An 88-year-old male was admitted with sepsis from a urinary tract infection to the step-down unit from a local long term care facility. On day 3 he was transferred to the medical-surgical unit. The pressure injury survey was conducted on day 4 of the hospitalization and the survey team noted an unstageable pressure injury on the back of his head. Review of the hospital admission assessment record revealed his skin was very warm and dry with a pressure injury documented at this site. The skin assessment documented on arrival to the medical-surgical unit also noted a pressure injury at this site. For the pressure injury survey, this would be reported as: