicates: Roho ordered - wound consult - tx (treatment) monitoring. Surveyor noted the alternating mattress was documented as added on this date and had not previously been in place. R39's skin care plan was updated to indicate: The resident has actual impairment to skin integrity: 05/16/23 - Actual skin impairment - facility acquired - DTI to left ischial tuberosity. Encourage resident to turn and reposition every 2-3 hours, initiated: 05/16/2023 Air mattress applied to bed. Check for function every shift, initiated: 05/16/2023 Encourage resident to turn and reposition every 2-3 hours. Resident often refuses to change position. Resident educated on the importance of frequent position change to help prevent wounds and heal wounds. Date Initiated: 05/16/2023, and revised on 05/30/23 The care plan said to encourage resident to turn and reposition every 2-3 hours, yet the MDS assessment on 4/26/23 indicated R39 needed extensive assist of two for bed mobility and partial to moderate assistance rolling left to right. The Resident skin impairment data collection worksheet provided to Surveyor was noted to have added on 5/17/23: per Licensed Practical Nurse (LPN)-H small OA (open area) within DTI (0.6 x 0.4) pink red/surrounding tissue purple - scant drainage. MD aware - new treatment orders. Surveyor noted it is unclear if this area was assessed by an RN at this time as the documentation indicates the OA was conveyed to DON-B by LPN-H. On 5/17/2023 at 9:53 PM, a nurse progress note documented: Called [name of medical office] and updated NP [name of NP] about resident's wound to left outer hip now open and skin around wound is reddened. NP [name of NP] said to go ahead and apply Xeroform and bordered foam dressing to wound daily and PRN. NP said she will let regular NP know about wound change on resident. Surveyor noted R39's nutritional care plan was revised on 05/17/23 to include Give shake when substitute needed (for Frozen Nutritional Supplement with lunch which was added on 3/10/23). R39's nutritional care plan was not revised further until 06/22/23 when R39 received an order for Prostat, which is a protein supplement. R39's Nutrition care plan was revised on 06/22/23 to include the 30 mls of Prostat and 8oz water TID (three times a day) and also revised on 06/22/23 from Glucerna to Ensure. On 05/23/23 R39's Skin and Wound Evaluation form documented R39's DTI was now Unstageable with 20% granulation and 80% slough. It measured 2.6 cm x 2.9 cm x 0.1 cm with moderate serosanguineous drainage. Peri wound skin was documented as having erythema and normal temperature. The wound was documented as deteriorating, but healable. At this time the treatment was changed to medihoney and foam daily. Surveyor reviewed R39's Electronic Medication Administration Record (EMAR) and noted the wound care orders were changed appropriately and per physician's recommendations. Surveyor did not note any gaps in wound care treatments. Surveyor also reviewed R39's nurse's progress notes from 05/17/23 to 05/23/23 and noted the nurses progress notes did not mention any change to R39's wound. Multiple notes during this time document either dressing changed with no concerns, no drainage noted or dressing is clean, dry, and intact. However, the 24 hour boards do not contain any assessment information, nor do they include who completed the documentation on who entered the information on the 24 hour board. Per documentation, the first time the wound appeared with slough and fully opened was on 05/23/23 when the wound NP did a weekly assessment. Surveyor interviewed Assistant Director of Nursing (ADON)-C on 10/5/23 at 8:19 AM. ADON-C informed Surveyor the wound first opened on 5/23/23 when NP-G was assessing the wound. Surveyor read R39's 5/17/23 progress note, which documented the wound being opened and receiving a new treatment. Surveyor asked if measurements and an assessment were done at that time. ADON-C informed Surveyor because it was the same wound as the DTI, there would not have been another risk management, and ADON-C stated she did not believe the staff would get another set of measurements or stage the wound. Surveyor explained the concern there was documentation R39's DTI changed on 05/17/23, but there was not a comprehensive wound assessment documented until 05/23/23. ADON-C reviewed R39's EMR and informed Surveyor, the staff did what they were supposed to do by notifying the doctor and getting a new order. ADON-C did not think another assessment would have been done at that time. Surveyor reviewed NP-G's progress note dated 05/23/23 which documented, .Wound Care Follow up .Patient seen resting in bed. Seen for wound to left ischium of surgery as a deep tissue pressure injury last week and has now developed into an unstageable pressure injury per wound RN (Registered Nurse). Patient denies pain, fever, chills. [R39] is eating and sleeping per her baseline . ***Diagnosis that could affect wound healing*** Cervical cancer Coronary artery disease Diabetes mellitus History of tobacco use Hyperlipidemia Hypertension Iron deficiency anemia Myocardial infarction ***Interventions in Place*** Pressure reduction devices, bed, cushion per facility protocol; nursing and wound care, nutritional support, PT/OT (physical therapy/occupational therapy) if needed. ***Physical Examination*** Left ischium (unstageable pressure injury) Full-thickness wound measuring 2.6 x 2.9 x 0.1 cm. 20% granulation, 80% slough. Moderate serosanguineous drainage. Peri wound denuded, fragile. No signs or symptoms of infection Status? [sic] decline Plan? [sic] Medihoney and bordered foam daily and as needed . Reviewed medical records Discussed plan of care with ADON Diligent offloading and incontinence cares Cushion in wheelchair at all times while up, no longer than 2 hours at a time in wheelchair Air mattress Protein supplementation as necessary per dietary Follow-up 1 week for reassessment . Surveyor noted R39's fall risk care plan was revised on 5/30/23 (7 days after the NP assessment and 14 days after the area developed) the pommel cushion was changed to a Roho for skin issue . R39's skin care plan was updated to include: The resident has actual impairment to skin integrity: 5/23/23 changed to Unstageable, with the following interventions; Encourage resident to turn and reposition every 2-3 hours. Resident often refuses to change position. Resident educated on the importance of frequent position change to help prevent wounds and heal wounds. Date Initiated: 05/16/2023, and revised on 05/30/23 Roho cushion to wheelchair. Date Initiated: 05/30/2023 Surveyor noted R39's plan of care was not updated to include up no longer than 2 hours at a time in wheelchair until 06/15/23 but was recommended by NP-G on 05/23/23. Surveyor also noted there were no incontinence care plan revisions at this time, even though NP-G indicated diligent offloading and incontinence cares. The next assessment of R39's wound occured on 05/30/23 when NP-G came to the facility for her weekly wound rounds. R39's Skin and Wound Evaluation form, dated 05/30/23, documented: R39 had an unstageable wound measuring 4.1 cm x 5.6 cm x N/A (depth) with 30% epithelial tissue and 70% necrotic tissue, there was increased drainage, redness/inflammation and warmth with heavy seropurulent drainage and moderate odor after cleansing; the peri wound tissue had discoloration of black/blue with erythema and was hot. This form documented R39 was educated on the importance of repositioning in bed as much as tolerated and to not spend long amounts of time up in wheelchair. This form also documented R39 would be sent to the emergency room for further evaluation and documented R39 regularly refuses to get out of the wheelchair and spends a long amount of time in the wheelchair. R39 was sent to the hospital on [DATE] and the hospital sent R39 back to the facility on the same day with an order for oral antibiotics. Per facility documentation, the hospital did not feel the wound needed debridement. Surveyor reviewed R39's EMR and noted the following documented in nurses' progress notes between 05/23/23 and 05/30/23: On 5/24/2023, resident repos. [sic] as tolerated Q2 (every 2) hours. DTI to Lt. buttock. VS (vital signs) WNL (within defined limits). On 5/24/2023 16:43, Dressing change DTI of left buttock. No noted bleeding/drainage. No c/o (complaints of) of pain/discomfort. On 5/25/2023, repositioned as tolerated Q2 hours. DTI to Lt. buttock. VSS (vital signs stable). slept well. On 5/25/2023, Treatment done this shift to L buttock for DTI. Cleaned with normal saline, medihoney applied to open area and covered with a bordered foam. On 5/25/2023, Dressing changed to left buttock. Scant drainage and soiled with urine on old dressing. States wound hurts when touched. On 5/26/2023, resident repositioned as tolerated Q2 hours d/t (due to) inability to move on own and DTI to Lt. (left) buttock. VSS. On 5/28/2023, Patient had x-large BM (bowel movement) that covered wound dressing on L outer buttocks. Writer cleaned wound and reapplied dressing. No visible S/S (signs/symptoms) of infection. bleeding or C/O pain or discomfort. On 5/29/2023, Dressing changed to left buttock. VSS and BSS [sic]. C/o pain when wound was touched; otherwise, states it does not hurt. On 5/30/2023, resident repositioned as tolerated Q2 hours. DTI to Lt. buttock. drsg. CDI (clean, dry, intact). VS WNL. Surveyor noted there was no mention of a change in R39's wound appearance until 05/30/23 when NP-G did her weekly assessment. Surveyor noted the 05/24/23, 05/25/23, 05/26/23, and 05/30/23 progress notes document the left buttock as a DTI however as of 05/23/23 the area was assessed to be deteriorating and was assessed as unstageable with 80% slough and 20% granulation. On 5/30/2023 there was an Interdisciplinary