**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice to prevent pressure ulcers (PU- a localized injury to the skin and underlying tissues) for one of four residents (Resident 1) when licensed nurses assessed Resident 1 upon admission on [DATE] and were aware of the Resident 1's high risk for pressure ulcers and did not implement effective interventions to prevent pressure ulcers such as changes for size, dimension, weekly description. Resident 1 was assessed to have a stage 2 (a partial-thickness skin injury that involves damage to the epidermis (outer layer of skin) and extends into the dermis (middle layer of skin) pressure ulcer on 5/5/25 and nurses did not implement interventions to prevent wound progression.Resident 1 was diagnosed by a wound specialist physician with an unstageable (a type of pressure injury where the depth of the wound cannot be determined because it is covered by slough or eschar. Slough is yellow, gray, or green dead tissue, while eschar is a hard, black or brown crust that covers the wound.) pressure ulcer on 6/9/25 and required wound vacuum (wound vac-medical device that uses suction to promote wound healing) for healing. These failures resulted in an avoidable Stage 2 pressure ulcer to left buttocks and shearing (a type of skin damage that occurs when tissue layers are pulled in opposite directions, causing them to separate) to the right buttocks that progressed to two avoidable Stage 4 (a severe form of pressure injury that involves full-thickness tissue loss, exposing bone, tendon, or muscle) pressure ulcers (left and right buttocks), suffering, pain and loss of mobility. Resident 1 stated because of the pressure ulcers he acquired, he did not feel the facility acted promptly in providing the care he needed to improve, which caused him to limit his rehabilitation because he was concerned about his wounds. Resident 1 made the decision to be discharged home on 8/8/25 with wound care and wound a vac because he was not accepted at another facility due to his wounds. Resident 1 experienced psychosocial harm when he felt hopeless in his recovery and did not feel the facility addressed his psychosocial needs and quality of care. During a review of Resident 1's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 1 was admitted from the general acute care hospital to the facility on 5/2/25. Resident 1 has a history that includes but not limited to cervical vertebral fracture with surgical intervention(a break in one or more of the seven vertebrae (bones) that make up the neck that required a surgical procedure to repair and stabilize structure), impaired/decrease mobility (a limitation in the independent and purposeful movement of the body or one or more extremities), idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic bodily functions, such as heart rate, blood pressure, digestion, and bladder function), ankylosing spondylitis (a chronic inflammatory disease that primarily affects the spine), cirrhosis of the liver (disease characterized by the formation of scar tissue (fibrosis) that replaces healthy liver cells), muscle weakness (a decreased ability of muscles to generate force or contract effectively), and neuromuscular dysfunction of the bladder (nerve damage to the brain, spinal cord, or peripheral nerves disrupts the coordination between the nerves and muscles needed to store and empty urine).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive (the process of acquiring knowledge and understanding through thought, experience, and the senses) and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating no cognitive impairment.During an interview and observation on 8/4/25 at 3:45 p.m., with Resident 1, Resident 1 was observed up in his wheelchair with a wound vac attached along the side of the wheelchair, Staff wheeled Resident 1 to a private area at his request for the interview. Resident 1 stated he was not comfortable discussing his care with the facility staff around because he stated he had concerns with the care he received. Resident 1 stated, he came into the facility with hopes of rehabilitating. Resident 1 stated he wanted to go home after he improved with physical therapy but stated that it did not occur in the facility because he was concerned about his wounds which he felt interfered with his physical therapy. Resident 1 stated, the facility delayed treating his wounds to his buttocks which caused him to lose hope for his recovery and interfered with his physical therapy and rehabilitation. Resident 1 stated, he mentally, physically and emotionally has declined since his arrival into the facility. Resident 1 stated the care he received did not meet his expectations for care and rehabilitation. Resident 1 stated, he came into the facility without any wounds and now has plans to discharge home with two wounds to his buttocks and a wound vac (medical device that uses suction to promote wound healing) in place. Resident 1 felt the facility should have taken actions once his wounds were initially identified to prevent them from getting worse and to work on healing them. Resident 1 stated he was told he could not go to another facility for rehabilitation because other facilities denied him due to his wounds. Resident 1 stated his wounds had limited his ability to receive further physical therapy. Resident 1 stated I came here for therapy the wounds have affect me enough where I can't do therapy to get better. I will refuse therapy because of my wounds, yes, they will give me pain medications, but I don't feel like going. I came to do therapy, I didn't come here to get wounds. Resident 1 stated he had a meeting with the facility leadership regarding his concerns, and he was told things would get better but remained the same.During a review of Resident 1's electronic medical record admission Summary Note, dated 5/2/25, the admission Summary Note indicated Resident 1 did not have any open skin areas to his buttocks.During a concurrent interview and record review on 9/24/25 at 10:30 a.m., with the Director of Nurses (DON), Resident 1's electronic medical record, Skin/Wound Note, dated 5/5/25, and IDT (IDT-a collaborative group of healthcare professionals and other relevant individuals who work together to plan, coordinate, and deliver care for a patient or resident) Note dated 5/16/25 were reviewed. The Skin/Wound Note on 5/5/25 indicated, . Primary medical provider reassessed skin and noted stage 2 PU to left buttocks. The DON stated, the IDT Note dated 5/16/25 indicated the wound was present on admission but that was not accurate. The DON stated the wound was observed three days post admission. The DON stated there were no facility records indicating it was identified on admission. The DON stated that the pressure ulcer found on 5/5/25 on Resident 1's left buttocks was a facility acquired. The DON stated Resident 1 had the standard interventions implemented on admission for all residents which included baseline labs and turning and repositioning. The DON stated wound treatment for Resident 1's left buttock started on 5/5/25 and was measured on 5/5/25 as 2 cm x 2 cm (centimeters (cm)a unit of measurement) the wound was measured on 5/16/25 and 5/22/25 with the same measurements. The DON stated the next measurement was not until 6/9/25 when the wound specialist completed an assessment and Resident 1's left buttock wound measured 4.5 cm x 3 cm and a second wound on the right buttock measuring 5 cm x 3 cm was identified. The DON stated the treatment nurse should follow professional standards for wound care and should have been documenting any changes for size, dimension, and description every week and as needed during daily treatments for Resident 1. The DON stated, because Resident 1 had a specific insurance group she did not initiate a wound consultation with a facility wound specialist until 6/9/25.During a concurrent interview and record review on 9/24/25 at 11:30 a.m., with the licensed vocation nurse (LVN 1), Resident 1's electronic medical record, Skin & Wound Evaluation, dated 5/5/25,5/16/25,5/22/25 and 6/9/25 were reviewed. The Skin & Wound Evaluation on 5/5/25 indicated, .stage 2 PU to left buttocks 2cm x 2cm. on 5/16/25 .stage 2 PU to left buttocks 2cmx2cm. on 5/22/25 .stage 2 PU to left buttocks 2cmx2cm. on 6/9/25 .left buttocks PU unstageable 4.5x3cm and right buttocks shearing 5cmx3cmx0.1cm. LVN 1 stated she is the facility treatment nurse and her roles and responsibilities include measuring residents' wounds weekly in order to identify if wounds are healing and treatment is appropriate. LVN 1 stated Resident 1's wound measurements were not conducted from 5/23/25 to 6/9/25 per professional standards that the facility follows. LVN 1 stated it would have been difficult to determine if Resident 1's wound was healing without an accurate assessment and measurement. LVN 1 stated she did not measure Resident 1's wounds weekly and missed it. LVN 1 stated from the measurement taken on 5/22/25 to wound specialist assessment on 6/9/25 new shearing was found on Resident 1. LVN 1 stated on 6/6/25 during assessment with Resident 1's primary care provider identified a second wound, and it was not measured. LVN 1 stated no staff documented any measurement changes from 5/23/25 to 6/9/25. LVN 1 stated it was not until the facility wound specialist assessed Resident 1 that additional wound measurements were conducted. LVN 1 stated the wound specialist assessed Resident 1 as having an unstageable PU to left buttock and a shearing to the right buttock. LVN 1 stated she is not wound certified but was trained by a previous wound nurse. LVN 1 stated in her new role as a treatment nurse she did not realize she missed the measurements for Resident 1. LVN 1 stated it is important to relay detailed information concerning wounds to a resident's primary care physician or wound specialists to identify further needs for each resident, this did not occur for this Resident 1 and his wounds worsened.During a concurrent interview and record review on 9/24/25 at 1:50 p.m., with the licensed vocation nurse (LVN) 2, Resident 1's electronic medical record, admission Summary Note, dated 5/2/25, was reviewed. LVN 2 was the admitting nurse for Resident 1. The admission Summary Note indicated, LVN 2 completed a full body assessment of Resident 1 on 5/2/25. LVN 2 stated he documented two surgical sites (chest and neck) on Resident 1. LVN 2 stated there was no visible skin breakdown to Resident 1's buttocks. LVN 2 stated that he is knowledgeable in wound care and is certified from an wound care certification program and would be able to identify the presence of pressure ulcers or injuries. LVN 2 stated, Resident 1's Braden scale (used to predict a patient's risk for developing pressure injuries: 19-23 No Risk, 15-18 Mild Risk, 13-14 Moderate Risk, 10-12 High Risk, and 9 or less Severe Risk) score was 17 which indicated resident was at mild risk for skin breakdown. LVN 2 stated, standard interventions used for Resident 1 included turning and repositioning every two hours, and baseline labs.During a concurrent interview and record review on 9/24/25 at 2:03 p.m., with the licensed vocation nurse (LVN) 3, Resident 1's electronic medical record, Skin & Wound Evaluation, dated 5/5/25,5/16/25,5/22/25 and 6/9/25 was reviewed. LVN 3 stated she was not aware that Resident 1 was admitted with any pressure ulcers. LVN 3 stated during the weeks of 5/26/25 to 6/7/25 she worked two times on the floor as the fill in treatment nurse and, there was no instruction indicating she was required to or that it was necessary to measure Resident 1 wounds. LVN 3 stated, she was not aware that the usual wound specialist was not overseeing the wound care for Resident 1 per the facilities (professional) standards. LVN 3 stated she assumed that all wounds were measured and accounted for every Monday by the full-time treatment nurse. LVN 3 stated she did not measure Resident 1 wounds on the days she covered for the full-time treatment nurse. LVN 3 stated because she used her naked eye to assess Resident 1's wounds she believed there was not a change of condition. LVN 3 stated wounds require measurement and detail explanation of appearance, to communicate to physicians. LVN 3 stated, since Resident 1 developed two different pressure ulcers at the facility, she would consider the standard interventions that were put into place inadequate and insufficient based on the needs of Resident 1. LVN 3 stated it is the responsibility of staff to assess skin.During an interview on 9/24/25 at 2:25 p.m., with the DON. The DON stated Resident 1's skin was assessed for the first time on 6/9/25 by the wound specialist. The DON stated Resident 1 wound assessments included two separate PUs to left and right buttocks The DON stated Resident 1's wound to the left buttock was 4.5cmx3cm and newly identified wound to the right buttock measured 5cmx3cmx0.1cm. The DON stated both wounds identified on 6/9/25 were facility acquired pressure ulcers. The DON stated, the treatment nurse failed to follow professional standards for wound care. The DON stated the required weekly assessments included gathering information to identify wound stages, drainage, and measurement of wounds which are used to communicate to the physician. The DON stated it is the expectation of the facility that professional standards of care for wounds are followed by staff. The DON stated that when wounds develop at the facility it means the interventions put into place were not sufficient. The DON stated that the facility failed to maintain the skin integrity of Resident 1 during his length of stay and limited his ability to receive physical therapy. The DON stated Resident 1 had expressed his concerns to her about his wounds interfering with his rehabilitation.During a review of Resident 1's electronic medical record Physical Therapy Missed Visit Details, dated 8/5/25, was reviewed. The Physical Therapy Missed Visit Details indicated, Resident 1 refused treatment because he was more concerned about his wounds at this time and doesn't wish to partake in physical therapy. During a review of the facilities job description manual titled, Treatment Nurse dated Feb. 2024, the job description indicated, . provide primary care to the resident under the medical direction and supervision of the residents attending physician, the DON or the Medical Director of the facility, with an emphasis on treatment and therapy of skin disorders .make written and oral reports/recommendations to the attending physician, Medical Director, or the DON concerning the status and care of the residents .work with the interdisciplinary care plan team in developing comprehensive assessment and care plan for assigned residents . provide written and/or oral status reports of residents that you are treating .evaluate and implement recommendations .identify, manage and treat specific skin disorders . provide assessment and diagnosis services to the resident .ensure that residents with decubitus ulcers (localized areas of skin damage that occur due to prolonged pressure on the body) receive appropriate prophylaxis (any measure taken to prevent disease, rather than treat it once it has occurred) and treatment daily, inspection, turning and activity .During a review of the facility policy and procedure (P&P) titled, Wound Care dated [DATE], the policy and procedure indicated, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. review the residents care plan to assess for any special needs of the resident.obtain equipment and supplies necessary.documentation in residents medical record.type of wound.date and time wound care provided.any change.all assessment data obtained when inspecting wound. problems or complaints by the resident.report other information in accordance with facility policy and professional standards of practice.During a review of the facility policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol dated April 2018, the policy and procedure indicated, .The nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length and depth, presence of exudates (fluid that leaks from blood vessels into surrounding tissues or cavities, rich in protein, cells, and solid