Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received care to prevent the development of pressure ulcers/injuries (PU/PI - areas of damaged skin caused by staying in one position for too long, usually over an area on the body where a bone is close to the skin's surface (bony prominence)) when: 1. Resident 1 was at risk for developing pressure ulcers and worsening of a shearing wound (a force that causes the skin and underlying tissues to move in opposite directions, often due to pressure and friction) on the coccyx (tailbone). Resident 1's skin assessments and wound documentation were incomplete, the physician was not notified the wound had worsened, and PU preventative measures were not correctly identified and implemented upon admission; and, 2. Resident 2 was at risk of developing pressure ulcers and worsening of a shearing wound on the coccyx and blanchable redness (a temporary reddening of the skin that disappears when pressure is applied) to both heels. Resident 2's skin assessments and wound documentation were incomplete and measures to prevent PU development were not implemented. These failures resulted in Resident 1 having wound pain and required surgical intervention at a hospital with the placement of a wound vacuum (VAC -a medical treatment that uses negative pressure to help severe wounds heal). In addition, these failures resulted in Resident 2 developing a deep tissue injury (DTI - deep skin and tissue loss where the extent of the damage cannot be determined because it is covered by eschar (black dead tissue)) to the left heel and had the potential to result in increased pain, infection (the invasion and growth of germs in the body), and muscle or bone loss. Findings: 1. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in Spring 2025 with diagnoses which included but not limited to: sepsis (a life-threatening infection), arthritis (swelling and tenderness where two or more bones meet, causing joint pain and/or stiffness) due to other bacteria (an infection in the joint fluid and tissues caused by bacteria), chronic obstructive pulmonary disease (COPD -a chronic lung disease causing difficulty breathing), and muscle weakness. A review of Resident 1's Minimum Data Set (MDS -an assessment tool), dated 4/22/25, in the section, M -Skin Conditions, indicated, Resident 1 was at risk of developing pressure ulcers. During a concurrent interview and record review on 5/13/25, at 1:19 PM, Resident 1's electronic health record (EHR) was reviewed with Licensed Nurse (LN) 1. LN 1 stated Resident 1 was admitted with two wounds, one on the left hand, and a shearing wound on the coccyx. Resident 1's admission -readmission Nursing Evaluation . dated 4/18/25, indicated, .Indicate Pressure Ulcers and/or other wound types .Sacrum [triangular shaped bone in the lower back located between the hip bones] .Type: Pressure [injury to skin and underlying tissue resulting from prolonged pressure on the skin] .Length 1.8 [cm- centimeter -a metric unit of length], Width 0.8 [cm], Depth 0.1 [cm], Stage II [2 -partial-thickness skin loss, presenting as a shallow open wound; wounds are classified into stages to indicate the depth of tissue damage and includes stages 1 through 4 and unstageable (when dead tissue is covering the wound making it unable to determine the depth of the wound)] . LN 1 stated the nurse who completed Resident 1's Admission-readmission Nursing Evaluation was not a wound nurse. LN 1 stated he updated the description of the wound on the order he entered after he assessed Resident 1's wounds. LN 1 confirmed he entered .Cleanse [clean] shearing wounds to coccyx . to Resident 1's orders on 4/18/25 which changed the type of wound listed on the order from pressure ulcer to shearing wound. LN 1 stated he did not document in a progress note (a written record that documents a resident's health status, treatment progress, and any changes in their condition over time) the measurements, location, and description of what the wound looked like after his initial assessment. LN 1 further stated he needed to get better at documentation, and he tried to make weekly progress notes but stated he missed the charting. LN 1 confirmed Resident 1's BRADEN SCALE [a widely used tool in healthcare to assess and predict a patient's risk for developing pressure ulcers] FOR PREDICTING PRESSURE SORE RISK, dated 4/18/25, indicated, .MOISTURE .Rarely Moist [the degree to which skin is exposed to moisture ranging from rarely moist to constantly moist], .MOBILITY [the ability to move or be moved freely and easily] .Very Limited: Makes occasional slight changes in body or extremity [arms and/or legs] position but unable to make frequent or significant changes independently .[Resident 1 was] AT RISK [risk levels for pressure ulcer development range from at risk, moderate risk, high risk, or very high risk based off of the score obtained from the Braden scale assessment tool] . for pressure ulcers. LN 1 stated he disagreed with Resident 1's initial Braden scale assessment risk level since Resident 1 was fully incontinent of bowel and bladder (involuntary loss of urine or feces), had a high moisture risk, was immobile (not capable of movement), and required assistance to turn or reposition in bed. LN 1 stated Resident 1's Braden Scale assessment should have been assessed as a high risk for pressure ulcer development. LN 1 further stated it was his expectation for Resident 1 to be turned and repositioned every two hours to prevent the wound from worsening. LN 1 explained he completed Resident 1's wound care based on the treatment listed on the treatment administration record (TAR - a document used to track the administration of various treatments, including medications, therapies, and procedures). LN 1 stated he noted on 4/24/25 Resident 1's wound to the coccyx worsened and the wound size increased. LN 1 reviewed Resident 1's Progress Notes, dated 4/24/25, written by LN 1, which indicated, .LATE ENTRY .Provided wound care for resident with shearing wound to coccyx .Wound size went from 3.5x1.5x0.1 [length, width, depth in cm] on admission to 6.2x3x0.1 .discolored sheared skin. Periwound [around the wound] is macerated [softening and breaking down of the skin resulting from prolonged exposure to moisture] .Resident complains of discomfort wound pain 6/10 [pain scale 0-no pain to 10-worse pain] with wound care . LN 1 confirmed that the late entry for the worsening of Resident 1's wound was written in Resident 1's EHR on 5/7/25. LN 1 stated he forgot to document Resident 1 had a worsening condition of the wound on 4/24/25 and confirmed he did not notify the doctor. LN 1 further stated it was facility policy to notify the doctor and to document worsened conditions immediately to obtain new physician orders for wound treatment. Resident 1's EHR was reviewed by LN 1, and he was unable to locate any further documentation regarding Resident 1's worsening wounds. During a follow up interview on 5/13/25 at 2:49 PM, LN 1 stated documentation in a resident's medical record was important because it provided accurate and efficient documentation on what was happening with the resident. LN 1 further explained it was important to document timely and notify the doctor of a change in a resident's medical condition to keep the doctor and care team up to date, and the doctor could give new orders to prevent wounds from getting worse. LN 1 stated the risk to a resident not being turned every two hours (q2h -a patient care practice where a patient is repositioned every two hours) was it increased skin breakdown, decreased circulation (inadequate blood flow through the body's blood vessels), was not good for anyone to stay in one position too long, and for comfort of the resident. LN 1 reviewed Resident 1's medical record but could not find evidence Resident 1 was turned every 2 hours, or where Resident 1 refused to be turned. During a concurrent telephone interview and record review on 5/14/25, at 1:16 PM, LN 4 (a nurse from the hospital Resident 1 was sent from and back out to), confirmed she wrote Resident 1's Progress Note, dated 4/18/25 (day Resident 1 discharged from the hospital and was admitted to the facility) and took photos of the wound to Resident 1's coccyx during her stay at the hospital. LN 4 further stated Resident 1's Progress Note, indicated, .Coccyx continues to have an area of friction [force of rubbing between two surfaces] to left coccyx, wound bed is pink with red frayed [ragged] edges, blanchable erythema [a reddening of the skin that disappears when pressure is applied and returns to normal color when pressure is released], hyperpigmentation [areas of skin that appear darker than the surrounding areas] is noted at gluteal cleft [the deep groove or crease that separates the two buttocks] .skin intact .goals are to .reduce friction and pressure .turn q2hours . LN 4 further stated when Resident 1 returned to the hospital on 4/27/25, Resident 1's wound was re-evaluated and confirmed Resident 1's coccyx had worsened. LN 4 stated the wound covered both sides of Resident 1's buttocks creating an unstageable pressure ulcer with a foul odor (likely indicating infection). LN 4 confirmed Resident 1 required surgical debridement (removal of damaged tissue from a wound) on 5/3/25 and Resident 1 had to have a wound vacuum placed on the coccyx to help close the wound. A review of Resident 1's, Care Plan Report, dated 4/19/25, indicated, . [Resident 1] has skin sheering to her coccyx upon admit .Goal [Resident 1's] skin will show signs of improvement .Interventions/Tasks .Monitor for s/sx [signs and symptoms] of infection .Notify MD [medical doctor] of s/sx of infection . A review of Resident 1's, Nursing Progress Note, dated 4/24/25 (late documentation on 5/7/25), indicated, .LATE ENTRY .Provided wound care