Team (IDT) progress note in R39's EMR which documented, IDT met to discuss resident's skin issues. Resident currently has a pommel cushion in her wheelchair from a fall in January. It was discussed that a Roho cushion would be more beneficial at this time to help prevent skin breakdown and to promote healing. Cushions changed. Surveyor noted there was reference to changing the cushion to a Roho going back to the 5/16/23 Resident Skin Impairment Data Collection sheet that was provided to Surveyor by DON-B. This was the first mention of a follow up to changing the pommel cushion that Surveyor could locate. R39's care plan was updated to include the Roho cushion on 05/30/23. Surveyor was provided with information regarding the pommel cushion R39 sat on until replaced by the Roho cushion on 05/30/23. The manufacturer's information for the pommel cushion documented, The four 3D Quadra gel compartments allow for even distribution of gel under the ischials and seated areas while dual density foam layer provides a soft layer of comfort and molded foam base for support and pressure redistribution .and a coccyx relief cutout . There was nothing in the manufacturer's information documenting this cushion would be appropriate for someone who has a DTI or an unstageable pressure injury. Surveyor reached out to the company for additional information but has not heard back. Surveyor reviewed an Unavoidable Pressure Injury document completed by the facility and signed by the NP-G on 05/30/23 which documented: (R39) was not at end of life and was not on hospice, did not have a history of healed skin issues; (R39) had the following diagnoses-severe peripheral vascular disease; chronic bowel incontinence; diabetes; hemiplegia/paraplegia/quadriplegia; R39's serum albumin was below 3.9, hemoglobin less than 12 and protein less than 6.4; (R39) had pale and poor skin; and (R39) was non-compliant with recommendations regarding off-loading of pressure areas such as floating heels, cushions, alternating times up in the chair with times in bed; (R39) did not comply with diet or supplements to increase wound healing and (R39) refused to be turned/repositioned. Surveyor is uncertain if this form is for the development of the wound, the decline in the wound or the infection of the wound. Surveyor reviewed R39's lab work and noted lab work completed on 05/15/23 documented R39's albumin was 3.2 (low with a range of 3.8-5); Protein, Total 5.8 (low with a range of 6.1-8.2) and hemoglobin 10.2 (low with a range of 11.3-15.1). R39's lab results form 06/26/23 documented an albumin of 3 (low); Protein, Total of 6.5 (normal) and hemoglobin 9.3 (low). Surveyor reviewed R39's EMAR (Medication Administration Record) from May and noted a physician's order documenting, Encourage resident to reposition in bed and w/c every 2-3 hours, every shift, with a start date of 05/16/23. Surveyor noted this order was documented as completed every shift. There were no refusals documented. Surveyor noted a physician's order documenting, Glucerna every evening shift for [sic] Give 8 oz, with a start date of 5/11/23. Surveyor noted this order was documented as completed every evening shift except 5/02/23 which documented R39 drank 50%. There were no refusals documented. Surveyor reviewed R39's April EMAR and noted the same Glucerna order which documented R39 refused the supplement two times; R39 drank 0% one day; R39 drank 50% one day and R39 drank 100% the remaining days in April. Of note, R39's Skin and Wound evaluation forms had a section entitled Goal of Care with three options to choose from: 1.) Healable, 2.) Slow to heal: wound healing slow or stalled but stable, little/no deterioration, 3.) Monitor/Manage: Wound healing not achievable due to untreatable underlying condition. On 05/16/23, 05/23/23 and 05/30/23 these Skin and Wound evaluation forms document 1.) Healable. On 5/30/23 the facility made an appointment for R39 at the wound clinic. R39 was seen at the wound clinic on 06/01/23. The wound clinic consult form documented large full thickness left ischial eschar with surrounding cellulitis, developed over last 2-3 weeks .admit for IV antibiotics and surgical debridement. R39 was admitted to the hospital until 06/14/23 when R39 returned to the facility. Surveyor reviewed R39's hospital discharge history and physical, dated 6/11/23 (with a discharge date of 06/14/23) which documented, Indication for admission: Infected Left ischial pressure wound, unstageable with necrosis and surrounding cellulitis .Hospital Course .underwent debridement on 06/02, repeat debridement on 06/07 and wound vac placement on 06/09 .Seen by infectious disease and was treated with cefepime, metronidazole, and vancomycin from 06/01-06/07. Upon readmission to the facility, R39's skin care plan was updated to include: The resident has actual impairment to skin integrity: 6/20/23 changed to stage 4. Resident not