materials) and necrotic tissue (dead or dying tissue).the staff.will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions.the physician will evaluate and document the progress of wound healing- especially for those with complicated, extensive, or poor-healing wounds.the physician will help identify factors contributing or predisposing resident to skin breakdown.the physician will order pertinent wound treatments, including pressure reducing surfaces, wounds cleaning and debridement (the removal of damaged tissue) approaches, dressings and application of topical agents (a medication or substance applied to a specific area of the body's surface, such as the skin) .when wounds are not healing as anticipated or new wounds develop. current approaches should be reviewed for whether they remain pertinent to the resident medical conditions, are affected by factors influencing wound development or healing and the impact of specific treatment choices.During a review of a professional reference titled, Pressure Ulcer, dated January 2024, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK553107/ the professional reference indicated . Examine the following in a patient with a PI (a localized area of skin and/or underlying tissue damage that develops when prolonged pressure or shear forces exceed the tissue's tolerance): Ulcer history, including etiology (the study of the cause or origin of a disease or abnormal condition) , duration, and previous treatment, Staging by thoroughly examining the depth of the wound, which this activity will cover in detail under staging, Size of the affected area, Sinus tracts (an abnormal, tube-like passage that connects an infected area to the surface of the skin), undermining (the lifting and separation of skin and underlying tissues), and tunneling (creating or traversing a passage), The presence of drainage, The presence of necrotic tissue. When evaluating the wound characteristics, it is also important to keep risk assessment instruments in mind to reduce the risk of a PI incidence. The primary goal is to prevent pressure injury. This goal requires an interprofessional team, including primary care providers, wound care specialists, surgeons, specialty-trained wound nurses, physical therapists, and nurse aides. Nurses provide care, monitor patients, and notify the team of issues. Nurse aides are often responsible for turning and repositioning patients.The patient should be kept pain-free by giving analgesics (medications that relieve pain) . They should try to increase physical activity, which a nurse's aide, medical assistant, or rehab nurse can facilitate. Frequent follow-ups are an absolute necessity, and a team approach to patient education and pressure injury management involving the wound care nurse and wound care clinician lead to the best results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview and record review, the facility failed to recognize and appropriately act on a change in condition for one of three sampled residents, Resident 1, when staff were provided a list of medications on Resident 1's admission on [DATE] that included insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood) and did not inform the physician. Nursing staff were aware of the diagnosis of diabetes (a disease that occurs when sugar in the blood is too high) and did not closely monitor symptoms of hyperglycemia (high blood sugar), nausea and malaise (general feeling of discomfort) and did not inform the physician of high blood glucose (sugar) measurements. These failures resulted in Resident 1 not being managed appropriately for diabetes, to not receive needed insulin medication to control high blood glucose, experienced several days of feeling unwell, nauseous and malaise and required emergently being transferred to an acute care hospital on 2/10/25. During admission, Resident 1 was diagnosed with uncontrolled hyperglycemia, Diabetic Ketoacidosis (DKA- a complication of diabetes in which acids build up in the blood to levels that can be life-threatening) and sepsis (body's extreme response to an infection a life-threatening medical emergency) he was hospitalized for nine days and was discharged back to the facility on 2/19/25. Findings: During a review of Resident 1's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/19/25, the admission record indicated, Resident 1 was admitted from the hospital to the facility on 1/30/25. The admission Record indicated Resident 1 has a history that includes but not limited to muscle wasting and atrophy ( is the wasting or thinning of your muscle mass leading to muscle weakness), Crohn's Disease (an inflammatory bowel disease that causes chronic inflammation of the GI tract), Chronic Kidney Disease III ( your kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood), Muscle Weakness (a lack of muscle strength), and diabetes type II (high levels of sugar in the blood) chronic pain syndrome (persistent pain). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 14 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had no cognitive impairment. During a concurrent observation and interview on 4/22/25 at 2:22 p.m., with Resident 1 in his room, Resident 1 was resting in bed comfortably, dressed appropriate for the season and doing better since his last hospitalization. Resident 1 stated on his first admission to the facility from 1/30/25 to 2/10/25 he did not receive his insulin medication. Resident 1 stated the facility did not provide him with his insulin and he had to go to the hospital due to his diabetes being too high . Residents 1 stated his daughter-in-law gave the facility admission nurse his home medication list when he was admitted on [DATE] and Resident 1 did not understand why the facility would not follow what his doctor had previously prescribed. Resident 1 stated he felt ill days prior to being sent out to the hospital on 2/10/25 and it wasn't until he was sent to the hospital that he was told at the hospital his sugar was high . During a record review of Resident 1's Diabetes Care Plan, dated 2/1/25, the Diabetes Care Plan indicated, .Resident has a diagnosis of diabetes and is at risk for complications on hypo(low)/hyperglycemia (low blood sugar) . administer medications as ordered . diet as ordered . educate on the signs and symptoms of hypo/hyperglycemia and to report promptly . interventions to manage hypo/hyperglycemia episodes as indicated . monitor for signs of hypo/hyperglycemia . During a concurrent interview and record review on 4/22/25 at 2:43 p.m., with License Vocational Nurse (LVN) 1, Resident 1's electronic medical records, Admission/readmission Evaluation/Assessment and Home Medications, dated 1/30/25 were reviewed. LVN 1 stated, he was aware the family provided the admission nurse with a list of home medications for Resident 1, and the expected normal process was to document order verification for all medications. The admission nurse did not do that for Resident 1. LVN 1 stated telephone communication to the primary care providers should have included the medications that were continued as well as discontinued to clarify the appropriate medications, dosages and frequency to continue while Resident 1 was in the facility. LVN 1 stated that since appropriate communication did not occur, Resident 1 did not receive medication needed to manage his diabetes which placed Resident 1's health and well-being in danger and possibly caused his hospitalization. During a concurrent interview and record review on 5/7/2025 at 9:14 a.m., with the Director of Nurses (DON), Resident 1's electronic medical records, Admission/readmission Evaluation/Assessment and Home Medications, dated 1/30/25 were reviewed. The DON stated the home medication list provided by family indicated Resident 1 was on insulin (medication used to turn food into energy and mange blood sugar levels) prior to admission and the admission nursing staff did not clearly identify or clarify what medications listed on the home medication list were to be continued or discontinued in her summary note documentation. The DON stated that her expectations are for nursing staff to contact the primary care physician or nurse practitioner and verify all medications listed on provided medication list in order to identify each individual medication and document. During a concurrent interview and record review on 5/7/2025 at 9:22 a.m., with the DON, Resident 1's electronic medical record, Blood Sugar Summary and Order Summary Report, dated 1/30/25 to 2/9/25 were reviewed. The DON confirmed that Resident 1's blood sugar ranged from 79 milligrams per deciliter (mg/dl-unit of measurement) to 389 mg/dl. The DON stated normal blood sugar ranges from 70mg/dl to 110 mg/dl for diabetic residents. The DON stated Resident 1's doctors' orders dated 1/30/25 to 2/9/25 indicated to Notify MD if blood sugar is less than 70 and/or greater than 400. The DON stated the physicians should have been notified regardless, because of the range. The DON stated there was no indication that nursing staff notified the primary care provider of blood sugar ranges prior to Resident 1 being sent to the hospital. During a concurrent interview and record review on 5/7/2025 at 9:30 a.m., with the DON, Resident 1's electronic medical records, Home Medications dated 1/30/25 and Order Summary Report, dated January 2025 and February 2025 were reviewed. The DON stated home medications provided by the family should have been clarified and listed individually with date and time of acknowledgment to verify which medications were to be continued in the facility. The DON stated the Home Medication list has markings with unknown origin and no signatures, dates or times documented on sheet. The DON stated it is not clear what medications were verified for Resident 1. The DON stated that because of the missed insulin order for Resident 1, it was a potential factor that could have caused Resident 1 to be admitted for DKA and his hospital admission. During a concurrent interview and record review on 5/7/25 at 10:25 a.m., with Registered Nurse (RN) 1, Resident 1's electronic medical records, Admission/readmission Evaluation/Assessment and Home Medications, dated 1/30/25 were reviewed. RN 1 stated insulin was indicated on home medications list and should have been continued or clarified by primary care provider. RN 1 stated she is unsure if clarification was obtained by the primary care provider with the admission nurse. RN 1 stated nursing staff should have documented in detail what medications were discussed with the primary care provider during admission evaluation/assessment to verify if any home medications would be continued. RN 1 stated Resident 1 was not on any insulin during his time at the facility from 1/30/25 to 2/10/25 but was receiving blood sugar checks three times a day. During a concurrent interview and record review on 5/7/25 at 10:30 a.m., with RN 1, Blood Sugar Summary, dated 1/30/25 to 2/9/25 were reviewed. RN 1 stated a baseline blood sugar ranges from 70-100 mg/dl and if they are diabetic anything less than 200 is best. RN 1 stated Resident 1's ranges from 79-389 mg/dl which are not within normal ranges and should have been communicated with the primary care provider. RN 1 stated the blood sugar ranges that were documented for Resident 1 should have prompted staff to place Resident 1 under change of condition protocol, due to abnormal blood sugar ranges, this did not occur. RN 1 stated due to the lack of insulin and failure to follow up on communication with primary care providers concerning Resident 1's abnormal blood sugars, these items could have potentially caused Resident 1's admission to the general acute care hospital (GACH) for DKA. During a concurrent interview and record review on 5/12/25 at 1:30 p.m., with the Registered Dietitian (RD), Resident 1's electronic medical records, Admission/Readmission/Evaluation/Assessment, dated 1/30/25 were reviewed. The Admission/Readmission/Evaluation/Assessment, indicated Resident 1 was placed on a regular diet without restrictions. The RD stated he is to evaluate all residents within seven days of admission to determine adequate nutritional needs are met with diet. The RD stated Resident 1 was admitted on [DATE] to 2/10/25 and he did not complete an assessment for Resident 1. During a concurrent interview and record review on 5/12/25 at 2:22 p.m., with the Assistant Director of Nurses (ADON), Resident 1's electronic medical records, Blood Sugar Summary, dated 1/30/25 to 2/9/25 were reviewed. The ADON stated baseline blood sugar ranges from 70-100 mg/dl and 70-120 mg/dl for diabetics. Resident 1 had blood sugar ranges from 79-389 mg/dl which should have been documented as out of range and should have been communicated to primary care providers. The ADON stated there is no documentation indicating any nursing staff communicated blood sugar ranges for Resident 1 to primary care provider. The ADON stated that by not communicating blood sugars, the patient can have uncontrolled blood sugars that can cause further harm to the resident if not treated on time. The ADON stated the abnormal blood sugar ranges should have triggered nursing staff to place resident under a change of condition charting. The ADON stated nursing staff did not indicate a change of condition for Resident 1. The ADON stated the facility was monitoring Resident 1's blood sugars but not communicating them to the primary provider. The ADON stated facility staff did not provide Resident 1 with his insulin and Resident home insulin orders were not clarified upon admission. The ADON stated the facility potentially caused the DKA by not providing the insulin to Resident 1. The ADON stated failure to document precise information caused confusion in medication orders which caused residents to not have his insulin. During a record review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR) Communication Form, dated 2/10/25, the SBAR Communication Form indicated, . The change in condition, symptoms or signs observed and evaluated is/are: Abnormal vital signs .Nausea/Vomiting . started on 2/10/25 .Vital signs (reflect essential body functions) .Blood Pressure (the pressure of the blood in the circulatory system) 60/37 (normal ranges for 60 + age group is 133-139/68-69 ) . pulse (the regular movement of blood through your body that is caused by the beating of your heart) 118 (normal ranges 60-100 beats per minute- units of measurement) .Respirations (the process of breathing) 19 (normal ranges 12-18 breaths per minute- units of measurement) .Temperature (the degree of hotness or coldness of an object) 97.8 (normal ranges 97-99 Degree Fahrenheit- units of measurement) .Summarize .observation and evaluation .writer went in to the resident room to give routine meds. Writer notified by the CNA (certified nursing assistant) that residents BP (Blood Pressure) had been low. Upon initial assessment, the resident complained of nausea and feeling weak. Writer took blood pressure manually and got a reading on 62/34. During this time the resident had green emesis (vomiting) .daughter in law was notified and wanted to send resident to acute care. Doctor agreed and emergency medical services was called at [9:42 a.m.] . Resident taken by gurney During an interview on 5/19/25 at 3:30 p.m., with the DON, the DON stated, change of condition assessments should be conducted when there are abnormal changes in the resident's condition. The DON stated facility staff failed to accurately identify, verify or document in Resident 1's chart any communication made to primary care providers regarding his insulin, the home medication list or blood sugar readings while being cared for in the facility. The DON's expectations are for detailed events to be documented for each resident to indicate what was discussed, what medications should be continued as well as discontinued as well as indicating any communications made for blood sugars being monitored since staff were taking blood sugars, but no one communicated them. The DON stated there is no record of medication reconciliation between two nurses for Resident 1 as indicated in the facility's policy and procedures titled, Reconciliation of