for resident with shearing wound to coccyx, increase in size r/t [related to] persistent watery stools. Wound size went from 3.5x1.3x0.1 on admission to 6.2x3x0.1. Wound bed is 100% [percent] granulation [pink or red, fleshy skin growth] with discolored sheared skin. Periwound is macerated. Resident complains of discomforting wound pain 6/10 with wound care . A review of Resident 1's Order Details, order date 4/18/25, indicated, .Cleanse shearing wounds to coccyx with NS [normal saline -salt water], pat dry .every day shift for skin shearing . A review of Resident 1's Order Details, order date 4/18/25, indicated, .Monitor shearing wounds to coccyx for s/s [signs/symptoms] of infection until resolved . A review of Resident 1's Order Details, order date 4/19/25, indicated, .Cleanse shearing wounds to coccyx with NS, pat dry .cover with foam dressing [an absorbent wound covering to promote wound healing] .every day shift for skin shearing AND as needed for soiled, lifting or missing [dressing] . A review of Resident 1's Nursing Progress Note, dated 4/26/25, indicated, . [Resident 1] transferred to ER [Emergency Room] . [Resident 1] was having hallucinations [sensing things such as visions, sounds, or smells that seem real but are not] and thinking people were in bed with her, nurse noted grayish appearance . Review of an online version of a published book titled NURSING FUNDAMENTALS SECOND EDITION, dated 2024, in the section 10.5 Braden Scale, indicated, .Each risk factor on the Braden Scale is rated from 1 to 4 based on the client's assessment findings. When using the Braden Scale, start with the first category and review each description listed across the row for each of the ratings from 1 to 4, and choose the one that best describes the client's current status. Continue this process for all rows. Add all six numbers to determine a total score, and then use the total score to determine if the client is at mild, moderate, high, or severe risk for developing a pressure injury. The lower the score, the higher the risk of developing a pressure injury. Additionally, customized nursing interventions are implemented based on the rating in each category. The lower the score, the more aggressive actions are taken to prevent or heal a pressure injury . (https://wtcs.pressbooks.pub/nursingfundamentals/chapter/10-5-braden-scale/) 2. A review of Resident 2's admission RECORD indicated Resident 2 was admitted to the facility in the Summer of 2022 with diagnoses which included but not limited to: Cerebral Infarction (otherwise known as Ischemic Stroke -the death of brain tissue due to a lack of blood supply), difficulty in walking, muscle weakness, and heart failure (when the heart is unable to pump enough blood to meet the body's needs). A review of Resident 2's Minimum Data Set (MDS -an assessment tool), dated 3/02/25, in the section, M -Skin Conditions, indicated, Resident 2 was at risk of developing pressure ulcers. During a concurrent interview and record review on 5/13/25 at 2 PM, Resident 2's EHR was reviewed with LN 1. LN 1 stated Resident 2's shearing wound to the coccyx was first documented on 3/11/25 and confirmed Resident 2 obtained the wound while residing in the facility. LN 1 confirmed Resident 2 also had blanchable redness (a red or discolored area that turns white or pale when pressed) documented to both the right and left heels on 4/5/25. LN 1 confirmed monitoring of Resident 2's coccyx and heels was placed on the TAR and began on 4/5/25. LN 1 confirmed Resident 2 was immobile, depended on staff for all care, and stated Resident 2 needed to be turned q2h and had heel lift boots (a type of boot or device designed to elevate the heel) applied to both heels to prevent worsening redness and pressure ulcer development. LN 1 further stated the heel lift boots were required anytime Resident 2 was in bed. LN 1 further stated the care plan indicated Resident 2 was to be turned every 2 hours and was incontinent of bladder and bowel. LN 1 further explained it was important that these interventions were implemented to prevent pressure ulcers or other skin wounds from worsening. LN 1 confirmed Resident 2 should be turned every 2 hours by the CNA's (Certified Nursing Assistants). LN 1 confirmed Resident 2's EHR showed no evidence she had been turned every 2 hours per the care plan. During a concurrent interview and record review on 5/13/25 at 2:31 PM, CNA 3 stated the CNA's do not turn residents every 2 hours because they did not have any residents that required it. CNA 3 reviewed Resident 2's EHR and confirmed the care plan for Resident 2 indicated for her to be turned at least every 2 hours, however, CNA 3 stated she would have no way of knowing what was in resident's care plans. CNA 3 further stated she relied on the nurses to tell them, and she stated she had never been told any resident's required being turned or repositioned every 2 hours. During a concurrent observation and interview on 5/13/25 at 2:09 PM, with LN 1, in Resident 2's room, Resident 2 was observed lying in bed on her back. LN 1 exposed Resident 2's legs by removing the covers. Resident 2 had on the right sided heel lift boot; however, the left heel was lying on the bed and not in the boot. LN 1 then proceeded with wound care to the left heel. LN 1 removed a foam bandage on Resident 2's left heel. Resident 2's left medial (situated toward the middle of the body) heel where the foam bandage was removed was indented with the bandage and exposed a 2-3 cm dark black puffy circle. LN 1 stated when he last saw the left heel on 5/10/25 it was not like this. LN 1 further stated it was unusual for the wound to turn from just redness to black calling it a deep tissue injury with eschar (dry, leathery, black or brown dead tissue that forms over a wound). LN 1 further explained he was off for the last 2 days and was not notified of any changes, and did not see any documentation in Resident 2's medical record to indicate worsening to the left heel. LN 1 cleansed the wound and replaced the bandage. LN 1 then rolled Resident 2 directly onto her right side exposing her back and buttocks. LN 1 removed the foam bandage covering the wound to Resident 2's coccyx. Resident 2's coccyx had two opened areas actively bleeding and just above on the sacrum was a round opened, and bleeding wound consistent with a Stage 3 pressure ulcer (full-thickness skin loss that extends into the deepest layer of skin) circular in size on a bony prominence, surrounded by non-blanchable redness (a red or discolored area that does not turn white or pale when pressed). LN 1 stated he still believed the wound to the coccyx and sacrum was a shearing wound due to the odd shape and stated it was not a pressure ulcer because it was not circular, but did state the wound was larger. During a concurrent interview and record review on 5/13/25 at 2:49 PM, LN 1 stated the last measurement of the wound was 1.9 x 1.2 cm that he had documented on a written piece of paper that listed each resident with wounds for the week of 4/24/25. LN 1 confirmed there was not any additional written documentation of the wound to Resident 2's coccyx or left heel other than checking off the wound care was completed in the TAR. LN 1 confirmed his documentation was lacking due to time restraints and could be better, but would document the changes he observed today, including getting the wound care clinic involved in treating Resident 2 since the wounds worsened. LN 1 reviewed Resident 2's EHR and stated the only documentation of the skin was done on 5/11/25 on the Long Term Care Weekly Evaluation . form and stated the nurse who completed the evaluation checked the box that indicated, .No New Impairment. Skin clean, dry and intact . LN 1 confirmed the skin was not intact and stated it was his understanding the wounds to the coccyx and left heel were healing and not worsening. During a concurrent interview and record review on 5/13/25 at 2:39 PM, LN 2 stated the expectation for residents who are unable to turn themselves or adjust their own body position in bed was to turn them every 2 hours. LN 2 explained that the CNA's were responsible for this task. Review of Resident 2's, Care Plan Report dated 8/25/22, indicated, . [Resident 2] has an ADL [activities of daily living] performance deficit related to s/p [status post] CVA [Cerebral Vascular Accident; otherwise known as stroke] . [Resident 2] requires substantial/maximal assistance by staff to turn and reposition in bed . In addition, LN 2 confirmed the same care plan report indicated . [Resident 2] was at risk for skin breakdown/pressure injury . [Resident 2] needs assistance to turn/reposition at least every 2 hours, more often as needed . LN 2 stated the residents were turned every two hours because it was a known standard of care. LN 2 further explained she was unable to find evidence in Resident 2's EHR which showed Resident 2 was turned every 2 hours per Resident 2's care plan. LN 2 stated it was important to document the residents turns to help prevent further skin breakdown and it allowed everyone to capture the whole picture of care being provided. LN 2 further stated the risk of not being turned every 2 hours was further skin breakdown or the creation of a new skin wound that could cause pain or infection. During a concurrent interview and record review on 5/15/25 at 8:46 AM, LN 3 confirmed she wrote Resident 2's Long Term Care Weekly Evaluation ., dated 5/11/25. LN 3 stated she did not recall the status of Resident 2's coccyx or left heel but stated if there was a change she would have documented the change instead of checking the box that indicated, .No new Impairment. Skin clean, dry and intact . LN 3 stated she did not take measurements of the wound on 5/11/25 and did not document the condition of the wounds. During