to be up in wheelchair for more than 2 hours per day to promote wound healing. Date Initiated: 06/15/2023. Surveyor noted this was originally recommended by the NP on 5/23/23 and not implemented until 6/15/23. On 6/15/23, R39 had the following active physician's order: Resident is not to be up in wheelchair for more than two hours a day to promote wound healing. Every shift for monitoring. On 9/13/23, R39 had the following active physician's orders: Wound TX: Left ischial tuberosity- Cleanse with NS (Normal Saline), pat dry. Apply Derma (hydrafera) blue from restorix and cover with super silicone dressing. Change three times a week and prn. one time a day every Tue, Thu, Sat for Wound Care AND as needed for wound care. R39's most recent MDS assessment, dated 09/30/23, documented R39 had one stage 4 pressure injury; R39 required extensive assistance of two staff for bed mobility and total staff assistance for transfers and R39's BIMS was a 9, indicating R39 had moderate cognitive impairment. On 10/03/23 at 8:52 AM, Surveyor observed R39 lying in bed with the head of the bed elevated about 45 degrees. Wound Nurse Practitioner (NP)-G and Assistant Director of Nursing (ADON)-C were outside of R39's room preparing for R39's wound care. ADON-C informed Surveyor R39 had the wound since May 16, 2023, and then it was unstageable. Per ADON-C, R39 went to the hospital for surgical debridement and now the wound is healing. ADON-C informed Surveyor, R39 had a lot of non-compliance issues such as sitting in the wheelchair all day. Per ADON-C, R39 has diabetes, smokes and leans to the left side due to a stroke. ADON-C informed Surveyor R39 is more compliant with off-loading and R39's son comes around 5 PM every day and that is when R39 gets up in the wheelchair. NP-G agreed with what ADON-C told Surveyor. On 10/03/23 at 8:54 AM, Surveyor observed NP-G and ADON-C perform wound care treatment on R39's left ischial tuberosity pressure injury. The wound appeared clean with no signs or symptoms of infection. Surveyor did not identify concerns with the observed wound care treatment. On 10/03/23 at 9:30 AM, Surveyor observed R39 lying in bed. R39 informed Surveyor R39's wound is getting better and does not hurt. R39 stated R39 usually gets out of bed in the afternoon when R39's son comes to visit and takes R39 out to smoke. Surveyor asked if staff provide education on repositioning or encourage R39 not to stay in the wheelchair for long periods. R39 could not remember and stated to Surveyor I do not think so. R39 informed Surveyor if staff suggested something like repositioning [R39] would do it. R39 did not think [R39] refused treatments, cares or repositioning. R39 did not have any concerns. At this time, Surveyor noted there was a Roho cushion in R39's wheelchair. On 10/04/23 at 1:25 PM, Surveyor observed R39 sitting upright in wheelchair. Surveyor asked R39 when staff assisted R39 into the wheelchair. Per R39, R39 got up before lunch and that is when R39 likes to get up. Surveyor asked how long R39 stays in the wheelchair. R39 informed Surveyor [R39] was unaware of how long [R39] stays up in the wheelchair because [R39] has never timed it. R39 did not think there was any time limit for [R39] to be up in the wheelchair. Surveyor asked R39 if staff encourage R39 to only stay in the wheelchair for a couple of hours and R39 replied I do not think so. Surveyor asked R39 if staff ask R39 to lay down or to change positions does [R39] ever refuse or not want to. R39 replied no, if staff want me to do something I do it. On 10/04/23 at 1:29 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-I. CNA-I was on R39's unit and per CNA-I, was familiar with R39's care. Per CNA-I, R39 was only getting up in the wheelchair when R39's son was in the building, but now per CNA-I R39 can stay up in the wheelchair longer. CNA-I informed Surveyor prior to R39's DTI, R39 would get up in the wheelchair around 1:30 PM. CNA-I informed Surveyor R39 was incontinent of bowel and bladder and usually would not call for assistance after an incontinence episode. Per CNA-I staff usually had to initiate incontinence cares for R39. CNA-I stated she was the one who found the DTI and informed the nurse of the area. Per CNA-I, R39 did not have any other wounds prior to the DTI. CNA-I stated she thought R39's DTI opened quickly. CNA-I stated R39 was not non-compliant and did not refuse cares or repositioning, but per CNA-I if staff placed R39 on R39's right side with a pillow under R39's left side, R39 would occasionally remove the pillow. CNA-I informed Surveyor R39 could move side to side in bed by self. CNA-I stated this is the first week R39 can get up in the wheelchair and stay up longer than when she was restricted to the 2 hours. On 10/04/23 at 3:47 PM, Surveyor interviewed PM Supervisor Licensed Practical Nurse (LPN)-H. LPN-H informed Surveyor R39's wound started as a DTI[TRUNCATED]