Medications on admission dated July 2017. The DON stated for Resident 1 who was diabetic, not on insulin and getting finger blood sugar checks three times a day, she would have expected the staff to address the change of condition with the MD. The DON stated that a diabetic resident with no insulin administration, abnormal blood sugar ranges required MD notification to make sure the MD is aware of the resident's condition and to give the MD an opportunity to adjust the residents' plan of care. The DON stated potentially that the lack of insulin could have contributed to his admission to the acute care hospital. During a record review of Resident 1's Emergency Department (ED) Provider Notes, dated 2/10/25, the ED Provider Notes indicated, Resident 1 .presented to the emergency department for vomiting and diarrhea. He was severely hypotensive (low blood pressure) but improved with IV (intravenous - a medical technique that administers fluids, medications and nutrients directly into a person's vein) fluids. He is severely acidotic (when acid builds up in your body) and has hyperkalemia (high levels of potassium in the body) . During a record review of Resident 1's General Acute Care Hospital Assessment and Plan for admission dated on 2/11/25, the Assessment and Plan indicated, . [Resident 1] was being admitted for sepsis and Diabetic Ketoacidosis (DKA- a complication of diabetes in which acids build up in the blood to levels that can be life-threatening) . The patient presented with nausea, vomiting, and diarrhea that has been ongoing for couple days. The skilled nursing facility staff reported subjective fever, productive cough and dysuria (painful or uncomfortable sensation experienced during urination) . He was found to be hypotensive at the skilled nursing facility, so he was transferred .in the emergency department (ER) . white blood count (WBC- a test that measures the number of white blood cells in your body) 27.4 (normal ranges 4.5-11.0) . potassium(It helps your nerves to function and muscles to contract) 6.9 (normal ranges-3.6-5.2) .bicarb (a byproduct of your body's metabolism) 12 (normal ranges 22-29), Glucose (sugar level in blood) was 496 During a review of the facility policy and procedure (P&P) titled, Diabetes- Clinical Protocol dated March 2025, the P&P indicated, .For resident with confirmed diabetes, the nurse will assess and document/report the following during the initial assessment . history of medication management . all other current medications . resident blood sugar history over 48 hours . where insulin is indicated, simplified treatment regiments are preferred .the staff will identify and report issues that may affect, or be affected by, a patients diabetes and diabetes management .hyperglycemia . staff will notify the practitioner as soon as possible . During a review of the facility policy and procedure (P&P) titled, Change in Resident Condition or Status dated February 2021, the policy and procedure indicated, .The nurse will notify the resident attending physician or physician on call when . significant change in the resident physical/emotional/mental condition . need to alter the resident medical treatment significantly . need to transfer the resident to a hospital .a significant change of condition is a major decline or improvement in the resident status that will not normally resolve itself without interventions by staff or by implement standard disease related clinical interventions . requires interdisciplinary review and /or revision to the care plan and ultimately is based on the judgment of the clinical staff .regardless of the resident current mental and physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatment . the nurse will record in the resident's medical record information relative to the changes . During a review of the facility policy and procedure (P&P) titled, Reconciliation of Medications on admission dated July 2017, the policy and procedure indicated, .The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility . Gather the information needed to reconcile the medications list . all prescription and supplement information obtained from the resident/family during the medication . Medication reconciliation is the process of comparing pre-discharge medications to the post discharge medications by creating an accurate list of both prescription and over the counter mediations that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care . if a medication history has not been obtained from the resident or family, complete this first. Information for the medication history should include prescription medications, including those taken only as needed . dose, route, frequency, and last dose taken for all items .document the medications discrepancies on the medication reconciliation form If the discrepancy was resolved, document how the discrepancy was resolved . During a review of professional reference from the American Diabetes Association (ADA) titled, Standards of Medical Care in Diabetes, dated January 2024, the professional reference indicated .Insulin therapy remains essential for individuals with type 1 diabetes and is often necessary for individuals with type 2 diabetes when glycemic goals are not met with oral agents. Insulin is the most effective agent in lowering blood glucose and reducing the risk of diabetes-related complications when used appropriately .continuous glucose monitoring are essential components of effective diabetes management, allowing for timely adjustments in therapy and prevention of hypoglycemia and hyperglycemia . During a review of professional reference from the Academy of Nutrition and Dietetics titled, Nutrition intervention and monitoring in long-term care settings for individuals with diabetes, dated September 2018, the professional reference indicated .In long-term care and skilled nursing facilities, individualized nutrition therapy is critical for optimizing glycemic control, maintaining nutrition status, and improving quality of life in resident with diabetes. Liberalized diets and consistent carbohydrate meal planning are recommended to enhance adherence and satisfaction while preventing complications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was notified for a change in condition for one of three residents (Resident 1) when on 5/14/24 Resident 1 was observed to have an acute change in mental status, an abrupt loss of in appetite, weakness, fatigue, and was difficult to arouse. CNA 4 communicated the changes of Resident 1 to the licensed nurse and the license nurse did not assess the resident, did not notify the physician and the Responsible Party (RP-a decisionmaker for the resident) regarding the change in condition. This failure resulted in a delay in physician notification of a change in condition that occurred on 5/14/24 and did not provide the physician the resident assessment to diagnose promptly to treat or transfer Resident 1 to a higher level of care. The delay in physician notification lead to a delay in transferring to a general acute care hospital where Resident 1 ' s CT (computerized tomography x-ray image) scan results were consistent with an acute ischemic stroke (when blood flow to the brain is blocked). The delay in physician notification lead to Resident 1 inability receive medication treatment for a stroke and decline in mental and physical abilities. This led the Responsible Party to place Resident 1 on hospice (care for people who are neat the end of life) and palliative care (care that focuses on providing relief from pain and symptoms of a serious illness). Findings: During a review of Resident 1's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included constipation, hypertension (high blood pressure), and muscle weakness, cardiac murmur (a blowing, whooshing, or rasping sound heard during a heartbeat), overactive bladder (a condition in which the bladder squeezes urine out at the wrong time). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 5/11/24, the MDS, indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 1 was cognitively intact. During a review of Resident 1's MDS assessment, dated 5/11/23, the MDS Section GG (Functional Abilities and Goals) indicated Resident 1 was a partial to moderate assistance (helper does 50% of assistance) with transfer, dressing and bathing. During an interview on 6/4/24 at 1:45 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated she worked at the facility for more than two years. CNA 4 stated she took care of Resident 1 on a regular basis and was familiar with her care. CNA 4 stated she remember Resident 1 was her normal talkative self in the chair the morning of 5/14/24. CNA 4 stated in the afternoon of 5/14/24 Resident 1 was weak, less talkative and was out of it after lunch. CNA 4 stated Resident 1 ' s .eyes were stuck to the side . while looking out the window and responded slower to questions. CNA 4 stated she provided care for Resident 1 after lunch and noticed she was not as strong. CNA 4 stated Resident 1 looked tired and did not want to eat lunch on 5/14/24. CNA 4 stated she notified License Vocation Nurse (LVN) 2 regarding Resident 1 ' s condition. CNA 4 stated LVN 2 told her to offer extra fluids to Resident 1. CNA 4 stated when she returned to work on 5/15/24 Resident 1 was not eating, not talkative, not able to drink out of the straw and she was total assistance which indicated she was worse than 5/14/24. CNA 4 stated Resident 1 had eaten 25% of breakfast on 5/14/24 and refused breakfast on 5/15/24. CNA 4 stated it was unusual for Resident 1 to not eat. During an interview on 6/6/24 at 10:36 a.m. with LVN 1, LVN 1 stated she was a float (a work assignment that moves from one section of the healthcare facility to another) nurse and worked for the facility for six years. LVN 1 stated she was assigned to Resident 1 on 5/14/24 for the afternoon (pm) shift. LVN 1 stated she had received report (update) about a change in condition from LVN 2 for Resident 1. LVN 1 stated she was told in report LVN 2 and the Assistance Director of Nursing (ADON) 1 assessed Resident 1 for a change in condition. LVN 1 stated on 5/14/24 during her afternoon shift Resident 1 was tired and difficult to arouse (stay awake) and slow to respond when spoken to. LVN 1 stated when a resident is difficult to arouse it was considered a changed in condition. LVN 1 stated Resident 1 had a change in condition and LVN 2 was responsible to notify the physician on 5/14/24, the RP and revise the care plan (an individualized plan of care that is personalized for a person's health conditions and current treatments needed for their care). LVN 1 stated the facility has a communication form for nurses to monitor for decline in residents when there a change in condition and one was not completed for Resident 1 on 5/14/24. During a review of Progress Notes (PN) dated 5/14/24 at 10:05 p.m., the PN indicated, Writer [received] report from [morning charge nurse] that resident [Resident 1] presented with normal vitals[clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions] however difficulty arousing on [morning] shift. ADON aware assess resident .Resident continue to exhibit difficulty arousing on [afternoon] shift .resident consumed less than 25% of dinner meal, intake 220 [milliliters- a unit of measurement for liquids] of fluids . There was no indication in the PN by LVN 1 that the doctor was notified regarding Resident 1 ' s change in condition. During an interview on 6/6/24 at 11:08 a.m. with LVN 2, LVN 2 stated she had been the nurse for Resident 1 for over a year and half. LVN 2 stated Resident 1 could feed herself and was a one-person assistance with showers. LVN 2 stated CNA 4 was familiar with Resident 1 and reported to her Resident 1 did not look like her normal self in the afternoon on 5/14/24. LVN 2 stated, Resident 1 was responding slowly and staring out the window on 5/14/24. LVN 2 stated she believed Resident 1 ' s slow response was from a side effect (unwanted undesirable effects) of an antibiotic. LVN 2 stated she did not notify Resident 1 ' s doctor on 5/14/24. LVN 2 stated Resident 1 ' s condition worsened on 5/15/24 when she responded slower to questions. LVN 2 stated she called the physician, RP, ADON 1, ADON 2 and Director of Nursing (DON) on 5/15/24 (one day after Resident 1 ' s change in condition was noticed). During an interview on 6/6/24 at 12:08 p.m. with the ADON 1, ADON 1 stated she went to assess Resident 1 on 5/15/24 at around 2:30 p.m. ADON 1 stated Resident 1 consumed 50-70% for breakfast and zero percent for dinner on 5/14/24. ADON 1 stated Resident 1 ate zero percent of her breakfast and lunch on 5/15/24. ADON 1 stated on 5/15/24 Resident 1 was not able to drink from a straw which Resident 1 had done before. ADON 1 stated a change of condition for a resident would include an elevated temperature, increased respirations, a change in mental status, a change in eating habits and a change in their ability to perform self-care and an increased demand for oxygen. During an interview on 6/6/24 at 2:05 p.m. with ADON 2, ADON 2 stated nurses were expected to complete a full head to toe assessment and compare the findings to the resident ' s baseline (initial measurement of a residents condition). ADON 2 stated a change of condition for a resident would include an increased pulse, headache, nausea, vomiting, lethargy, change in vital signs, increased oxygen demand, not eating or drinking and difficult to arouse. The ADON 2 stated, all certified nursing assistants were responsible to notify a charge nurse when there was a change in meal consumption. ADON 2 stated charge nurses were responsible to start the process for a change in condition assessment. The ADON 2 stated Resident 1 was lethargic and speaking slowly on 5/14/24 and Resident 1 ' s change in condition should have been assessed. During an interview on 6/6/24 at 2:34 p.m. with the Director of Nursing (DON), the DON stated, a change in condition was when a resident had abnormal vital signs and/or a clinical change from the baseline. The DON stated nurses were to assess residents from head to toe during a change in condition and to complete a situation, background, assessment, and recommendation (SBAR a structured communication framework that help teams share information about the condition of a resident.) The DON stated staff completed change in condition training in March 2024. During an interview on7/15/24 at 3:41 p.m. with the Medical Doctor (MD), the MD stated, when a resident was difficult to arouse or lethargic it was considered a change in condition. The MD stated staff were to notify him or the nurse practitioner. The MD stated each resident was treated differently depending on the family or RP ' s wishes. The MD stated each resident ' s medical care was dependent on the Physician Orders for Life-Sustaining Treatment (a POLST is a physician order that helps give seriously ill patients more control over their end-of-life care) form and medical history. During a review of the facility ' s document titled SBAR Communication Form and Progress Note for RNs/LPN/LVNs (SBAR) for Resident 1, dated 5/15/24, the SBAR indicated .Situation .The change in condition, symptoms, or signs observed and evaluated is/are: Altered Mental Status .This started on 05/15/2024 .Since this started it has gotten: .[box checked] Better .Things that make this condition or symptom better are: IV Hydration (replenishes lost fluids through a tube in a vein) .This condition, symptom, or sign has occurred before: [box checked] Yes .Treatment for last episode .: Changing the [Residents] [Medication] and IV Hydration .Resident/Patient Evaluation .1. Mental Status Evaluation (compared to baseline check all that changes that you observe) .[box checked] Altered level of consciousness .Describe symptoms or signs [blank] .2. Functional Status (capacity an individual can perform activities and tasks) Evaluation (compared to baseline; check all that you observe) . No changes observed .10. Neurological Evaluation .