an interview on 5/13/25 at 3:53 PM, the Director of Nursing (DON) stated they do not document in the EHR when residents were turned. When asked if she had a way to know if the residents were being turned, the DON stated she did not know, because turning the residents was not charted, but stated they should since it was her expectation. The DON further stated they only document when a resident refused care. The DON stated her expectation to document and chart a change in condition or wound, would be to document the worsened condition, put the resident on 72-hour alert charting (typically consists of nursing staff documenting on the change of condition every shift, three times a day, over a 72 hour period), and document the doctor was notified after the assessment was done by the nurse. The DON explained notifying the doctor was important so he can give further orders for care. During an interview on 5/13/25, at 5:09 PM, the Administrator (ADM) stated her expectation for documenting an assessment was for the assessment to be documented by the end of the nurse's shift. The ADM confirmed documentation of an assessment several days after an assessment and change in condition, did not meet her expectation. The ADM stated her expectation to notify the doctor of a change in condition was about 24 hours. The ADM further stated the risk to the resident if the doctor was not notified in a timely manner would be the resident not getting the treatment needed to improve. The ADM explained the importance of turning and repositioning a resident was to change pressure points. A review of Resident 2's care plan dated 3/11/25, indicated, . [Resident 2] has a sheering wound on coccyx .Goal . [Resident 2] will not have any complications related to sheering wound .Interventions .Assist pt [patient] or remind her to change positions when in bed .Monitor for worsening condition daily . A review of Resident 2's care plan dated 4/7/25, indicated, . [Resident 2] has blanchable redness to her left heel .Goal .Redness will resolve without complications .Interventions .Heel protectors while in bed .Monitor for increased redness, swelling, drainage or open areas and report any adverse changes [undesired effects] to MD/PA [medical doctor/physician's assistant] until resolved . A review of Resident 2's care plan dated 8/25/22, indicated, .[Resident 2] is at risk for skin breakdown/pressure injury development related to malnutrition [lack of sufficient nutrients in the body], incontinence and requires staff assistance with ADL's .Goal .[Resident 2 will have intact skin, free of redness, blisters or discoloration .Interventions .[Resident 2] needs assistance to turn/reposition at least every 2 hours, more often as needed or requested .Monitor/document/report PRN [as needed] any changes in skin status: appearance, color, wound healing, s/sx [signs/symptoms] of infection, wound size . A review of Resident 2's Order Details, dated 3/11/25, indicated, .Monitor sheering wound to coccyx for s/s of infection or worsening condition until resolved .every day and evening shift . A review of Resident 2's Order Details order date 4/5/25, indicated, .Cleanse open area to coccyx with normal saline, pat dry with gauze, apply [brand name bandage] to wound bed, cover with dry dressing .every day shift Change dressing PRN [as needed] if soiled or dislodge . A review of Resident 2's Order details, dated 4/5/2025, indicated, .Monitor left heel blanchable redness for skin breakdown .every shift . A review of Resident 2's Order details, dated 5/13/25, indicated, .Apply skin prep to L [left] heel DTI .every day and evening shift for DTI pressure injury . A review of a facility policy and procedure (P&P) titled, Charting and Documentation, revised 7/17, indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .The following information is to be documented in the resident medical record .treatments or services performed .changes in the resident's condition .progress toward or changes in the care plan goals .documentation of procedures and treatments will include care-specific details .The date and time the procedure/treatment was provided .The assessment date and/or any unusual findings obtained during the procedure/treatment .How the resident tolerated the procedure/treatment .Notification of family, physician or other staff . A review of a facility P&P titled, Change in a Resident's Condition or Status, revised 11/15, indicated, .Our facility shall promptly notify the resident, his or her Attending Physician .of changes in the resident's medical .condition and/or status .A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions .notifications will be made within twenty-four (24) hours of a change . A review of a facility P&P titled, Goals and Objectives, Care Plans, revised 4/09, indicated, .Care plan goals and objectives are defined as the desired outcome for a specific resident problem .When the goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved .Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . A review of an undated facility P&P titled, Wound Prevention, indicated, .The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds .Upon admission .and when a significant change in the resident status occurs, the resident's skin will be evaluated head-to-toe by licensed nurse .Weekly skin checks will be conducted by the licensed nurse. This will be documented in the resident's Electronic Medical Record (EMR) . A review of an undated facility P&P titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, indicated, .The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers .the nurse shall describe and document/report .full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .pain assessment .Resident's mobility status .current treatments, including support surfaces . A review of an online John Hopkins Medicine article, copyright 2024, titled, Bedsores [pressure ulcers], indicated, .Bedsores can happen when a person is bedridden or otherwise immobile .Bedsores are ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a prolonged time. Bedsores are also called pressure injuries, pressure sores, pressure ulcers, or decubitus ulcers. Bedsores can be a serious problem among frail older adults. They can be related to the quality of care the person receives. If an immobile or bedridden person is not turned, positioned correctly, and given good nutrition and skin care, bedsores can develop .A bedsore develops when blood supply to the skin is cut off for more than 2 to 3 hours. As the skin dies, the bedsore first starts as a red, painful area, which eventually turns purple. Left untreated, the skin can break open and the area can become infected. A bedsore can become deep. It can extend into the muscle and bone. Once a bedsore develops, it is often very slow to heal. Depending on the severity of the bedsore, the person's physical condition, and the presence of other diseases .bedsores can take days, months, or even years to heal . The most severe sores may require a hospital stay to fight infection or surgery may be needed . (https://www.hopkinsmedicine.org/health/conditions-and-diseases/bedsores#:~:text=A%20bedsore%20develops%20when%20blood,A%20bedsore%20can%20become%20deep.) Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received care to prevent the development of pressure ulcers/injuries (PU/PI – areas of damaged skin caused by staying in one position for too long, usually over an area on the body where a bone is close to the skin's surface (bony prominence)) when: 1. Resident 1 was at risk for developing pressure ulcers and worsening of a shearing wound (a force that causes the skin and underlying tissues to move in opposite directions, often due to pressure and friction) on the coccyx (tailbone). Resident 1's skin assessments and wound documentation were incomplete, the physician was not notified the wound had worsened, and PU preventative measures were not correctly identified and implemented upon admission; and, 2. Resident 2 was at risk of developing pressure ulcers and worsening of a shearing wound on the coccyx and blanchable redness (a temporary reddening of the skin that disappears when pressure is applied) to both heels. Resident 2's skin assessments and wound documentation were incomplete and measures to prevent PU development were not implemented. These failures resulted in Resident 1 having wound pain and required surgical intervention at a hospital with the placement of a wound vacuum (VAC -a medical treatment that uses negative pressure to help severe wounds heal). In addition, these failures resulted in Resident 2 developing a deep tissue injury (DTI - deep skin and tissue loss where the extent of the damage cannot be determined because it is covered by eschar (black dead tissue)) to the left heel and had the potential to result in increased pain, infection (the invasion and growth of germs in the body), and muscle or bone loss. Findings: 1. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in Spring 2025 with diagnoses which included but not limited to: sepsis (a life-threatening infection), arthritis (swelling and tenderness where two or more bones meet, causing joint pain and/or stiffness) due to other bacteria (an infection in the joint fluid and tissues caused by bacteria), chronic obstructive pulmonary disease (COPD -a chronic lung disease causing difficulty breathing), and muscle weakness. A review of Resident 1's Minimum Data Set (MDS -an assessment tool), dated 4/22/25, in the section, M -Skin Conditions, indicated, Resident 1 was at risk of developing pressure ulcers. During a concurrent interview and record review on 5/13/25, at 1:19 PM, Resident 1's electronic health record (EHR) was reviewed with Licensed Nurse (LN) 1. LN 1 stated Resident 1 was admitted with two wounds, one on the left hand, and a shearing wound on the coccyx. Resident 1's admission -readmission Nursing Evaluation . dated 4/18/25, indicated, .Indicate Pressure Ulcers and/or other wound types .Sacrum [triangular shaped bone in the lower back located between the hip bones] .Type: Pressure [injury to skin and underlying tissue resulting from prolonged pressure on the skin] .Length 1.8 [cm- centimeter -a metric unit of length], Width 0.8 [cm], Depth 0.1 [cm], Stage II [2 -partial-thickness skin loss, presenting as a shallow open wound; wounds are

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) received adequate supervision and that care plan (an individualized set of goals and interventions specific to the Resident 1 ' s needs) interventions were implemented to prevent an injury when, Resident 1 ' s care plan interventions of a fall mat (a soft pad at the side of the bed to soften a fall) and two person staff assist with activities of daily living (ADL ' s; a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility) were not implemented and Resident 1 fell from the bed on 9/24/24. This failure led to Resident 1 sustaining multiple skin tears, pain, a broken clavicle (also called collarbone; is a long, slightly curved bone that connects your arm to your body and located in your upper chest area), and a decline in ability to feed herself. Findings: During a review of Resident 1 ' s undated clinical record titled admission RECORD, (a document that contained Resident 1 ' s demographic information) indicated, Resident 1 ' s diagnosis included encephalopathy (a brain dysfunction that caused confusion, memory loss, and personality changes), muscle weakness, and Parkinson ' s disease (a long-term brain disorder that caused involuntary body movements, stiffness, and difficulty with balance and coordination). A review of Resident 1 ' s clinical record titled, Brief Interview of Mental Status, (BIMS – an interview that assessed Resident 1 ' s mental function), dated 6/26/24, indicated Resident 1 ' s BIMS score was 11 (8 to 12 points suggests moderate cognitive impairment; Problems with a person's ability to think, learn, remember, use judgement, and make decisions). A review of Resident 1 ' s clinical record titled, Morse Fall Scale, (an assessment tool that determined Resident 1 ' s fall risk factors and targeted interventions to reduced fall risks), dated 1/12/24, indicated Resident 1 ' s fall risk score was 55 (45 and higher indicated a high risk for falls). Resident 1 ' s contributing factors for falls included a history of falls, use of a wheelchair, overestimated or forgot physical limits, and had more than one medical diagnosis. A review of Resident 1 ' s clinical record titled, [FACILITY NAME] Progress Notes *New* Post Fall Evaluation, dated 9/10/24, at 4:42 p.m., by the Licensed Nurse (LN 1), indicated the Certified Nursing Assistant (CNA 1) witnessed Resident 1 fall on 9/10/24, at 4:07 p.m., in Resident 1 ' s room. At the time of the fall, CNA 1 was changing Resident 1 ' s brief (adult diaper). After the fall, Resident 1 was sent to the Emergency Department (ED) at [ACUTE CARE HOSPITAL NAME] where it was determined Resident 1 had a fractured (broken) left clavicle. A review of Resident 1 ' s clinical record titled, [ACUTE CARE HOSPITAL NAME] Progress Notes *New*, dated 9/10/24, at 9:06 p.m., by LN 5, indicated Resident 1 rolled out of bed and had complaints of pain scored at 10 out of 10 using the Numerical Rating Pain Scale (assessment tool 0 through 10; 0 = no pain and 10= the worst pain). A review of Resident 1 ' s fall risk care plan, initiated on 8/29/22, indicated Resident 1 was at risk for falls related to her diagnosis of Parkinson's disease, weakness, urinary incontinence (unable to hold urine), use of antianxiety and antidepressant medications, history of falls, and required staff assistance with transfers and toileting. Interventions included fall mats at the bedside which was initiated on 9/1/2022. A review of Resident 1 ' s clinical record titled, Post Fall Evaluation, dated 9/10/24, at 4:42 p.m., indicated there was no fall mat in place at the time of the fall. A review of Resident 1 ' s clinical record titled, Interdisciplinary Team [IDT – a group of health care providers and other staff members that work together to discuss the care of Resident 1] Post Fall Meeting, dated 9/11/24, at 9:55 a.m., by LN 1, indicated Resident 1 rolled out of bed on 9/10/24, at 4:07 p.m. and sustained a fracture to her left clavicle, skin tears to the right and left side of her wrists, skin tears to the right index (finger next to the thumb) finger, a knot (bump) to the left side of her head, and complained of severe left shoulder pain that radiated (sent out) down to the elbow. At 4:45 p.m., Resident 1 was sent to [ACUTE CARE HOSPITAL NAME] for further evaluation. A review of Resident 1 ' s clinical record titled, [ACUTE CARE HOSPITAL NAME] Progress Notes *New*, dated 9/11/24, at 2:12 a.m., by LN 4, indicated Resident 1 returned to the facility from [ACUTE CARE HOSPITAL NAME] on 9/11/24, at 1:31 a.m. During a concurrent observation and interview on 10/16/24, at 11:50 a.m., in Resident 1 ' s room, Resident 1 had skin tears on her right hand that had steri-strips (thin, sticky bandages that are applied to the skin to help small cuts or wounds stay closed as they heal) in place, and a scabbed wound (a rough surface made of dried blood that forms over a cut or broken skin while it is healing) on her left fourth finger. There was no fall mat on either side of the bed. Resident 1 stated she was unsure how she fell out of bed on 9/10/24. During a concurrent observation and interview on 10/16/24, at 11:57 a.m., with LN 2, LN 2 stated Resident 1 required two staff members on each side of the bed when Resident 1 was turned and/or her brief was changed because Resident 1 was very fragile. LN 2 acknowledge there was not a fall mat at the bedside and that Resident 1 required a fall mat as part of her fall precaution interventions. During an interview on 10/15/24, at 12:05 p.m., with CNA 2, CNA 2 stated Resident 1 was a one person assist with brief changes and transfers (move from bed to wheelchair). CNA 2 stated she was unsure if Resident 1 needed a fall mat and was not sure where to look in Resident 1 ' s clinical record to verify if Resident 1 needed a one person or a two person assist with care needs. CNA 2 was unsure where to locate Resident 1 ' s care plan. During an interview on 10/15/24, at 12:10 p.m., with LN 3, LN 3 stated Resident 1 was a two person assist with brief changes (staff assistance to remove and replace an absorbent cloth or disposable products which is worn by humans who are incapable of, or have difficulty, controlling their bladder or bowel movements) and transfers because of her limited ability to assist with cares and because Resident 1 was very weak. During a phone interview on 10/15/24, at 12:36 p.m. with CNA 1, CNA 1 stated before Resident 1 ' s fall on 9/10/24, Resident 1 sometimes required a one person assist and sometimes required a two person assist with cares (depending on Resident 1 ' s strength on a given day). CNA 1 stated on the day of the fall, CNA 1 rolled Resident 1 ' s body away from her on the bed and then CNA 1 turned to grab the brief off of the nightstand. CNA 1 stated that was when Resident 1 fell out of bed. CNA 1 stated after the fall, Resident 1 declined in her physical ability to be helpful with her own cares. CNA 1 stated after the fall Resident 1 complained her head and shoulder hurt and Resident 1 was later transferred to [ACUTE CARE HOSPITAL NAME]. During a concurrent interview and record review on 10/15/24, at 1:20 p.m., with the Minimum Data Set (MDS - standardized assessment of Resident 1) Nurse, Resident 1 ' s clinical record titled, Section GG – Functional Abilities and Goals (a section of a comprehensive assessment that reviewed Resident 1's physical abilities), dated 6/30/24 and Section GG – Functional Abilities and Goals, dated 9/16/24, were reviewed. Section GG, dated 6/30/24 (before the fall), indicated Resident 1 required supervision or touch assistance (the helper provided verbal cues and/or touching/steadying assistance and the helper set up or cleaned up, but Resident 1 completed the activity) when she ate her meals. Resident 1 was dependent on staff when she rolled to the right and to the left (the helper did all the effort) and with all other ADLs. Section GG – Functional Abilities and Goals, dated 9/16/24 (after the fall), indicated Resident 1 was dependent on assistance when she ate her meals (the helper did all the effort and Resident 1 did none of the effort to complete the activity). Resident 1 remained dependent on staff when she rolled to the right and to the left and with all other ADLs. The MDS Nurse stated before the fall, Resident 1 was able to feed herself most of the time and after the fall she needed total assistance with eating. The MDS Nurse stated Resident 1 ' s care plan was supposed to be read and followed by all CNAs, Licensed Vocational Nurses (LVN), Registered Nurses (RNs), and the entire care team to guide them in how to specifically care for Resident 1. During an interview on 10/15/24, at 2:04 p.m., with the Occupational Therapist (OT), the OT stated before the fall, Resident 1 was able to feed herself independently more often than she was not able to feed herself independently and Resident 1 had started Occupational Therapy on 10/7/24 to increase independence with ADLs. The OT stated before the fall Resident 1 had use of both of her arms (Resident 1 was right-handed). The OT stated after the fall, Resident 1 had increased trouble with feeding and did not have use of her left arm (arm was in a sling; a device used to support and keep still (immobilize) an injured part of the body). The OT stated all