[box checked] Altered level of consciousness .Describe symptoms or signs: [Resident] noted Not responding as Normal .Appearance .Summarize your observations and evaluations: [Resident] was noted with [Altered Mental Status] and is slow to respond. [Resident] was not eating and had to be fed .Review and Notify . Primary Care Physician Notified: Yes .Date 05/15/2024 .Time: 9:20 AM .Interventions .IV (soft flexible tube placed inside the vein) . During review of SNF/NF to Hospital Transfer Form dated 5/15/24, the SNF/NF to Hospital Transfer Form indicated Resident 1 was transferred from the skilled nursing facility to the acute care hospital on 5/15/24 at 4:13 p.m. During a review of Resident 1 ' s General Acute Care Hospital (GACH) H&P Addendum (H&P), dated 5/15/24, the H&P indicated, .CT (computerized tomography x-ray imaging) head shows acute [experienced to a severe or intense degree]or early subacute [ a recent onset or rapid change] infract [stroke] in the right PCA (posterior cerebral artery -one of a pair of arteries that supply oxygenated blood to the back of the brain) .Neurology was consulted. Not a candidate for TPA (tissue plasminogen activator- medication used to dissolve blood clots in stoke patients and must be given with 3 hours of onset of symptoms) since her symptoms started 3 days ago . During a review of Resident 1 ' s General Acute Care Hospital (GACH) Discharge Summary (DS) dated 5/24/24, the DS indicated, .admit date : [DATE] discharge date : [DATE] .Indication for admission: Chief Complaint Patient presents with Altered Mental Status . [chief complaint of Altered Mental Status for] 3 days .baseline glasgow coma scale 15 (a system to measure how conscious a person is, a score of 15 means you ' re fully awake, responsive and have no problems with thinking ability or memory) .admission Diagnoses: Acute CVA (cerebrovascular accident) .Active Hospital Problems Diagnosis .(Principal) Acute Ischemic stroke .AMS (altered mental status) .Hemiparesis (one sided muscle weakness) affecting left side .05/17 .Failed swallow evaluation .05/21 .Daughter agreed to meet with Palliative care to discuss goals of care .Disposition .Hospice . During review of Resident 1 ' s facility Discharge Document (DC) dated 6/11/24, the DC indicated .admission date: 2/3/2021 .discharge date [DATE] .Condition on discharge: Guarded .Significant Findings and Events: Long term patient became weak and altered sent to the hospital .Recommendation and Arrangements for Future Care: Per hospital course Prognosis Fair to poor Physician ' s Signature [signed] Date 06-11-2024 . During a review of the facility ' s policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status, revised dated 2/202, the P&P indicated, .the nurse will notify the resident ' s attending physician or physician on call when there has been a .significant change in the resident ' s physical/emotional/mention condition .2. A significant change of condition is a major decline or improvement in the resident ' s status .the nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 83) remained free from developing pressure ulcers (localized injury to the skin and or underlying flesh usually over a bony area as a result of pressure/friction/shear) when Resident 83 had a known history of recurrent skin breakdown and was not repositioned every two hours and kept clean and dry as per the plan of care to prevent pressure ulcers. Resident 83 was bedridden following a fall that resulted in a hip fracture, after admission to the facility experienced a significant weight loss and nursing failed to conduct accurate skin risk assessments. This failure resulted in Resident 83 developing a preventable Stage 3 (Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia) pressure ulcer to the coccyx area (tailbone). Findings: During a concurrent observation and interview with Resident 83, on 5/6/19, at 8:15 a.m., Resident 83 was in her room sitting upright in bed on an air loss mattress (special mattress to distribute weight and minimize pressure to bony prominences) and a urinary catheter (a flexible tube inserted into the bladder to drain urine) at the side of her bed, her eyes were closed and sunken. Resident 83 was thin with sunken cheeks and dry wrinkled skin. Resident 83 grimaced and stated the bed was uncomfortable and her backside was hurting. During an interview with Certified Nursing Assistant (CNA) 3, on 5/6/19, at 3:25 p.m., she stated Resident 83 required assistance with turning and repositioning and set-up with meal trays. CNA 3 stated Resident 83 was incontinent of bowel and occasionally had loose stools. CNA 3 stated Resident 83 did not have open areas on her skin with the exception of redness to the lower back. CNA 3 stated the redness on Resident 83's lower back was related to moisture in the skin from the loose stools Resident 83 experienced. CNA 3 stated Resident 83 was bedridden and did not get out of bed. During a concurrent observation and interview with CNA 9, on 5/7/19, at 1:05 p.m., Resident 83 was in bed on her back side and awake. CNA 9 stated Resident 83 had redness to her lower back and was unsure if there were any open areas on Resident 83's skin. CNA 9 stated he did not recall completing a skin check to document Resident 83's skin condition. CNA 9 stated CNA's were required to check residents skin during care and position changes and inform the nurse if the CNA noticed any skin issues or wounds. During a concurrent interview and record review with the Unit Manager (UM) 1, on 5/7/19, at 1:30 p.m., UM 1 stated Resident 83 had a pressure ulcer stage 3 on the coccyx area. UM 1 stated the Stage 3 was reported on 5/6/19 to the nurse in the evening shift. UM 1 stated the treatment nurse and Registered Nurse Supervisor were asked to assess Resident 83's skin breakdown. During a concurrent interview and clinical record review with the UM 1, on 5/7/19, at 2 p.m., she reviewed the document titled BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK dated 3/12/19 and 5/7/19 which indicated, Moisture, degree to which skin is exposed to moisture, rarely moist: skin is usually dry .Activity, degree of physical activity, Chairfast .assisted into wheelchair .Nutrition, usual food intake pattern, Adequate. Wats over ½ of most meals. Eats a total of four servings of protein each day . The UM 1 stated the skin risk assessments were inaccurate because Resident 83 had loose stools and was exposed to moisture from the loose stools. The UM 1 Resident 83 was bedridden and did not get up in a wheelchair. The UM 1 stated Resident 83 was admitted to the facility on [DATE] weighing 130.6 lbs. and now weighted 82.0 lbs. 5/6/19 (total weight loss of 48. 6 lbs. within nine months). The UM stated Resident 83 had experienced significant weight losses during her stay in the facility which compromised the integrity of her skin making Resident 83 a high risk for skin breakdown. The UM 1 stated, the skin risk assessment (BRADEN) was not completed accurately because the BRADEN assessment indicated a score of 18 (Mild risk: total score of 15-18). The UM 1 stated an accurate BRADEN assessment would ensure Resident 83 received interventions to attempt to prevent the development of pressure ulcers. The UM 12 stated, That did not happen. During an interview with Licensed Nurse (LN) 11, on 5/7/19, at 2:50 p.m., LN 11 stated, Resident 83 has a Stage 3 to coccyx area. LN 11 stated Resident 83 was occasionally non-compliant with turning and repositioning in bed. LN 11 stated Resident 83 was incontinent of bowel which caused the redness to her buttocks area. During a concurrent observation and interview with CNA 9, on 5/8/19, at 11 a.m., Resident 83 was in bed on her left side. CNA 9 stated Resident 83 was supposed to be on her right side and not on the left side. CNA 9 stated the position change was scheduled on the facilities turning schedule. CNA 9 stated he was approximately 20 minutes late in turning Resident 83 on her right side. CNA 9 stated the turning and repositioning was due every two hours and as needed. CNA 9 stated Resident 83 sometimes was non-compliant with turning and repositioning and favored to be positioned on her back. CNA 9 stated Resident 83 was incontinent of bowel and had redness to her buttocks area related to her loose stools. During a review of the clinical record for Resident 83, the document titled, Skin Check dated 7/27/18, indicated Resident 83 was admitted to the facility on [DATE] with a Stage 1 (Intact skin with non-blanchable redness over a bony prominence) to the coccyx area. The document indicated Resident 83 had scattered bruises to both upper arms and a surgical incision site to the right hip. During an interview with the Director of Nursing (DON), on 5/8/19, at 2:33 p.m., she stated Resident 83's air loss mattress was put in place on 3/19/19 because of the risk of pressure ulcer development. The DON stated Resident 83 was at risk for skin breakdown and pressure ulcer development because of her poor nutrition, significant weight loss and stool incontinence. During a concurrent observation and interview with Treatment Nurse (TN), on 5/8/19, at 3:35 p.m., TN prepared to measure Resident 83's pressure ulcer and administer the treatment. The pressure ulcer on the coccyx area was partially covered with slough (dead tissue, usually cream or yellow in color) and granulating (healing tissue) red in color on the wound. TN stated the pressure ulcer on Resident 83's coccyx was 1.5 centimeters (cm) in length by 1 cm in width by .1 cm in depth. TN stated she was informed about Resident 83 having a pressure ulcer on 5/6/19. TN stated the last time she saw Resident 83 was on 5/1/19 when Resident 83 received treatment for a Stage 1 pressure ulcer on the coccyx. TN did not give additional information on why Resident 83's newly identified pressure ulcer did not receive treatment for two days after it was identified on 5/6/19. TN stated the new pressure ulcer was a Stage 3. TN stated she did not know why the wound was not seen before it progressed to a Stage 3. TN stated the CNAs give care and should have identified the worsening skin condition earlier and informed her but that did not occur. During a concurrent interview and record review with UM 1, on 5/9/19, at 3:12 p.m., UM 1 reviewed Resident 83's medical record and stated Resident 83 required assistance of two people with turning and repositioning in bed. UM 1 stated Resident 83 was initially admitted to the facility on [DATE] with a diagnoses of fracture of the right hip status post fall, pneumonia (lung infection), muscle weakness and unsteadiness of feet. UM 1 stated Resident 83 weighed 130.6 pounds (lbs.) on 7/28/18 and was now 82 lbs. UM 1 stated Resident 83 experienced a weight loss of 48.6 lbs. UM 1 stated resident was identified at risk for pressure ulcer due to her incontinence of bowel and her poor meal intake and weight loss. UM 1 stated Resident 83 could not make position changes without staff assistance and did not tolerate being up in a chair. UM 1 stated Resident 83 always remained in bed. UM 1 stated pressure ulcers could develop overnight, and Resident 83's pressure ulcer was an avoidable pressure ulcer because Resident 83 was not turned or repositioned by nursing staff consistently every two hours. UM 1 stated CNA's were supposed to complete skin checks on a weekly basis and document the skin check. UM 1 stated the weekly skin checks were not documented and could not produce documentation of the skin checks.UM 1 stated the skin checks were supposed to help in the identification of skin changes and to address a skin change before the skin status worsened. UM 1 stated the care plan interventions for Resident 83 dated 2/19/19 indicated Evaluate for any localized skin problems .dryness, redness .Observe skin for signs/symptoms of skin breakdown .Encourage resident to consume all fluids of choice during meals, assist resident in turning and repositioning every two hours .Apply barrier cream with each cleansing . UM 1 stated care plan interventions for Resident 83's pressure ulcer risk were revised on 5/8/19, 48 hours after the identification of the Stage 3 pressure ulcer. UM 1 stated the charge nurse were able to modify care plans and interventions when the interventions in place were not effective. UM 1 stated this was not done for Resident 83. UM 1 stated Resident 83 had occasional loose stools that increased her risk for skin breakdown. UM 1 stated there were no interventions to address the possibility for bowel retraining because this was not in the facility policy and procedure. UM 1 stated there were no care planned interventions to address Resident 83's loose stools. During a concurrent interview and record review with LN 7, on 5/9/19, at 3:49 p.m., LN 7 stated Resident 83 required 2-person assistance with turning and repositioning. LN 7 stated Resident 83 had redness to her lower back prior to the Stage 3. LN 7 stated Resident 83 received treatment for a Stage 1 on her coccyx's every shift and CNA's were instructed to make sure Resident 83 was kept clean and dry. LN 7 stated Resident 83's weekly skin assessment was last completed on 5/2/19. The skin assessment indicated there was skin moisture associated dermatitis (MASD) on Resident 83's to coccyx area. LN 7 stated a treatment was started to apply the barrier cream every shift for 14 days. During an interview with the Registered Dietician (RD), on 5/10/19, at 11:47 a.m., RD stated Resident 83 was at risk for pressure ulcer development secondary to her weight loss. RD stated the main goal for Resident 83 was to have good oral intake to meet the caloric needs. RD stated Resident 83 was underweight and was not consuming the required caloric amount to prevent weight loss. RD stated she reviewed meal rounds when she did nutrition assessments but did not document all of her encounters concerning Resident 83's poor nutritional intake. RD stated Resident 83 experienced weight loss since her admission to the facility on 7/27/18. RD stated residents who experienced weight loss were discussed in the Customer at risk meeting. RD stated she attended to two meetings for Resident 83 and she did not address or discuss the weight loss. RD was unable to explain why she did not discuss or address Resident 83's reduced meal intake and weight loss in the two meetings she attended. RD stated she did not make recommendations for laboratory work up to follow up on Resident 83's weight loss and was unable to explain why she did not make these recommendations. RD stated she was responsible to participate with the interdisciplinary team (IDT) (a group formed by a physician, nurse, social worker and a dietician) to develop nutrition plans of care for the Resident 83. RD stated she could have improved the outcome of Resident 83 if she attended the meeting and actively discuss the weight loss trend of Resident 83. RD stated Resident 83's Physician Orders for Life Sustaining Treatment (POLST) dated 2/23/19, indicated Resident 83's son selected for a trial period of artificial nutrition which included feeding tubes under section C of the POLST form. RD stated she did not discuss the progressive weight loss with Resident 83's son and she did not discuss the wishes selected on the POLST for a trial of artificial nutrition. RD stated the weight loss increased Resident 83's risk for skin breakdown. During an interview with CNA 3, on 5/10/19, at 3:45 p.m., CNA 3 stated she reported the open area to Resident 83's coccyx area, she stated Resident 83 complained of discomfort on her back while she was providing care. CNA 3 stated that was the time she noticed the open area on Resident 83's coccyx (5/6/19). CNA 3 stated Resident 83 did not always accept to be repositioned and was placed on an air mattress to prevent skin breakdown. During a concurrent interview and record review with the DON, on 5/13/19, at 9:55 a.m., the DON reviewed Resident 83's record and stated Resident 83 had care planned interventions to prevent skin breakdown which included turning and repositioning, skin check every week by CNA's, use of therapeutic mattress and gel cushion when up in wheelchair, and application of skin moisturizer to skin. The DON stated if a skin issue was identified, nurses were responsible to notify the physician, obtain treatment order, start a change in condition monitoring for 72 hours and initiate a care plan. The DON stated when Resident 83 was first admitted she had a stage 1 to her coccyx area that healed on 10/25/18. The DON stated Resident 83 developed incontinence associated skin dermatitis (IASD) to coccyx area on 1/23/19. The DON reviewed Resident 83's pressure ulcer risk care plan and stated the interventions were not effective to prevent recurrent skin breakdown based on the development of Resident 83's pressure ulcer. The DON stated the charge nurses were responsible for checking the interventions were effective and to revise them when they were not. During a concurrent observation and interview with Resident 83 and CNA 10, on 5/15/19, at 2:32 p.m., CNA 10 stated Resident 83's scheduled turning and repositioning was to occur every hour but sometimes Resident 83 wiggled herself to her back again. During a review of Resident 83's Minimum Data Set (MDS) assessment (an evaluation of cognitive function and care needs) dated 4/5/19, indicated Resident 83 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 10 out of 15. During a review of the facility policy and procedure titled SKIN INTEGRITY CARE DELIVERY PROCESS dated 6/1/16, indicated .Perform daily observation of the skin. Promote adequate nutrition and hydration .Encourage ambulation and movement .Incontinent of .feces .Evaluate for continence management program .toileting program) . During a review of the facility policy and procedure titled NSG 236 Skin Integrity Management dated 11/28/16, indicated, . 3.3 Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. 3.4 Perform daily monitoring of wounds or dressings for presence of complications or declines and document . 9. Review care plan weekly and revise as indicated . During a review of the facility policy and procedure titled 8.5 Nutrition/Hydration Management dated 12/1/06, indicated . Staff will consistently observe and monitor residents for changes and implement revisions to the service plan as needed. Resident will receive care and support to enhance potential or attaining the highest level of nutrition and hydration status and the pleasure of eating . Consult with dietitian may be indicated . 3.1 unplanned weight loss . 3.2 Any stage pressure ulcer . 3.3 skin breakdown 3.4 inadequate oral intake, less than 50% of meals in 72 hours period .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received treatment and care to attain and maintain their highest practical wellbeing for two of four sampled residents (Resident 83, Resident 95) when: 1. Resident 83's nutritional needs were not accurately and consistently assessed on admission and as needed and effective interventions were not identified and implemented for weight loss. 2. Resident 83's assessment and nursing interventions to address pressure ulcer were not monitored and evaluated for effectiveness. 3.Resident 95's nutritional needs were not accurately and consistently assessed on admission and as needed and effective interventions were not identified and implemented for weight loss. These failures resulted in actual decline in physical wellbeing for Resident 83 and Resident 95. Findings: 1. During an observation in Resident 83's room, on 5/6/19, at 8:15 a.m., Resident 83 was in her room, in bed and sitting upright with her eyes closed. Resident 83's collar and shoulder bones were easily visible and her skin appeared dry and wrinkled. Resident 83's wrist and arms were visibly thin and without muscle mass. An over bed table was observed at the left side of Resident 83 with a breakfast tray. The following uneaten meal items were observed on the meal tray: pancakes with syrup and margarine, oatmeal in a bowl, scrambled eggs, a glass of juice, and a glass of milk. On the meal tray was an empty cup with a dry tea bag and a bowl with a small amount of cottage cheese. Resident 83 opened her eyes and began grimacing (facial expressions of pain) and stated the bed was uncomfortable and her backside was hurting. Resident 83 stated the meal tray was hers but she did not want it. Resident 83's face sheet (a document containing resident profile information) undated, indicated Resident 83 was admitted to the facility on [DATE] for a planned short rehabilitation stay to recover from a surgical repair of a broken hip. Resident 83 was admitted with diagnoses which included Pneumonia (infection in the lung), muscle weakness, iron deficiency Anemia (low red blood cells), Hypothyroidism (condition of low thyroid hormone which helps regulate body functions such as body temperature and heart rate), Major depression (mood disorder causes persistent feeling of sadness and loss of interest), Insomnia (inability to sleep), Gastroesophageal reflux disease (GERD- a digestive disorder characterized by reflux of stomach acid into the esophagus). During a review of the clinical record for Resident 83, the Minimum Data Set (MDS) assessment (functional and cognitive abilities assessed), dated 4/5/19, under Section C, Brief Interview for Mental Status (BIMS) score was 10 which indicated Resident 83 was moderately impaired in cognition (memory and judgement). During an interview with Certified Nursing Assistant (CNA) 3, on 5/6/19, at 3:25 p.m., she stated Resident 83 required assistance with the set-up of her meal tray. CNA 3 stated, Resident 83 was able to feed herself with set-up but required staff supervision and constant reminders to eat during her meals. CNA 3 stated, The staff member feeding Resident 83's roommate had to make sure to keep an eye on Resident 83 and to give constant reminders to eat. During a concurrent observation of Resident 83 in her room and interview with CNA 9, on 5/7/19, at 1:15 to 1:30 p.m., Resident 83 was in bed with the head of the bed elevated. Resident 83 was moving her food on her plate from one area to the next without bringing the food to her mouth. The lunch meal consisted of: Macaroni and cheese, stewed tomatoes, [NAME] slaw, bread roll, peaches, one glass of milk and a cup of hot tea. CNA 9 was in the room feeding Resident 83's roommate for 15 minutes and was not heard providing reminders or encouragement for Resident 83 to eat her meal. Resident 83 stated she was full and did not want to eat more. CNA 9 replied to Resident 83 Okay and continued to feed Resident 83's roommate. CNA 9 did not offer a substitute for the uneaten lunch meal. CNA 9 removed Resident 83's meal tray and stated that Resident 83 usually did not eat her meals. CNA 9 stated he should have offered Resident 83 an alternative food choice. During a concurrent interview and record review with Licensed Vocational Nurse (LVN 11), on 5/7/19, at 2:35 p.m., LVN 11 stated Resident 83 required supervision with meals. LVN 11 stated CNA's assigned to Resident 83 had to make sure to give her reminders to eat and report to the nurse when Resident 83 refused to eat. LN 11 stated she had not received a report from CNA 9 that Resident 83 refused her meals. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated, Resident 83 eats what she wants to eat. She is confused too so I have to talk to the CNA's taking care of her [for meal consumption information]. The RD stated Resident 83 liked yogurt, cottage cheese and fruits and hot tea. The RD stated those were options that could be given to Resident 83 if she refused her meal. RD stated she had not observed Resident 83 eat a meal since admission and relied on the CNAs documentation for the meal percentage. The RD stated she continued to monitor the documentation of Resident 83's weights weekly as well as her meal intake. The RD stated Resident 83 was admitted to the facility on [DATE] with a weight of 130.6 lbs. The RD stated Resident 83's current weight on 5/8/19 was 82.7 lbs. (a total of 47.3 lbs. weight loss within nine months from the date of admission of 7/27/18). The RD stated Resident 83 was currently under her ideal body weight of 160 to 130 lbs. The RD stated on admission, Resident 83's weight was 130.6 lbs. The RD stated she reviewed her initial assessment dated [DATE] and Resident 83's weight was at the lower end of Resident 83's Body Weight Range (BWR) of 160 to 130 lbs. and height was 64 inches. The RD stated Resident 83's usual weight was 130 lbs. per Resident 83. The RD stated she identified Resident 83 at nutritional risk due to her inadequate oral intake which would not meet her nutritional needs. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated between 7/27/18 and 8/27/18, Resident 83's weight dropped from 130.6 lbs. to 119.3 lbs., representing a weight loss of 11.3 lbs or 8.7 percent for one month. The RD stated she calculated Resident 83's meal intake using the CNAs documented meal percentages. The RD stated her calculations were that Resident 83 was eating 71 percent of her meals. The RD stated the weight loss was related to Resident 83's diagnosis of Clostridium difficile (C. diff, is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) infection. The RD stated Resident 83 was started on Flagyl (antibiotic medication to treat the infection) 500 mg three times a day times for 10 days. A stool culture to check for C-diff was collected on 8/3/18 and indicated positive for C. diff. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated, between 8/27/18 through 9/24/18 Resident 83's weight dropped from 119.3 lbs. to 104.9 lbs., representing a weight loss of 14.4 lbs., a 1 percent loss over one month. The RD stated Resident 83 was sent out to the general acute care hospital (GACH) from 9/9/18 thru 9/18/18 with diagnoses that included sepsis (is a potentially life-threatening condition caused by the body's response to an infection), Urinary tract infection (UTI- bladder infection) and was re-admitted on [DATE]. The RD reviewed the nutritional assessment dated [DATE] which indicated, Resident 83 was to continue with the current diet of Regular/Liberalized diet, looks visibly thin. The RD stated, Resident is meeting energy needs, the weight loss might have been related to the UTI, and the main goal was to prevent further weight loss. RD stated no new nutritional interventions were implemented at that time. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated between 9/24/18 through 11/6/18 the weight dropped from 104.9 lbs. to 97.8 lbs., representing a weight loss of 7.1 lbs., or 6.8 percent in 6 weeks. The RD reviewed the nutritional assessment dated [DATE], and stated Resident 83 continued on a Regular/liberalized diet, [new intervention of] House supplement two times a day. No chewing or swallowing problem, eats in her room for all meals and continue to require tray set-up. Intake 59% . [Resident 83] looks visibly thin. The RD note dated 10/3/18, indicated, Saw [Resident 83] food services and visited often and collect food preferences. The RD reviewed her RD notes dated 11/5/18, which indicated, RD saw resident and checked chewing and swallowing problem and collected food preferences. The RD note indicated, [Resident 83] likes cottage cheese and fruits and added as interventions. The RD stated, [Resident 83] was at risk for further weight loss. The RD reviewed the clinical record for her documented Frequent resident visits and interventions and was unable to find documentation of the frequent nutritional visits or interventions. The RD stated, I don't have those. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated between 11/6/18 through 12/6/18 the weight dropped from 97.8 lbs. to 93.3 lbs., a weight loss of 4.5 lbs. or 4.6 percent. The RD reviewed her RD note dated 11/7/18 and 11/12/18 which indicated, Per clinical meeting resident with soft/loose stools despite diet intake of fiber, resident will benefit from Nutrisource (fiber) packet twice a day to provide additional fiber. Appetite improving consuming 63% of meals, Resident 83 meeting estimated energy needs. The RD stated she was unsure why Resident 83 was continuing to lose weight when she was meeting her estimated nutritional needs. The RD stated she had not observed Resident 83's meal consumption since admission, but relied on the CNA's meal consumption documentation. RD stated she did not implement new nutritional interventions to slow or attempt to stop ongoing weight loss. During a concurrent record review and interview with the RD, on 5/8/19, at 10:43 a.m., the RD stated, between 12/6/18 through 1/8/19 the weight dropped from 93.3 lbs. to 88.7 lbs., representing a weight loss of 4.6 lbs., or 4.9 percent. The RD stated the weight loss was not significant, and no new interventions were added at that time. During a concurrent record review and interview with the RD, on 5/8/19, at 10:44 a.m., the RD stated, between 1/8/19 through 2/4/19 the weight dropped from 88.7 lbs. to 88.4 lbs., representing a weight loss of 0.3 lbs. The RD stated the weight loss was not significant and weight had been stable, but the RD did add one nutritional supplement with breakfast. During a concurrent record review and interview with the RD, on 5/8/19, at 10:46 a.m., the RD stated, between 2/4/19 through 3/4/19, the weight dropped from 88.4 lbs. to 84.6 lbs., representing a weight loss of 3.8 lbs., or 4.3 percent. The RD reviewed the nutritional assessment dated [DATE] which indicated, Continue on Regular/Liberalized . Evaluation/Nutrition plan: [Resident 83] meeting estimated energy needs, previous oral intake was meeting estimated energy needs, main goal to prevent further weight loss. Resident had snacks in between meals. The RD stated Resident 83 was underweight. During a concurrent record review and interview with the RD, on 5/8/19, at 10:47 a.m., the RD stated, between 3/4/19 through 4/15/19, the weight dropped from 84.6 lbs. to 81.3 lbs., representing a weight loss of 3.3 lbs., or 3.9 percent. The RD stated she reviewed the nutritional assessment dated [DATE] and 4/2/19, which indicated, Continue on Regular Liberalized diet . Nutrition History: Has triggered for significant weight loss X [for] 6 months, -[lost] 24.9%, -[lost] 28lbs. comparison weight of -[lost] 8.7lbs, -[lost] 9.3% X 3 months . Resident weight loss continues . During a concurrent record review and interview with the RD, on 5/8/19, at 10:48 a.m., the RD stated between 4/5/19 through 4/29/19, the weight was 82.7 lbs. The RD stated Resident 83's weight loss had stabilized since March, and she did not add new interventions. The RD stated she did not attend any of the interdisciplinary team meeting (IDT) or care plan conferences to communicate Resident 83's ongoing weight loss with the team. The RD stated the IDT would invite her to the meetings but she had not attended the meetings for any of the residents that were losing weight, including Resident 83. RD stated she should have been present in the care conferences and should have discussed the continued weight losses but she had not. The RD stated she did not monitor or validate the CNA's capability to document meal percentages accurately. The RD stated, I assumed that they are calculating it correctly, I relied on the data that was presented to me. The RD stated CNAs were not documenting Resident 83's meal percentages accurately based on the intake documented and the weight loss that had occurred. The RD stated the meal percentages documented by the CNAs did not match or support Resident 83's ongoing weight loss. The RD stated she did not provide in-service education to CNA's on how to accurately document meal percentages. The RD stated, The director of staff development (DSD) does the in-services regarding food percentages and there are postings for the CNA's to follow in regards to the calculations of meals percentages. RD stated she attended Customer at Risk (CAR) meetings every Tuesday morning with the MD, DON, Social Service Director (SSW), and RN supervisor. In the CAR meeting the group discussed recent weight loss, weight changes and new admissions. The RD stated she had not discussed the weight loss of Resident 83 in the meetings. She stated, For some reason, I just missed it [Resident 83's ongoing weight loss]. The RD stated she did not remember talking to Resident 83's Responsible Party about the weight loss and did not look at the Provider Orders for Life-Sustaining Treatment (POLST) form. The RD stated she was responsible for the nutrition care plans, evaluating and updating the interventions as needed when nutritional issues were identified. The RD stated she reviewed the care plan interventions but was unable to find documentation where she evaluated and/or revised her nutritional interventions for Resident 83. The RD stated she did not know why Resident 83 was losing weight. The RD stated, I just missed it [the weight loss]. During a review of Resident 83's clinical records the Weights and Vitals Summary dated 7/27/18 to 4/26/19 indicated Resident 83's admission weight on 7/27/18 was 130.6 lbs. and on 5/8/19 the weight was 82.7 lbs. There was a total loss of 47.9 lbs. or 36.7 percent weight loss within nine months. During a review of the facility document the, [RD] JOB DESCRIPTION: DIETITIAN dated 5/29/17 indicated . RESPONSIBLITIES and ACCOUNTABILITILITIES .4. Collaborates with the interdisciplinary team to develop nutritional plans of care for the residents/patients. 5. Monitor and evaluate effectiveness of nutritional interventions . 12. Participates in the education and training of center staff . Review of facility document titled HIGH RISK NOTE FORMAT dated July 2013 indicated . Pressure Ulcer Review: . 2. Weight and weight history, trend . 4. Current nutritional interventions, if any. Are they accepted and effective? . Significant Weight Loss Review: . 6. Do meal rounds on resident as appropriate, document observations. Anything in the dining situation that should be improved? . 11. In IDT weekly weight meeting, evaluate current weekly weight on resident. If the resident has continued to lose weight, add or change current interventions. 12. Update Care Plan (CP). During a concurrent interview and record review with LN 7, on 5/8/19, at 11:21 a.m., she stated Resident 83 required supervision with eating, set-up with meals and encouragement and prompting while eating. LN 7 stated staff feeding Resident 83's roommate, should have monitored Resident 83 at the same time giving cueing and encouragement to eat. LN 7 stated the CNA's should have reported to the nurse if Resident 83 refused to eat so the nurse could encourage her to eat or offer a food alternative. LN 7 stated she had not received reports of Resident 83 refusing to eat. LN 7 stated she had not observed Resident 83's meal consumption. LN 7 stated she relied on the CNAs documented meal percentages and reports. LN 7 stated Resident 83 liked hot tea, cottage cheese, yogurt and nourishment and those items were available for Resident 83. LN 7 stated the rehabilitative nurse aide (RNA) took Resident 83's weights every week and reported any weight changes to the registered nurse supervisor (RNS). LN 7 stated the RN'S were the nurses responsible for the calculation of percentages of the meals eaten, weight loss or gains and notification to the Medical Doctor (MD) and family. LN 7 stated the RN was the person who would identify resident weight changes (LN 7 was a Licensed Vocational Nurse). LN 7 stated she did not review weights. LN 7 stated the RD recommendations were handled by her or other LNs. LN 7 reviewed the RD nutritional notes for Resident 83 and stated the RD had not given nutritional recommendations for Resident 83. During a concurrent observation and interview with CNA 9, on 5/8/19, at 2 p.m., Resident 83 was lying in bed with a lunch tray at the bedside. The lunch tray contained an empty cup of tea and empty bowl of cottage cheese. There was an uneaten sandwich, uneaten sliced peaches, a full glass of milk and house nourishment. CNA 9 stated Resident 83 ate 25 percent of her lunch based on the eaten cottage cheese and tea. CNA 9 stated Resident 83's appetite varied from okay to poor. CNA 9 stated Resident would eat approximately 25 to 75 percent of her meals. CNA 9 stated Resident 83 ate 75 percent of her breakfast the morning of 5/6/19 (Resident 83 was observed as refusing her breakfast meal on 5/6/19). CNA 9 stated he usually let the nurse know if Resident 83 ate 50 percent or less or if she refused to eat. CNA 9 stated he did not document that Resident 83's refused her breakfast the morning of 5/6/19 because Resident 83 ate what she wanted and documented that she ate 75 percent on 5/6/19. During an interview and record review with the unit manager (UM) on 5/9/19 at 9:24 a.m., UM stated she was aware of Resident 83's poor meal intake. The UM stated the CNA's assigned to Resident 83 were instructed to inform the nurses if Resident 83 refused to eat or the intake was 25 percent or less so the nurse could encourage the resident to eat or offer alternates. The UM stated the charge nurse monitored the meal intake of Resident 83 by checking the meal intake percentages the CNA's documented. The UM stated Resident 83 had an order for house supplements and protein supplements that were documented on the Medication Administration Record (MAR) by the nurse's once the LN observed Resident 83 drink the supplements. The UM reviewed the MAR dated 4/2019 through 5/2019 and did not find documentation of a house supplement or protein drinks consumed by Resident 83. The UM stated she did not find documentation of the amount of supplement consumed by Resident 83. During an interview with the UM, on 5/9/19, at 3:12 p.m., the UM stated, Resident 83 did not need to be fed because the resident was able to hold her spoon to feed herself and pick up her cup to drink. The UM stated the resident just needed reminders and cueing. The UM stated during meals CNA's feeding Resident 83's roommate were supposed to give Resident 83 reminders to pick up her spoon and cue Resident 83 to eat her meal. The UM stated, [Resident 83] sometimes will eat, sometimes refused to eat and sometimes she spits out her food. The UM stated meal intakes and supplements were monitored through the CNA's documentation of the meal intakes. The UM stated, When residents refused to eat or the meal intake are 25 percent or less the CNA's let me know and I go and talk to the resident to give encouragement and offer alternate food. The UM stated, I can only talk about myself, I don't know if all the nurses are doing it. The UM reviewed the meal intake of Resident 83 for the last three months and the record had not indicated any meal refusals. The UM stated, I did not understand how [Resident 83] continued to lose weight when meal intake and supplements are charted [documented by CNAs] that she did not refuse any meal or consumed only 25 percent and the supplements charted [documented] also as consumed. The UM stated weights were done by the Rehabilitative Nurse Aide (RNA) every week and every month. The UM stated Resident 83's weight loss was identified six months ago around the end of August 2018. The intervention was to weigh Resident 83 weekly, monitor her intake and provide more nutritional supplements. The UM stated due to the poor communication between the RD and the nursing department Resident 83's weight loss was not aggressively addressed and could have been prevented. During a concurrent interview and record review with the RNA, on 5/9/19, at 3:56 p.m., the RNA stated weights were done weekly and monthly. Weekly weights were performed on residents who were losing weight. The RNA stated if the scale showed a weight gain or loss of 5 lbs., he called the charge nurse who would confirm the weight. The RNA stated he made copies of the weights and Resident 83's weight loss was documented with copies given to the director of nursing (DON), RD and the RN supervisors. During a review of the facility policy and procedure titled, Weights and Heights, revised date 3/5/19, indicated, .1.2 The Weights Exception Report will be reviewed by a licensed nurse with follow-up as indicated .2.1 Significant weight changes will be reviewed by the licensed nurse for assessment . 3. The Interdisciplinary care plan will be updated to reflect individualized goals and approaches for managing the weight changes . 12. Document all interventions, support of oral intake, resident's response, and notifications (physician, resident representative, dietitian, etc.) . During an interview with the DON, on 5/9/19, at 5:15 p.m., the DON stated they held customer at risk (CAR) meetings every week with the other management staff, including the RD, and discussed weight loss. The DON stated the RD did not discuss Resident 83's weight loss in the meeting. The DON stated the RD was responsible for the weights and for nutritional assessments and notes. The DON stated the RD had not informed the team of the significant ongoing weight loss Resident 83 had experienced. The DON stated, We don't have the [RD weight loss] documentation. The DON stated she did not talk with the resident or the family about the weight loss or go over the wishes indicated in the POLST form for artificial nutrition (the provision of nutrients and liquids through the use of tubes). The DON stated she spoke with Resident 83's primary physician to ask him if he had discussed the option of artificial nutrition with the resident and family and the physician denied speaking to the resident or family member. The DON stated she expected her nurses to do a change of condition assessment when residents were experiencing significant weight changes. The DON stated the nurses did not do that. The DON stated the interdisciplinary team (IDT a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) reviewed changes of conditions every morning, discussed and checked care plans, and made sure family and physicians were notified. The DON stated the unit managers and supervisors were also responsible in following up on weight loss issues and making sure that actions were taken to resolve the issues when the DON was not available. The DON stated the weight loss for Resident 83 was avoidable and could have been prevented if the team would have communicated effectively. During a concurrent observation and interview with CNA 8, on 5/10/19 at 2 p.m., a lunch tray (photo obtained for comparison) came out of a Resident 83's room. On the tray was a plate with partially eaten pot pie with 2 slices of bread, uneaten bowl of fruit, a cup of tea, uneaten container of yogurt, uneaten bowl of peaches, uneaten covered soup and milk that got partially transferred to a plastic cup. CNA 8 stated the lunch meal contained the pot pie with bread, bowl of fruit, soup and milk. CNA 8 stated they (CNAs) calculate the food on the plate as 100%. CNA 8 stated, We only focus on the plate, we don't count the other stuff [other meal items on the tray]. CNA 8 stated the meal tray's intake was calculated as 50 percent. CNA 8 stated, We document it as 50% . if the meal intake is low, like 25%, we inform the charge nurse. During a concurrent photo (dated 5/10/19 of Resident 83's uneaten meal on the tray) review and interview with LVN 7, on 5/10/19 at 4:22 p.m., she stated, Nobody taught me how to do meal percentage. I think that is 25 percent [meal consumption] . we just measure the plate [CNA documented meal percentage as 50%]. During a concurrent photo (dated 5/10/19 of Resident 83's uneaten meal on the tray) review and interview with Registered Nurse Supervisor (RNS) 1, on 5/10/19, at 4:32 p.m., she stated, I think that is 50 percent. The plate is half eaten. I just look at it (plate) and calculate it in my head. I don't remember any training on meal intake measurement. During a concurrent photo (dated 5/10/19 of Resident 83's uneaten meal on the tray) review and interview with DON, on 5/10/19, at 5:02 p.m., she stated, I do not recall having any in-service or training for measuring food intake. The staff answers are different which means meal measurement documented were not accurate. During an interview and record review with the DON, on 05/13/19, at 2:03 p.m., the DON reviewed Resident 83's clinical record the Care Plan undated and stated, We did interventions for the nutrition and weight loss, provided care but now looking back we could have added to it. The DON stated, She [RD] should have involved the IDT and considered another interventions and tried to follow the POLST and tried the trial artificial nutrition then, we did not do it and when we addressed it, it was already too late. During a phone interview with Resident 83's Physician, on 5/17/19, at 5:40 p.m., the Physician stated he knew Resident 83 was admitted to the facility for a short term period with the goal to return home. The Physician stated Resident 83 did not achieve her short term goal and was moved to the long term wing. The Physician stated the nurse had called regarding weight loss and he had ordered some blood tests. The Physician stated he did not remember the nurse talking to him about the extent of the weight loss. The Physician stated he was not aware Resident 83 had lost so much weight. The Physician stated he did not speak with the family about a weight loss nor discussed a trial tube feeding because he was not informed of the significant weight loss by the nurse. The Physician stated he was never made aware about the Resident POLST form indicated wishes for a trial of artificial nutrition tube feeding (tube surgically inserted into the stomach to provide nutrition, hydration and medications). The Physician stated it should have been initiated prior to Resident 83 losing a significant amount of weight. During a review of Resident 83's clinical record, the Physician's orders, dated 7/27/18, indicated, Citalopram Hydrobromide [depression medication] tablet give 20 [milligrams] mg, give 1 tablet by mouth one time a day .Levaquin (type of antibiotic to treat lung infection) tablet 500 mg 1 tablet daily X [for] 5 days for Pneumonia. Levothyroxine [medication to treat hypothyroidism] Sodium tablet 75 mcg (unit of measurement) 1 tablet by mouth in the morning for hypothyroidism . Zolpidem tartrate (improves sleep in patients with insomnia) tablet 10 mg. Give 1 tablet every 24 hours as needed for Insomnia . The facility policy and procedure titled, Nutrition/Hydration Management dated 3/15/16 indicated.Staff will consistently observe and monitor patients for changes and implement revisions to the plan of care as needed . 6. Develop an interdisciplinary plan of care for enhancing oral intake and promoting adequate nutrition and hydration . 7. Observe oral intake of meals, supplements and snacks and complete the Meal Monitor Data Collection Sheet when ordered or indicated .9.1 Review advance directives or healthcare instructions to determine appropriateness of new or ongoing recommendations . The facility policy and procedure titled, Nutrition/Hydration Management dated 12/1/06 indicated . Staff will consistently observe and monitor residents for changes and implement revisions to the service plan as needed. Resident will receive care and support to enhance potential or attaining the highest level of nutrition and hydration status and the pleasure of eating . Consult with dietitian may be indicated . 3.1 unplanned weight loss . 3.2 Any stage pressure ulcer . 3.3 skin breakdown 3.4 inadequate oral intake, less than 50% of meals in 72 hours period. 