health care professionals were supposed to read and follow Resident 1 ' s care plan to ensure safety during cares and treatments. A review of Resident 1 ' s clinical record titled, Occupational Therapy (exercises designed to increase independence with Activities of Daily Living (ADLs – brushing teeth, getting dressed, toileting, eating) Treatment Encounter Note(s), dated 10/11/24, at 2:24 p.m., by the Occupational Therapist (OT - health care provider who assisted Resident 1 with Occupational Therapy), indicated Resident 1 attempted therapy and then immediately requested to lay back down in bed. A two-person assist (two health care providers assisted Resident 1) was used when Resident 1 was repositioned. Resident 1 ' s body movements led to pain (as evidenced by Resident 1 yelled out) and limited her functional activities. During a phone interview on 10/15/24, at 2:39 p.m., with the Medical Director (MD), the MD stated the facility should have provided the correct number of staff while providing cares to Resident 1 to ensure quality care was delivered. During a follow-up interview on 10/15/24, at 2:50 p.m., with CNA 1, CNA 1 stated on 10/15/24, the Director of Staff Development (DSD) showed CNA 1 (for the first time) that the information regarding the amount of assistance Resident 1 required was located in Resident 1's care plan in the Electronic Heath Record ( a digital version of a patient's medical history that can be used to improve patient care) and in the [NAME] (a system that nurses used to organize and access resident ' s information for care planning). CNA 1 stated prior to 10/15/24, CNA 1 was unsure where to find information regarding the amount of assistance Resident 1 required during cares. CNA 1 stated after Resident 1 ' s fall, Resident 1 had a decline in her ability to feed herself. CNA 1 stated before the fall, Resident 1 used to call CNA 1 by name and after the fall Resident 1 did not recall CNA 1 ' s name. During a concurrent phone interview and record review on 10/16/24, at 12:27 p.m., with the Director of Nursing (DON), Resident 1 ' s Medication Administration Record (MAR – a document that indicated when and what medication was administered to Resident 1), dated 9/24, was reviewed. The DON stated Tramadol (a government regulated pain mediation used to treat moderate pain (4 through 6 on the Numerical Rating Pain Scale) to severe pain (7 through 9 on the Numerical Rating Pain Scale) 50 milligrams (mg – unit of measurement) was ordered to be given every 6 hours following the fall on 9/10/24. The DON verified Resident 1 was given Tramadol 54 times for pain control in the month of September 2024. A review of Resident 1 ' s left clavicle fracture care plan, initiated on 9/11/24, in the section titled Interventions, indicated for Resident 1 to use a sling to her left arm at all times and was not supposed to put weight on the left arm. During a concurrent interview and record review on 10/15/24, at 3:25 p.m., with the DON, the following documents were reviewed: - Resident 1 ' s care plan related to ADL deficits, initiated on 8/30/22, - [Resident 1 ' s] [NAME], undated, - Certified Nursing Assistant Job Description, dated 10/20, - The facilities Fall and Fall Risk, Managing Policy and Procedure (P&P), dated 9/23, and - The facilities Care Plan, Comprehensive Person-Centered P&P, dated 3/22. The DON confirmed Resident 1 ' s ADL deficit care plan, initiated on 8/30/22, indicated Resident 1 ' s ADL interventions, also initiated on 8/30/22, included: extensive assistance by two staff members when Resident 1 was turned in bed and toileted. The DON confirmed Resident 1 ' s clinical record titled, [NAME], indicated Resident 1 required two staff members to assist Resident 1 when she was repositioned in bed, turned in bed, and with brief changes. A concurrent interview and record review with the DON continued with a review of the facility ' s document titled, Certified Nursing Assistant Job Description, indicated, . Duties and Responsibilities .review care plans daily to determine if changes in the resident ' s daily care routine have been made on the care plan The facility ' s P&P titled, Fall and Fall Risk, Managing, indicated, . the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . The facility ' s P&P titled, Care Plan, Comprehensive Person-Centered, indicated, . The . team . develops and implements a . person centered care plan for each resident . After reviewing Resident 1 ' s ADL deficit care plan, Resident 1 ' s [NAME], the Certified Nursing Assistant Job Description, the Fall and Fall Risk, Managing P&P, and the Care Plan, Comprehensive Person-Centered P&P, the DON stated that CNA 1 should have used a two person assist to turn Resident 1 and two persons assist to change Resident 1 ' s brief. The DON stated Resident 1 ' s care plan was created to ensure Resident 1 received safe care from the healthcare team. The DON stated her expectation was that all the staff members would have read and followed Resident 1 ' s care plan. The DON verified Resident 1 ' s care plan, the CNA Job Description, and the above listed P&Ps were not followed. A review of the facility ' s undated educational power point titled, Lifting and Transferring, indicated, .WHEN CHANGING A RESIDENT-TIPS AND REMINDERS . Ensure there are appropriate staff to assist. For example, if the resident requires a 2 person assist, be sure to have 2 CNAs to assist . Ensure that all supplies are within reach, so you do not have to leave the resident ' s side. Always review the Care Plan or [NAME] prior to providing care to ensure proper plan of care is maintained . A review of the facility ' s P&P titled, Repositioning, dated 5/13, indicated, .check the care plan, . or the communication system to determine resident ' s specific positioning needs including Resident level of participation and the number of staff required to complete the procedure .

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that two of twenty-one sampled residents (Resident 64 and Resident 49) functional abilities did not diminish when: 1. Resident 64 had a decline in her ability to feed herself and services were not provided to determine the cause and/or maintain her abilities. 2. Resident 49 was not provided Restorative Nursing Assistant (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services per her care plan interventions. These failures resulted in Resident 64's decline in range of motion (ROM, the full movement potential of a joint) to her right arm, left arm and hand, increased pain, and a loss of the ability to feed herself; and in a decline in Resident 49's ability to transfer from a sit to stand position, requiring substantial to maximum assistance when transferring from a bed or chair. Findings: 1. A review of Resident 64's admission RECORD, indicated, Resident 64 was admitted to the facility in May of 2023, with diagnoses which included Alzheimer's disease (a progressive disease that affects the parts of the brain that control thought, memory and language) and muscle weakness. During a concurrent observation and interview, in Resident 64's room, on 1/23/24, at 8:58 AM, Certified Nurse Assistant (CNA) 1 stated Resident 64 had been able to move both of her arms and feed herself. CNA 1 further stated Resident 64 declined and stopped moving her arms after she had COVID-19 (a respiratory virus which can cause serious health complications and requires 10 days isolation) in June 2023. During an observation on 1/24/24, at 9:02 AM, Home Health Aide (HHA-a hospice staff who provides personal care) 1 was observed putting a t-shirt on Resident 64. Resident 64 was grimacing and gasping when HHA 1 moved her arms and attempted to uncurl her fingers from her palm. A review of Resident 64's MDS (minimum data set, a resident assessment and screening tool) Section GG, dated October 17, 2023, indicated, .Functional limitation in Range of Motion .upper extremity [arm] . no impairment .lower extremity [leg] .no impairment .Eating .Supervision or touching assistance . A review of Resident 64's MDS Section GG, dated December 12, 2023, indicated, .Functional limitation in Range of Motion .upper extremity . Impairment on both sides .lower extremity .impairment on both sides .Eating .Dependent . A review or Resident 64's care plan, revised on 8/18/2023, indicated, .Goal . [Resident 64] will remain free of complications related to immobility, including contractures [a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff] . During an interview on 1/24/24, at 3:12 PM, the Hospice Case Manager (CM) stated Resident 64's arms had no, obvious contractures on admission to hospice on 12/5/23. During an interview on 1/30/24, at 8:04 AM, the Director of Staff Development (DSD) stated staff should have informed the charge nurse or unit manager of the change in Resident 64's condition so they could intervene and request occupational therapy or RNA services. During a concurrent observation and interview, in Resident 64's room, on 1/30/24, at 9:27 AM, Licensed Nurse (LN) 2 confirmed Resident 64 had contractures to both arms and her left hand. LN 2 stated Resident 64 had been able to feed herself with set up assistance previously. LN 2 further stated when a resident's condition declined the physician and the responsible party should be informed. LN 2 stated social services should have been contacted and a care conference (a meeting with everyone involved in the person's care) should have occurred when Resident 64's mobility had significantly changed. LN 2 further stated the decline should have been documented to indicate the changes in her mobility. LN 2 confirmed there was no documentation in Resident 64's clinical record indicating her upper extremity contractures. LN 2 stated had the issue been addressed there would have been opportunities to increase her ROM and prevent the contractures from getting worse, prevent pain and further decline. LN 2 further stated Resident 64 should have a hand roll (device placed in the palm of the hand to prevent skin breakdown) to prevent her nails cutting into her hand. LN 2 stated the lack of documentation and follow up put resident 64 at risk of more severe contractures. During a telephone interview on 1/30/24, at 2:51 PM, the Medical Director (MD) stated RNA services would have helped Resident 64 with her mobility and made her more comfortable. The MD further stated the goal of care was to emphasize comfort and quality of life. 2. A review of Resident 49's admission RECORD, indicated Resident 49 was admitted to the facility in October of 2023 with diagnoses which included hydronephrosis (swelling of one or both kidneys) and muscle weakness. A review of Resident 49's MDS Section GG, dated November 27, 2023, indicated, .03 Partial /moderate assistance-Helper does LESS THAN HALF the effort .Sit to stand: the ability to come to a sitting position from sitting in a chair, wheelchair, or side of the bed .Chair/bed-to-chair transfer .Toilet transfer .Tub/shower transfer . A review of Resident 49's MDS Section GG, dated December 8, 2023, indicated, .02. Substantial/maximal assistance-Helper does MORE THAN HALF the effort . Sit to stand: the ability to come to a sitting position from sitting in a chair, wheelchair, or side of the bed .Chair/bed-to-chair transfer .Toilet transfer .Tub/shower transfer . During an interview on 1/22/24, at 11:34 AM, Resident 49 stated, .I can't move my legs, they don't exercise them . During an interview on 1/25/24, at 7:47 AM, LN 3 stated Resident 49 was unable to move her lower extremities. A review of Resident 49's care plan initiated on 11/26/21 with a revised date of 11/9/2023., indicated, [Resident 49] has limited physical mobility .Interventions .NURSING REHAB/RESTORATIVE: ACTIVE ROM [active range of motion, moving a part of your body by using your muscles] Program to both legs, 5x/week [5 times per week] . A review of Resident 49's Progress Note dated 11/9/2023, indicated, .RNA meeting held this AM with DSD and RNAs in attendance. Resident will continue RNA for AROM [active range of motion, moving a part of your body by using your muscles] and walking . A review of facility documents titled, RNA program assignment sheet, dated December 1-31, 2023, indicated Resident 49 did not receive RNA services in the month of December 2023. A review of facility documents titled, RNA program assignment sheet, dated January 1-24, 2024, indicated, Resident 49 refused RNA services on January 1, 2024, and received them on January 2, 2024. Resident 49 did not receive RNA services January 3 through January 24, 2024, During an interview on 1/30/24, at 7:42 AM, the DSD confirmed Resident 49's care plan indicated she was to receive RNA services 5 times per week. The DSD stated the purpose of the RNA services was for Resident 49 to receive ROM to maintain her level of function and decrease her risk of contractures. The DSD stated it was her expectation that residents on the RNA program would be provided services. A review of a facility policy and procedure (P&P) titled, Resident Mobility and Range of Motion, revised July 2017, indicated, .Residents will not experience an avoidable reduction in range of motion (ROM) .Residents with a limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM . A review of a facility P&P titled, Activities of Daily Living (ADL's-essential basic self care tasks), Supporting, revised March 2018, indicated, .Residents will be provided with care treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .Interventions .will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice . A review of a facility P&P titled, Restorative Nursing Services, revised July 2021, indicated, .Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure quality care was provided to one of three sampled residents (Resident 2) when: 1. Staff were notified on [DATE] that Resident 2 had signs and symptoms of a urinary tract infection (UTI, a common infection which happens when bacteria, often from the skin or rectum, enter the urinary system) by Resident 2's family member but assessment and monitoring of Resident 2's condition was not done; and, 2. Resident 2 had a lung infection which began on [DATE]. Resident 2's physician examined her on [DATE] and did not document an assessment of Resident 2's lung infection was done; and, 3. Resident 2 had one instance of bleeding from her rectum with a medium sized blood clot on [DATE] and the nurse removed hard stool from the rectum without a physician's order, the physician was never notified, and monitoring of Resident 2's condition was not done. These failures resulted in Resident 2 being sent to acute care hospital (ACH) 1 on [DATE] with diagnoses of pneumonia (an infection that affects one or both lungs. It causes the air sacs of the lungs to fill up with fluid or pus), UTI, and anemia (when your blood produces a lower-than-normal amount of healthy red blood cells) then transferred to ACH 2 the next day ([DATE]) with diagnoses of septic shock (most severe form in which the infection causes low blood pressure, resulting in damage to multiple organs, Sepsis), pneumonia, and UTI which ultimately contributed to her death on [DATE]. A review of Resident 2's Face Sheet was admitted to the facility in mid-2023 with diagnoses which included diabetes (an abnormal amount of sugar in the blood which can affect the eyes, kidneys, and nerves of the body), overactive bladder (causes a frequent and sudden urge to urinate that may be difficult to control) and had a history of urinary tract infections. A review of Resident 2's Quarterly MDS, dated [DATE], revealed a score of 4 on the BIMS which indicated significant cognitive impairment. Resident 2's mobility documented on the [DATE] MDS indicated Resident 2 needed the assistance of one person for bed mobility and transfers. The MDS also revealed Resident 2 was frequently incontinent of bowel and bladder and was not on a toileting program (scheduled or prompted use of the bathroom for bowel or bladder retraining.) 1. A review of Resident 2's assessment titled, .Bowel and Bladder Screener ., dated [DATE], revealed a score of 9 which indicated Resident 2 was a .good candidate for retraining . During a concurrent interview and record review on [DATE], at 12:38 p.m., LN 1 confirmed Resident 2 had not been on a toileting program. A review of Resident 2's care plans indicated, .[Resident 2] has bladder incontinence [little or no control of bladder] .at risk for .UTI's .Date initiated [DATE] .risk for septicemia [the body's most extreme response to an infection, Sepsis] will be minimized/prevented via prompt recognition and treatment of symptoms of UTI .monitor/document for s/sx [signs and symptoms] of UTI: pain, burning .deepening of urine color .foul smelling urine .altered mental status [confusion] . During an interview on [DATE] at 11:47 a.m., CNA 3 stated she could not remember the exact date but when she took over care for Resident 2 one morning, she was soaked with urine and her bed was wet (large amounts of urine can be a symptom of UTI called polyuria.) CNA 3 added Resident 2 would not drink much water but would complain about going more frequently but then she won't pee, but she had the feeling to go. I think it was happening for days . During an interview on [DATE] at 9:32 a.m., Certified Nursing Assistant (CNA) 4 remembered Resident 2's urine had a strong odor but was unsure of the date. She was not drinking enough water. A review of Resident 2's nurse progress note dated [DATE] indicated, .This writer received in report that resident [2] had one episode of emesis [vomit, throwing up] during lunch . A review of Resident 2's nurse progress note dated [DATE] at 6:53 a.m., indicated, .Resident appears to have increased confusion .all information endorsed to oncoming shift . A review of Resident 2's nurse progress note dated [DATE] indicated, .notified charge nurse resident [2] was found on the floor . A review of Resident 2's nurse progress note dated [DATE] at 2:29 p.m., indicated, .Per resident's [family member], the way her mom has been acting is like when she has a UTI. Resident has no symptoms of UTI [symptoms can include poor appetite, drowsiness, frequent falls, foul smelling urine, dark colored urine, vomiting, and confusion] .will place on alert charting [charting done by nurses on all shifts to monitor a change of condition] to increase water intake and monitor for s/sx of UTI . During an interview on [DATE], at 12:38 p.m., with Licensed Nurse (LN) 1, LN 1 verified a nurse documented Resident 2 would be placed on alert charting for signs and symptoms of a UTI. LN 1 confirmed Resident 2 was never put on alert charting to monitor for signs and symptoms of a UTI. During an interview with the Administrator (ADM) on [DATE] at 4:15 p.m., the ADM stated if family was concerned about Resident 2 having a UTI, they (staff at the facility) should have notified the doctor and should have followed up on the family's concern. Staff should follow up if there was any concern from the resident or the family. During an interview with the Director of Nursing (DON) on [DATE] at 11:29 a.m., the DON stated if staff were alerted that a resident had symptoms of a UTI staff should monitor for temperature changes, urinary symptoms, vital sign changes, color of urine, and if they are retaining (urine is unable to leave the body). Interventions could have been cranberry supplements and forcing fluids. I expect them (staff) to monitor for a UTI. The risk of not monitoring for symptoms would be the infection could travel to the kidneys. It could lead to worsening infection. She should have been tested for a UTI if she had a history of UTI's. A review of Resident 2's ACH 2 records dated [DATE]-[DATE] indicated, .Discharge Diagnosis .septic shock .Likely secondary combination of underlying pneumonia and UTI .acute [sudden] encephalopathy [alteration of mental status] .very likely secondary to hypercapnic respiratory failure [when you have too much carbon dioxide (CO2), a gas waste product from the lungs when breathing out] and UTI .Acute hypercapnic respiratory failure: Very likely secondary to decompensated CHF [congestive heart failure, a weakened heart condition that causes fluid buildup in .lungs], and possibly underlying pneumonia .due to patients advanced age, being very frail, in septic shock and CHF as well, respiratory failure, patients prognosis is guarded .afternoon of [DATE], patient expired peacefully 1850 [6:50 p.m.] . 