2. During a concurrent observation and interview with Resident 83, on 5/6/19, at 8:15 a.m., Resident 83 was in her room sitting upright in bed on an air loss mattress (special mattress to distribute weight and minimize pressure to bony prominences) and a urinary catheter (a flexible tube inserted into the bladder to drain urine) at the side of her bed, her eyes were closed and sunken. Resident 83 was thin with sunken cheeks and dry wrinkled skin. Resident 83 grimaced and stated the bed was uncomfortable and her backside was hurting. During an interview with Certified Nursing Assistant (CNA) 3, on 5/6/19, at 3:25 p.m., she stated Resident 83 required assistance with turning and repositioning and set-up with meal trays. CNA 3 stated Resident 83 was incontinent of bowel and occasionally had loose stools. CNA 3 stated Resident 83 did not have open areas on her skin with the exception of redness to the lower back. CNA 3 stated the redness on Resident 83's lower back was related to moisture in the skin from the loose stools Resident 83 experienced. CNA 3 stated Resident 83 was bedridden and did not get out of bed. During a concurrent observation and interview with CNA 9, on 5/7/19, at 1:05 p.m., Resident 83 was in bed on her back side and awake. CNA 9 stated Resident 83 had redness to her lower back and was unsure if there were any open areas on Resident 83's skin. CNA 9 stated he did not recall completing a skin check to document Resident 83's skin condition. CNA 9 stated CNA's were required to check residents skin during care and position changes and inform the nurse if the CNA noticed any skin issues or wounds. During a concurrent interview and record review with the Unit Manager (UM) 1, on 5/7/19, at 1:30 p.m., UM 1 stated Resident 83 had a pressure ulcer stage 3 on the coccyx area. UM 1 stated the Stage 3 was reported on 5/6/19 to the nurse in the evening shift. UM 1 stated the treatment nurse and Registered Nurse Supervisor were asked to assess Resident 83's skin breakdown. During a concurrent interview and clinical record review with the UM 1, on 5/7/19, at 2 p.m., she reviewed the document titled BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK dated 3/12/19 and 5/7/19 which indicated, Moisture, degree to which skin is exposed to moisture, rarely moist: skin is usually dry .Activity, degree of physical activity, Chairfast .assisted into wheelchair .Nutrition, usual food intake[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents maintained their usual body weight for two of four sampled residents (Residents 83 and 95) when Registered Dietician (RD) did not conduct accurate nutritional assessments, communicate weight loss to interdisciplinary (IDT) team (members of the care team that include nurses, social workers, doctors, therapists and others) and implement effective actions and services to prevent significant weight loss. The RD and nursing staff failed to accurately document and monitor the daily meal consumption for Resident 83 and Resident 95. These failures resulted in Resident 83 experiencing a 47.9 pound (lbs.) weight loss or 36.7 percent weight loss over a period of 9 months. Resident 83 weighed 130 lbs. on admission on [DATE] and on 4/19/19 weighed 82 1b. For Resident 95 the failure resulted in a 25.3 lb. weight loss or 21.4 percent weight loss over a period of ten months. Resident 95 weighed 118 lbs. on admission on [DATE] and on 4/29/19 weighed 92.7 lbs. Findings: 1. During an observation in Resident 83's room, on 5/6/19, at 8:15 a.m., Resident 83 was in her room, in bed and sitting upright with her eyes closed. Resident 83's collar and shoulder bones were easily visible and her skin appeared dry and wrinkled. Resident 83's wrist and arms were visibly thin and without muscle mass. An over bed table was observed at the left side of Resident 83 with a breakfast tray. The following uneaten meal items were observed on the meal tray: pancakes with syrup and margarine, oatmeal in a bowl, scrambled eggs, a glass of juice, and a glass of milk. On the meal tray was an empty cup with a dry tea bag and a bowl with a small amount of cottage cheese. Resident 83 opened her eyes and began grimacing (facial expressions of pain) and stated the bed was uncomfortable and her backside was hurting. Resident 83 stated the meal tray was hers but she did not want it. Resident 83's face sheet (a document containing resident profile information) undated, indicated Resident 83 was admitted to the facility on [DATE] for a planned short rehabilitation stay to recover from a surgical repair of a broken hip. Resident 83 was admitted with diagnoses which included Pneumonia (infection in the lung), muscle weakness, iron deficiency Anemia (low red blood cells), Hypothyroidism (condition of low thyroid hormone which helps regulate body functions such as body temperature and heart rate), Major depression (mood disorder causes persistent feeling of sadness and loss of interest), Insomnia (inability to sleep), Gastroesophageal reflux disease (GERD- a digestive disorder characterized by reflux of stomach acid into the esophagus). During a review of the clinical record for Resident 83, the Minimum Data Set (MDS) assessment (functional and cognitive abilities assessed), dated 4/5/19, under Section C, Brief Interview for Mental Status (BIMS) score was 10 which indicated Resident 83 was moderately impaired in cognition (memory and judgement). During an interview with Certified Nursing Assistant (CNA) 3, on 5/6/19, at 3:25 p.m., she stated Resident 83 required assistance with the set-up of her meal tray. CNA 3 stated, Resident 83 was able to feed herself with set-up but required staff supervision and constant reminders to eat during her meals. CNA 3 stated, The staff member feeding Resident 83's roommate had to make sure to keep an eye on Resident 83 and to give constant reminders to eat. During a concurrent observation of Resident 83 in her room and interview with CNA 9, on 5/7/19, at 1:15 to 1:30 p.m., Resident 83 was in bed with the head of the bed elevated. Resident 83 was moving her food on her plate from one area to the next without bringing the food to her mouth. The lunch meal consisted of: Macaroni and cheese, stewed tomatoes, [NAME] slaw, bread roll, peaches, one glass of milk and a cup of hot tea. CNA 9 was in the room feeding Resident 83's roommate for 15 minutes and was not heard providing reminders or encouragement for Resident 83 to eat her meal. Resident 83 stated she was full and did not want to eat more. CNA 9 replied to Resident 83 Okay and continued to feed Resident 83's roommate. CNA 9 did not offer a substitute for the uneaten lunch meal. CNA 9 removed Resident 83's meal tray and stated that Resident 83 usually did not eat her meals. CNA 9 stated he should have offered Resident 83 an alternative food choice. During a concurrent interview and record review with Licensed Vocational Nurse (LVN 11), on 5/7/19, at 2:35 p.m., LVN 11 stated Resident 83 required supervision with meals. LVN 11 stated CNA's assigned to Resident 83 had to make sure to give her reminders to eat and report to the nurse when Resident 83 refused to eat. LN 11 stated she had not received a report from CNA 9 that Resident 83 refused her meals. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated, Resident 83 eats what she wants to eat. She is confused too so I have to talk to the CNA's taking care of her [for meal consumption information]. The RD stated Resident 83 liked yogurt, cottage cheese and fruits and hot tea. The RD stated those were options that could be given to Resident 83 if she refused her meal. RD stated she had not observed Resident 83 eat a meal since admission and relied on the CNAs documentation for the meal percentage. The RD stated she continued to monitor the documentation of Resident 83's weights weekly as well as her meal intake. The RD stated Resident 83 was admitted to the facility on [DATE] with a weight of 130.6 lbs. The RD stated Resident 83's current weight on 5/8/19 was 82.7 lbs. (a total of 47.3 lbs. weight loss within nine months from the date of admission of 7/27/18). The RD stated Resident 83 was currently under her ideal body weight of 160 to 130 lbs. The RD stated on admission, Resident 83's weight was 130.6 lbs. The RD stated she reviewed her initial assessment dated [DATE] and Resident 83's weight was at the lower end of Resident 83's Body Weight Range (BWR) of 160 to 130 lbs. and height was 64 inches. The RD stated Resident 83's usual weight was 130 lbs. per Resident 83. The RD stated she identified Resident 83 at nutritional risk due to her inadequate oral intake which would not meet her nutritional needs. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated between 7/27/18 and 8/27/18, Resident 83's weight dropped from 130.6 lbs. to 119.3 lbs., representing a weight loss of 11.3 lbs or 8.7 percent for one month. The RD stated she calculated Resident 83's meal intake using the CNAs documented meal percentages. The RD stated her calculations were that Resident 83 was eating 71 percent of her meals. The RD stated the weight loss was related to Resident 83's diagnosis of Clostridium difficile (C. diff, is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) infection. The RD stated Resident 83 was started on Flagyl (antibiotic medication to treat the infection) 500 mg three times a day times for 10 days. A stool culture to check for C-diff was collected on 8/3/18 and indicated positive for C. diff. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated, between 8/27/18 through 9/24/18 Resident 83's weight dropped from 119.3 lbs. to 104.9 lbs., representing a weight loss of 14.4 lbs., a 1 percent loss over one month. The RD stated Resident 83 was sent out to the general acute care hospital (GACH) from 9/9/18 thru 9/18/18 with diagnoses that included sepsis (is a potentially life-threatening condition caused by the body's response to an infection), Urinary tract infection (UTI- bladder infection) and was re-admitted on [DATE]. The RD reviewed the nutritional assessment dated [DATE] which indicated, Resident 83 was to continue with the current diet of Regular/Liberalized diet, looks visibly thin. The RD stated, Resident is meeting energy needs, the weight loss might have been related to the UTI, and the main goal was to prevent further weight loss. RD stated no new nutritional interventions were implemented at that time. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated between 9/24/18 through 11/6/18 the weight dropped from 104.9 lbs. to 97.8 lbs., representing a weight loss of 7.1 lbs., or 6.8 percent in 6 weeks. The RD reviewed the nutritional assessment dated [DATE], and stated Resident 83 continued on a Regular/liberalized diet, [new intervention of] House supplement two times a day. No chewing or swallowing problem, eats in her room for all meals and continue to require tray set-up. Intake 59% . [Resident 83] looks visibly thin. The RD note dated 10/3/18, indicated, Saw [Resident 83] food services and visited often and collect food preferences. The RD reviewed her RD notes dated 11/5/18, which indicated, RD saw resident and checked chewing and swallowing problem and collected food preferences. The RD note indicated, [Resident 83] likes cottage cheese and fruits and added as interventions. The RD stated, [Resident 83] was at risk for further weight loss. The RD reviewed the clinical record for her documented Frequent resident visits and interventions and was unable to find documentation of the frequent nutritional visits or interventions. The RD stated, I don't have those. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated between 11/6/18 through 12/6/18 the weight dropped from 97.8 lbs. to 93.3 lbs., a weight loss of 4.5 lbs. or 4.6 percent. The RD reviewed her RD note dated 11/7/18 and 11/12/18 which indicated, Per clinical meeting resident with soft/loose stools despite diet intake of fiber, resident will benefit from Nutrisource (fiber) packet twice a day to provide additional fiber. Appetite improving consuming 63% of meals, Resident 83 meeting estimated energy needs. The RD stated she was unsure why Resident 83 was continuing to lose weight when she was meeting her estimated nutritional needs. The RD stated she had not observed Resident 83's meal consumption since admission, but relied on the CNA's meal consumption documentation. RD stated she did not implement new nutritional interventions to slow or attempt to stop ongoing weight loss. During a concurrent record review and interview with the RD, on 5/8/19, at 10:43 a.m., the RD stated, between 12/6/18 through 1/8/19 the weight dropped from 93.3 lbs. to 88.7 lbs., representing a weight loss of 4.6 lbs., or 4.9 percent. The RD stated the weight loss was not significant, and no new interventions were added at that time. During a concurrent record review and interview with the RD, on 5/8/19, at 10:44 a.m., the RD stated, between 1/8/19 through 2/4/19 the weight dropped from 88.7 lbs. to 88.4 lbs., representing a weight loss of 0.3 lbs. The RD stated the weight loss was not significant and weight had been stable, but the RD did add one nutritional supplement with breakfast. During a concurrent record review and interview with the RD, on 5/8/19, at 10:46 a.m., the RD stated, between 2/4/19 through 3/4/19, the weight dropped from 88.4 lbs. to 84.6 lbs., representing a weight loss of 3.8 lbs., or 4.3 percent. The RD reviewed the nutritional assessment dated [DATE] which indicated, Continue on Regular/Liberalized . Evaluation/Nutrition plan: [Resident 83] meeting estimated energy needs, previous oral intake was meeting estimated energy needs, main goal to prevent further weight loss. Resident had snacks in between meals. The RD stated Resident 83 was underweight. During a concurrent record review and interview with the RD, on 5/8/19, at 10:47 a.m., the RD stated, between 3/4/19 through 4/15/19, the weight dropped from 84.6 lbs. to 81.3 lbs., representing a weight loss of 3.3 lbs., or 3.9 percent. The RD stated she reviewed the nutritional assessment dated [DATE] and 4/2/19, which indicated, Continue on Regular Liberalized diet . Nutrition History: Has triggered for significant weight loss X [for] 6 months, -[lost] 24.9%, -[lost] 28lbs. comparison weight of -[lost] 8.7lbs, -[lost] 9.3% X 3 months . Resident weight loss continues . During a concurrent record review and interview with the RD, on 5/8/19, at 10:48 a.m., the RD stated between 4/5/19 through 4/29/19, the weight was 82.7 lbs. The RD stated Resident 83's weight loss had stabilized since March, and she did not add new interventions. The RD stated she did not attend any of the interdisciplinary team meeting (IDT) or care plan conferences to communicate Resident 83's ongoing weight loss with the team. The RD stated the IDT would invite her to the meetings but she had not attended the meetings for any of the residents that were losing weight, including Resident 83. RD stated she should have been present in the care conferences and should have discussed the continued weight losses but she had not. The RD stated she did not monitor or validate the CNA's capability to document meal percentages accurately. The RD stated, I assumed that they are calculating it correctly, I relied on the data that was presented to me. The RD stated CNAs were not documenting Resident 83's meal percentages accurately based on the intake documented and the weight loss that had occurred. The RD stated the meal percentages documented by the CNAs did not match or support Resident 83's ongoing weight loss. The RD stated she did not provide in-service education to CNA's on how to accurately document meal percentages. The RD stated, The director of staff development (DSD) does the in-services regarding food percentages and there are postings for the CNA's to follow in regards to the calculations of meals percentages. RD stated she attended Customer at Risk (CAR) meetings every Tuesday morning with the MD, DON, Social Service Director (SSW), and RN supervisor. In the CAR meeting the group discussed recent weight loss, weight changes and new admissions. The RD stated she had not discussed the weight loss of Resident 83 in the meetings. She stated, For some reason, I just missed it [Resident 83's ongoing weight loss]. The RD stated she did not remember talking to Resident 83's Responsible Party about the weight loss and did not look at the Provider Orders for Life-Sustaining Treatment (POLST) form. The RD stated she was responsible for the nutrition care plans, evaluating and updating the interventions as needed when nutritional issues were identified. The RD stated she reviewed the care plan interventions but was unable to find documentation where she evaluated and/or revised her nutritional interventions for Resident 83. The RD stated she did not know why Resident 83 was losing weight. The RD stated, I just missed it [the weight loss]. During a review of Resident 83's clinical records the Weights and Vitals Summary dated 7/27/18 to 4/26/19 indicated Resident 83's admission weight on 7/27/18 was 130.6 lbs. and on 5/8/19 the weight was 82.7 lbs. There was a total loss of 47.9 lbs. or 36.7 percent weight loss within nine months. During a review of the facility document the, [RD] JOB DESCRIPTION: DIETITIAN dated 5/29/17 indicated . RESPONSIBLITIES and ACCOUNTABILITILITIES .4. Collaborates with the interdisciplinary team to develop nutritional plans of care for the residents/patients. 5. Monitor and evaluate effectiveness of nutritional interventions . 12. Participates in the education and training of center staff . Review of facility document titled HIGH RISK NOTE FORMAT dated July 2013 indicated . Pressure Ulcer Review: . 2. Weight and weight history, trend . 4. Current nutritional interventions, if any. Are they accepted and effective? . Significant Weight Loss Review: . 6.Do meal rounds on resident as appropriate, document observations. Anything in the dining situation that should be improved? . 11. In IDT weekly weight meeting, evaluate current weekly weight on resident. If the resident has continued to lose weight, add or change current interventions. 12. Update Care Plan (CP). During a concurrent interview and record review with LN 7, on 5/8/19, at 11:21 a.m., she stated Resident 83 required supervision with eating, set-up with meals and encouragement and prompting while eating. LN 7 stated staff feeding Resident 83's roommate, should have monitored Resident 83 at the same time giving cueing and encouragement to eat. LN 7 stated the CNA's should have reported to the nurse if Resident 83 refused to eat so the nurse could encourage her to eat or offer a food alternative. LN 7 stated she had not received reports of Resident 83 refusing to eat. LN 7 stated she had not observed Resident 83's meal consumption. LN 7 stated she relied on the CNAs documented meal percentages and reports. LN 7 stated Resident 83 liked hot tea, cottage cheese, yogurt and nourishment and those items were available for Resident 83. LN 7 stated the rehabilitative nurse aide (RNA) took Resident 83's weights every week and reported any weight changes to the registered nurse supervisor (RNS). LN 7 stated the RN'S were the nurses responsible for the calculation of percentages of the meals eaten, weight loss or gains and notification to the Medical Doctor (MD) and family. LN 7 stated the RN was the person who would identify resident weight changes (LN 7 was a Licensed Vocational Nurse). LN 7 stated she did not review weights. LN 7 stated the RD recommendations were handled by her or other LNs. LN 7 reviewed the RD nutritional notes for Resident 83 and stated the RD had not given nutritional recommendations for Resident 83. During a concurrent observation and interview with CNA 9, on 5/8/19, at 2 p.m., Resident 83 was lying in bed with a lunch tray at the bedside. The lunch tray contained an empty cup of tea and empty bowl of cottage cheese. There was an uneaten sandwich, uneaten sliced peaches, a full glass of milk and house nourishment. CNA 9 stated Resident 83 ate 25 percent of her lunch based on the eaten cottage cheese and tea. CNA 9 stated Resident 83's appetite varied from okay to poor. CNA 9 stated Resident would eat approximately 25 to 75 percent of her meals. CNA 9 stated Resident 83 ate 75 percent of her breakfast the morning of 5/6/19 (Resident 83 was observed as refusing her breakfast meal on 5/6/19). CNA 9 stated he usually let the nurse know if Resident 83 ate 50 percent or less or if she refused to eat. CNA 9 stated he did not document that Resident 83's refused her breakfast the morning of 5/6/19 because Resident 83 ate what she wanted and documented that she ate 75 percent on 5/6/19. During an interview and record review with the unit manager (UM) on 5/9/19 at 9:24 a.m., UM stated she was aware of Resident 83's poor meal intake. The UM stated the CNA's assigned to Resident 83 were instructed to inform the nurses if Resident 83 refused to eat or the intake was 25 percent or less so the nurse could encourage the resident to eat or offer alternates. The UM stated the charge nurse monitored the meal intake of Resident 83 by checking the meal intake percentages the CNA's documented. The UM stated Resident 83 had an order for house supplements and protein supplements that were documented on the Medication Administration Record (MAR) by the nurse's once the LN observed Resident 83 drink the supplements. The UM reviewed the MAR dated 4/2019 through 5/2019 and did not find documentation of a house supplement or protein drinks consumed by Resident 83. The UM stated she did not find documentation of the amount of supplement consumed by Resident 83. During an interview with the UM, on 5/9/19, at 3:12 p.m., the UM stated, Resident 83 did not need to be fed because the resident was able to hold her spoon to feed herself and pick up her cup to drink. The UM stated the resident just needed reminders and cueing. The UM stated during meals CNA's feeding Resident 83's roommate were supposed to give Resident 83 reminders to pick up her spoon and cue Resident 83 to eat her meal. The UM stated, [Resident 83] sometimes will eat, sometimes refused to eat and sometimes she spits out her food. The UM stated meal intakes and supplements were monitored through the CNA's documentation of the meal intakes. The UM stated, When residents refused to eat or the meal intake are 25 percent or less the CNA's let me know and I go and talk to the resident to give encouragement and offer alternate food. The UM stated, I can only talk about myself, I don't know if all the nurses are doing it. The UM reviewed the meal intake of Resident 83 for the last three months and the record had not indicated any meal refusals. The UM stated, I did not understand how [Resident 83] continued to lose weight when meal intake and supplements are charted [documented by CNAs] that she did not refuse any meal or consumed only 25 percent and the supplements charted [documented] also as consumed. The UM stated weights were done by the Rehabilitative Nurse Aide (RNA) every week and every month. The UM stated Resident 83's weight loss was identified six months ago around the end of August 2018. The intervention was to weigh Resident 83 weekly, monitor her intake and provide more nutritional supplements. The UM stated due to the poor communication between the RD and the nursing department Resident 83's weight loss was not aggressively addressed and could have been prevented. During a concurrent interview and record review with the RNA, on 5/9/19, at 3:56 p.m., the RNA stated weights were done weekly and monthly. Weekly weights were performed on residents who were losing weight. The RNA stated if the scale showed a weight gain or loss of 5 lbs., he called the charge nurse who would confirm the weight. The RNA stated he made copies of the weights and Resident 83's weight loss was documented with copies given to the director of nursing (DON), RD and the RN supervisors. During a review of the facility policy and procedure titled, Weights and Heights, revised date 3/5/19, indicated, .1.2 The Weights Exception Report will be reviewed by a licensed nurse with follow-up as indicated .2.1 Significant weight changes will be reviewed by the licensed nurse for assessment . 3. The Interdisciplinary care plan will be updated to reflect individualized goals and approaches for managing the weight changes . 12. Document all interventions, support of oral intake, resident's response, and notifications (physician, resident representative, dietitian, etc.) . During an interview with the DON, on 5/9/19, at 5:15 p.m., the DON stated they held customer at risk (CAR) meetings every week with the other management staff, including the RD, and discussed weight loss. The DON stated the RD did not discuss Resident 83's weight loss in the meeting. The DON stated the RD was responsible for the weights and for nutritional assessments and notes. The DON stated the RD had not informed the team of the significant ongoing weight loss Resident 83 had experienced. The DON stated, We don't have the [RD weight loss] documentation. The DON stated she did not talk with the resident or the family about the weight loss or go over the wishes indicated in the POLST form for artificial nutrition (the provision of nutrients and liquids through the use of tubes). The DON stated she spoke with Resident 83's primary physician to ask him if he had discussed the option of artificial nutrition with the resident and family and the physician denied speaking to the resident or family member. The DON stated she expected her nurses to do a change of condition assessment when residents were experiencing significant weight changes. The DON stated the nurses did not do that. The DON stated the interdisciplinary team (IDT a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) reviewed changes of conditions every morning, discussed and checked care plans, and made sure family and physicians were notified. The DON stated the unit managers and supervisors were also responsible in following up on weight loss issues and making sure that actions were taken to resolve the issues when the DON was not available. The DON stated the weight loss for Resident 83 was avoidable and could have been prevented if the team would have communicated effectively. During a concurrent observation and interview with CNA 8, on 5/10/19 at 2 p.m., a lunch tray (photo obtained for comparison) came out of a Resident 83's room. On the tray was a plate with partially eaten pot pie with 2 slices of bread, uneaten bowl of fruit, a cup of tea, uneaten container of yogurt, uneaten bowl of peaches, uneaten covered soup and milk that got partially transferred to a plastic cup. CNA 8 stated the lunch meal contained the pot pie with bread, bowl of fruit, soup and milk. CNA 8 stated they (CNAs) calculate the food on the plate as 100%. CNA 8 stated, We only focus on the plate, we don't count the other stuff [other meal items on the tray]. CNA 8 stated the meal tray's intake was calculated as 50 percent. CNA 8 stated, We document it as 50% . if the meal intake is low, like 25%, we inform the charge nurse. During a concurrent photo (dated 5/10/19 of Resident 83's uneaten meal on the tray) review and interview with LVN 7, on 5/10/19 at 4:22 p.m., she stated, Nobody taught me how to do meal percentage. I think that is 25 percent [meal consumption] . we just measure the plate [CNA documented meal percentage as 50%]. During a concurrent photo (dated 5/10/19 of Resident 83's uneaten meal on the tray) review and interview with Registered Nurse Supervisor (RNS) 1, on 5/10/19, at 4:32 p.m., she stated, I think that is 50 percent. The plate is half eaten. I just look at it (plate) and calculate it in my head. I don't remember any training on meal intake measurement. During a concurrent photo (dated 5/10/19 of Resident 83's uneaten meal on the tray) review and interview with DON, on 5/10/19, at 5:02 p.m., she stated, I do not recall having any in-service or training for measuring food intake. The staff answers are different which means meal measurement documented were not accurate. During an interview and record review with the DON, on 05/13/19, at 2:03 p.m., the DON reviewed Resident 83's clinical record the Care Plan undated and stated, We did interventions for the nutrition and weight loss, provided care but now looking back we could have added to it. The DON stated, She [RD] should have involved the IDT and considered another interventions and tried to follow the POLST and tried the trial artificial nutrition then, we did not do it and when we addressed it, it was already too late. During a phone interview with Resident 83's Physician, on 5/17/19, at 5:40 p.m., the Physician stated he knew Resident 83 was admitted to the facility for a short term period with the goal to return home. The Physician stated Resident 83 did not achieve her short term goal and was moved to the long term wing. The Physician stated the nurse had called regarding weight loss and he had ordered some blood tests. The Physician stated he did not remember the nurse talking to him about the extent of the weight loss. The Physician stated he was not aware Resident 83 had lost so much weight. The Physician stated he did not speak with the family about a weight loss nor discussed a trial tube feeding because he was not informed of the significant weight loss by the nurse. The Physician stated he was never made aware about the Resident POLST form indicated wishes for a trial of artificial nutrition tube feeding (tube surgically inserted into the stomach to provide nutrition, hydration and medications). The Physician stated it should have been initiated prior to Resident 83 losing a significant amount of weight. During a review of Resident 83's clinical record, the Physician's orders, dated 7/27/18, indicated, Citalopram Hydrobromide [depression medication] tablet give 20 [milligrams] mg, give 1 tablet by mouth one time a day .Levaquin (type of antibiotic to treat lung infection) tablet 500 mg 1 tablet daily X [for] 5 days for Pneumonia. Levothyroxine [medication to treat hypothyroidism] Sodium tablet 75 mcg (unit of measurement) 1 tablet by mouth in the morning for hypothyroidism . Zolpidem tartrate (improves sleep in patients with insomnia) tablet 10 mg. Give 1 tablet every 24 hours as needed for Insomnia . The facility policy and procedure titled, Nutrition/Hydration Management dated 3/15/16 indicated.Staff will consistently observe and monitor patients for changes and implement revisions to the plan of care as needed . 6. Develop an interdisciplinary plan of care for enhancing oral intake and promoting adequate nutrition and hydration . 7. Observe oral intake of meals, supplements and snacks and complete the Meal Monitor Data Collection Sheet when ordered or indicated .9.1 Review advance directives or healthcare instructions to determine appropriateness of new or ongoing recommendations . The facility policy and procedure titled, Nutrition/Hydration Management dated 12/1/06 indicated . Staff will consistently observe and monitor residents for changes and implement revisions to the service plan as needed. Resident will receive care and support to enhance potential or attaining the highest level of nutrition and hydration status and the pleasure of eating . Consult with dietitian may be indicated . 3.1 unplanned weight loss . 3.2 Any stage pressure ulcer . 3.3 skin breakdown 3.4 inadequate oral intake, less than 50% of meals in 72 hours period. 2. During a review of the clinical record for Resident 95, the Weights and Vitals Summary dated 5/15/19, indicated Resident 95 was admitted on [DATE] weighing 118.0 lbs. and on 4/29/19 weighed 92.7 lbs. Resident 95 had a weight loss of 25.3 lbs or 21.4 percent in the last ten months (4/29/19). Review of the Weights and Vital Summary report dated 5/15/19, indicated the following weights: (7/3/18) admission weight of 118.0 lbs and height 60 inches. 7/9/18, 116.2 lbs 7/16/18, 114.3 lbs, 7/23/18 111.9 lbs, 7/30/18 111.2 lbs 8/6/2018 112 lbs 9/9/18, 113.9 lbs. 10/5/18, 112.3lbs 11/6/18, 108.7lbs 12/6/18, 111.8 lbs 1/8/19, 106.7 lbs 2/8/19, 103.8 lbs 3/5/19, 91.7 lbs 3/11/19, 91.0 lbs 3/18/19, 89 lbs 3/25/19, 94 lbs. 4/1/19, 92.0 lbs 4/8/19, 91.1 lbs 4/15/19, 92.0 lbs 4/22/19, 91.8 lbs., [weight loss of 26.2 lbs] 4/29/19, 92.7 lbs. [weight loss of 25.3 lbs.] During a concurrent record review and interview with Registered Nurse Supervisor (RNS) 2, on 5/15/19, at 1:31 p.m., she stated Resident 95 was admitted to the facility on [DATE] with a diagnosis of fracture of second lumbar vertebrae (broken bone of the lower back) for therapy. RNS 2 stated Resident 95's admission weight on 7/3/18 was 118 lbs. The RNS 2 stated the weight summary report indicated Resident 95's weight of 112 lbs (a total of 6 lbs. lost) on 8/6/18 date. RNS 2 stated Resident 95 had experiences a weight loss of 5% during the first month of admission from 7/3/18 to 8/6/18. RNS 2 stated she was the person responsible for monitoring resident weight changes and identifying weight concerns timely. RNS 2 sated, This weight loss was not identified by nursing department and it should have been identified. RNS 2 stated since the weight loss went unnoticed Resident 95 did not receive nutritional assessments. The RNS 2 stated Resident 95's physician was not notified of the 5% weight loss. RNS 2 stated, There should have been a nursing assessment, nutritional assessment, physician notification and new care plan interventions [to prevent ongoing weight loss] for the significant weight loss . RNS 2 stated the RD progress note dated 8/9/18 indicated, Resident current body weight is 112 .