2. A review of Resident 2's nurse progress note dated [DATE] indicated, .coughing and fine crackles [a series of short, explosive sounds that can also sound like bubbling, rattling, or clicking] noted during shift. Resident appears to have increased confusion .MD notified of findings .This writer requested order for chest x ray (an image of the lungs and heart to diagnose disease) .all information endorsed to oncoming shift . A review of Resident 2's nurse progress note dated [DATE] indicated, .reports .crackles all lung bases [bottom of the lungs] .anxious .[physician assistant] notified and made aware of the resident's current status .orders were received: Levaquin [antibiotic], Duoneb [an inhaled medication used to treat breathing problems], Robitussin [cough medicine] . A review of Resident 2's nurse progress note dated [DATE] indicated, .productive cough [a cough that brings up mucus], sputum [mucus/spit] is light yellow in color. Expiratory wheezes [a whistle type sound when breathing out] heard to upper lobes [upper lungs] . A review of Resident 2's Physician Assistant's (PA) note indicated the PA examined Resident 2 on [DATE] which read, .complaints: none .lungs .exam .yes . Further review revealed under the area for the Physician Assistant (PA) to write a Plan the area was blank. During an interview on [DATE] at 2:12 p.m., with Resident 2's PA, the PA stated if a nurse notified him or the physician that a resident had signs and symptoms of an infection, one of us would go and see the patient the same day. The PA explained for respiratory infections he would listen to residents' lungs, heart and throat and make a diagnosis and treat them. I saw her (Resident 2) on [DATE] (no documentation was found) and she had no complaints that day. On [DATE] her chest was clear. When asked why antibiotics were ordered on [DATE] if Resident 2's chest was clear, the PA stated she had crackles. The PA confirmed he did not order an x-ray of Resident 2's chest and told staff We will see if that medicine helps. The PA stated when he visits the facility Everyone wants to talk to me, and I forget to document. She [Resident 2] was getting better on [DATE], there is no documentation because I was busy. During an interview on [DATE], at 12:38 p.m., with Licensed Nurse (LN) 1, LN 1 confirmed a transfer form (outlining Resident 2's basic information for the ACH) was done on the day of discharge ([DATE]) but there was not a nurse's progress note/change in condition note done that outlined Resident 2's signs and symptoms or the reason she was sent to the ACH. A review of Resident 2's ACH 2 records dated [DATE]-[DATE] indicated, .Discharge Diagnosis .septic shock .Likely secondary combination of underlying pneumonia and UTI .acute [sudden] encephalopathy [alteration of mental status] .very likely secondary to hypercapnic respiratory failure [when you have too much carbon dioxide (CO2), a gas waste product from the lungs when breathing out] and UTI .Acute hypercapnic respiratory failure: Very likely secondary to decompensated CHF [congestive heart failure, a weakened heart condition that causes fluid buildup in .lungs], and possibly underlying pneumonia .due to patients advanced age, being very frail, in septic shock and CHF as well, respiratory failure, patients prognosis is guarded .afternoon of [DATE], patient expired peacefully 1850 [6:50 p.m.] . 3. A review of Resident 2's nurse progress note dated [DATE] indicated, .Called to room by CNA, pt [patient] having moderate amount of blood coming out of rectum with a medium size blood clot, I could see hard stool inside of rectum, I removed what I could see and noticed the rest was soft. Pt tolerated procedure well with minimal discomfort. I notified RN [registered nurse] on duty and will endorse to Day shift to let MD know if bleeding continues . During an interview on [DATE] at 10:09 a.m., LN 5 stated the amount of blood from Resident 2's rectum was moderate, enough to soak a peri pad (a soft absorbent pad worn in the underwear used to catch urine or blood) and there was a large blood clot. When asked, LN 5 stated she should have notified Resident 2's physician and completed a change of condition assessment for Resident 2. If the assessment was done the CNAs would have done vital signs and if any changes were noted Resident 2 would have been sent to the hospital. During an interview with the DON on [DATE] at 11:29 a.m., the DON stated the risk of the physician not being notified of a change in condition was the condition could get worse. The DON confirmed bleeding from the rectum was a change in condition and the physician should have been notified immediately. The DON stated, You can't guess where it's [blood] coming from. The DON added Resident 2 should have been put on alert charting because her hemoglobin (Hgb, red blood cells that are responsible for delivery of oxygen to the body) could have dropped (due to abnormal bleeding), and harm could have come to Resident. The DON confirmed a nurse should not have removed stool from Resident 2's rectum without a physician's order. A review Resident 2's ACH 1 records dated [DATE] indicated, .Hgb 8.1 L [low, normal Hgb is 12.0-16.0] .OB [occult blood, a test used to detect blood in the stool] positive stool .worsening anemia 8.1 now, 11 in March this year . A review of the facility's policy and procedure (P&P) titled, Change in Resident's Condition or Status, revised 2/2021, indicated, .Our facility promptly notifies the .physician .resident representative of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's .physician .when there has been a(an) .significant change in the resident's physical .mental condition .need to alter the resident's medical treatment significantly .A significant change of condition is a major decline .in the resident's status that .will not normally resolve itself without intervention by staff .Prior to notifying the physician or healthcare provider, the nurse will make detailed observation and gather relevant and pertinent information for the provider .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . A review of the facility's policy and procedure (P&P) titled, .Surveillance for Infections, revised 9/2017, indicated, .The infection preventionist will conduct ongoing surveillance for healthcare-associated infection .that have substantial impact on potential resident outcome .and that may require .other preventative interventions .clinically significant .mortality [death] associated with infection .pneumonia, UTI's .nursing staff will monitor residents for signs and symptoms that may suggest infection .and will document and report suspected infections to the charge nurse .The charge nurse will notify the attending physician .of suspected infections . A review of an article by the National Library of Medicine published [DATE] indicated, .Urinary tract infection (UTI) is a common infection in the elderly, mainly due to age-related risk factors like .inadequately controlled diabetes mellitus, poor bladder control leading to urinary retention or incontinence .and altered mental state .UTIs are responsible for around 25% of all geriatric hospitalizations attributing to almost 6.2% of deaths due to infectious diseases and repeated emergency department and office visits yearly .UTI usually presents with localized symptoms like painful urination, new onset or worsening urinary urgency or frequency .but symptoms of UTI are atypical in the elderly population. UTI manifests more atypically for this age group as delirium, confusion, dizziness, drowsiness, falls, urinary incontinence, or poor appetite . https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9827929/#:~:text=Symptoms%20of%20UTI%20are%20atypical,the%20absence%20of%20a%20fever.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to evaluate resident specific risk factors and changes in health conditions that caused the development of pressure ulcers (an injury that breaks down the skin and underlying tissue caused by being in one position for too long) for two of three residents (Resident 1 and Resident 2) when: 1. Resident 1's person centered risk factors to prevent and treat pressure ulcers were not documented on a risk for skin breakdown care plan, risk factor interventions were not implemented to prevent/heal pressure ulcers, and Resident 1's nursing assessment was not completed on 8/3/23 upon the discovery of a stage three pressure ulcer (affecting the deepest layer of your skin) to Resident 1's ischial tuberosity (also known as the sitting bone, as this is where the weight of the body is held when seated); and, 2. Resident 2's person centered risk factors to prevent and treat pressure ulcers were not documented on a risk for skin breakdown care plan, risk factor interventions were not implemented to prevent/heal pressure ulcers, and Resident 2's nursing assessment done on 8/8/23 was not completed upon the discovery of a stage two pressure ulcer (Partial thickness loss of the middle layer of skin presenting as a shallow open ulcer) to Resident 2's tailbone. These failures resulted in the development of a stage three pressure ulcer to Resident 1's right ischial tuberosity and the development of a stage two pressure ulcer to Resident 2's tailbone. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included weakness on the right side of the body, hyperglycemia (an abnormal amount of sugar in the blood which can affect the eyes, kidneys, and nerves of the body ) chronic wounds (a wound that does not heal in a predictable amount of time), edema (swelling caused by too much fluid trapped in the body's tissues) to both lower legs and nicotine dependence. A review of Resident 1's Quarterly Minimum Data Set (MDS, an assessment tool), dated 7/9/23, revealed a score of 12 on the Brief Interview for Mental Status which indicated slight cognitive impairment (BIMS, a score of 0-15, zero being significant impairment and fifteen being no impairment.) Further review of the MDS indicated Resident 1 was at risk for developing pressure ulcers and was not on a turning/repositioning program. Resident 1's mobility documented on the 7/9/23 MDS indicated Resident 1 did not walk, needed the assistance of two people for bed mobility and transfers, and used a wheelchair. The MDS also revealed Resident 1 was frequently incontinent of bowel and bladder (little or no control of bowel and bladder function) and was not on a toileting program (scheduled or prompted use of the bathroom for bowel or bladder retraining.) A review of Resident 1's assessment titled, .Bowel and Bladder Screener ., dated 7/3/23, revealed a score of 9 which indicated Resident 2 was a .good candidate for retraining [bladder retraining] . During a concurrent interview and record review on 11/10/23, at 12:38 p.m., LN 1 confirmed Resident 1 had not been on a toileting program and incontinence was a risk factor for pressure ulcers. A review of Resident 1's assessment titled, BRADEN SCORE FOR PREDICTING PRESSURE SORE RISK [an assessment used to determine if a resident is at risk for developing pressure ulcers], dated 4/19/23, revealed a score of 18 which indicated Resident 1 was at risk of developing pressure ulcers on admission to the facility. The next Braden completed was dated 7/3/23 and revealed a score of 13 which indicated a moderate risk for developing pressure ulcers (at risk 15-18, moderate risk 13-14, high risk 10-12, very high risk 9 or below). During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's meal intake for the months of July, August, and September of 2023 were reviewed. LN 1 confirmed Resident 1 was on a low salt, double portioned diet and that in July facility staff did not document Resident 1's meal intake for breakfast 7 times, for lunch 8 times, and for dinner 3 times. Resident 1 refused three meals, ate 0-25 percent of his meals 10 times, and ate 26-50 percent of his meals 12 times. In August facility staff did not document Resident 1's meal intake for breakfast 11 times, and for lunch 12 times. Resident 1 refused 11 meals, ate 0-25 percent of his meals 11 times, ate 26-50 percent of his meals 5 times, and N/A (non-applicable) was documented 2 times. In September Resident 1 was in the facility for 12 days. Facility staff did not document Resident 1's meal intake for breakfast 5 times, and for lunch 7 times. Resident 1 ate 0-25 percent of his meals 6 times and ate 26-50 percent of his meals 2 times. LN 1 confirmed Resident 1 consumed 50 percent or less of his meals over half the time and there was no offer of an alternative meal documented or any type of calorie replacement supplements ordered. LN 1 confirmed the findings and verified poor nutrition was a risk factor for the development of pressure ulcers. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's weights were reviewed. On 4/25/23 (six days after admission) Resident 1 weighed 235.4 pounds, on 8/1/23 (three months after admission) Resident 1 weighed 202 pounds. LN 1 stated Resident 1's weight loss was attributed to a medication used to reduce the fluid accumulation in his lower legs. LN 1 confirmed Resident 1 was admitted to the facility with 2-3+ pitting edema (a score given to measure how long it takes for the skin to rebound after being pressed) to both lower legs according to his admission assessment dated [DATE]. A review of Resident 1's daily nursing monitors to measure the edema revealed from 8/1/23-8/14/23 Resident 1 continued to have 2-3+ pitting edema. From 4/25/23-8/1/23 Resident 1 lost 33.4 pounds (a 14 percent loss). During an interview on 11/10/23, at 12:38 p.m., LN 1 stated pressure ulcer risks for Resident 1 included being a daily smoker, refusal of care, incontinence, right sided weakness, right sided hand, and knee contractures (a fixed tightening of muscle, tendons, and ligaments which prevents normal movement of the associated body part) and a decline in mobility. LN 1 stated on admission in early 2023 Resident 1 was able to transfer himself from bed to his wheelchair, and around June of 2023 Resident 1 was no longer able to transfer himself and required staff to use a lift device to transfer Resident 1. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's care plans and clinical record were reviewed with LN 1. The first care plan reviewed, dated 4/27/23, indicated, .Focus .alteration in skin integrity due to: edema, PVD [peripheral vascular disease, a disease affecting the veins], stasis ulcers [a wound that takes longer to heal due to vein and blood flow issues] .Interventions .Assess/record changes in skin status .avoid pressure .complete skin report weekly . LN 1 confirmed during the nurses required weekly summary of Resident 1, the summary should include a skin report. LN 1 verified in June 2023 two summaries were completed (out of 4), and one summary in August 2023 (out of 4) was completed. An additional care plan reviewed, dated 5/1/23, indicated, .[Resident 1] has potential for impairment to skin integrity r/t [related to] .venous stasis ulcers .to lower extremities, with episodes of incontinence .he is at risk for further skin breakdown .Interventions .Monitor for skin breakdown/pressure ulcer formation daily . LN 1 confirmed on both of Resident 1's at risk for skin breakdown care plans the care plans did not include other identified risk factors such as being a daily smoker, poor mobility, refusal of care, weakness on the right side, and contractures. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's nurses notes were reviewed with LN 1. LN 1 confirmed there was not a progress note, a change in condition note, or any other type of entry from a nurse that Resident 1's pressure ulcer to his right ischial tuberosity was assessed for cause, location, stage, size (length, width, depth), odor, or necrotic/eschar tissue (dead skin tissue) but should have been to monitor if the pressure ulcer was improving or worsening. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's care plans were reviewed with LN 1. LN 1 confirmed on 8/3/23 a care plan was initiated which read, .Focus .[Resident 1] has cellulitis (a skin infection) to wound right ischium UTD [unable to determine, unable to see the wound entirely due to dead skin tissue] PU [pressure ulcer] .Goal .The resident will have no complications resulting from the cellulitis through the review date .Interventions .Educate the resident that prevention of cellulitis starts with good hygiene .importance of compliance with showers and turning and repositioning .give antibiotics .monitor/document and report to MD [medical doctor] the following symptoms of Cellulitis .WOUND/DRESSING per MD order . LN 1 confirmed the care plan was geared towards the potential infection of the pressure ulcer as opposed to person centered interventions to treat/heal the pressure ulcer. LN 1 confirmed there was never a specific care plan initiated for the pressure ulcer discovered on 8/3/23 to Resident 1's right ischial tuberosity outlining interventions to prevent worsening of the pressure ulcer. A review of Resident 1's Physician Assistant's (PA) note, dated 8/9/23, indicated the PA examined Resident 1 on 8/9/23 (six days after the discovery of the pressure ulcer) which read, .complaints: none .Skin .exam .yes . Further review of the note revealed under the area for the PA to write a Plan the area was blank. A review of Resident 1's wound physician's note, dated 8/10/23, indicated, .Patient has a large pressure injury on right ischium. He now spends most of his time in his wheelchair. I discussed repositioning with him. I also am recommending a LAL mattress [an air mattress that redistributes pressure] and a Roho cushion [a chair cushion designed to relieve pressure] for his wheelchair .Initial wound encounter measurements are 7cm [centimeters, a unit of measure] length x 6.5cm width with no measurable depth, with an area of 45.5 sq [square] cm .wound bed has 100% eschar .surgical debridement .removed .necrotic/eschar .used .scalpel .post debridement measurements: 7cm length x 6.5cm width x 3cm depth . A review of Resident 1's wound physician's note, dated 8/17/23, indicated, .Right Ischium is a Stage 3 Pressure Injury .no change in the wound progression . During an interview with Certified Nursing Assistant (CNA) 1 on 10/26/23, at 5:24 p.m., CNA 1 stated Resident 1 would get up into his wheelchair on the day shift and not go back to bed until approximately 9 p.m.[Resident 1] would just want to stay in his chair .we told nurses every time he did not want to go back to bed. Sometimes he won't let us change him either . During an interview with the Director of Nursing (DON) on 11/1/23, at 11:29 a.m., the DON stated Resident 1 should have had a Roho cushion prior to the pressure ulcer forming because he shifted to one side due to his right sided weakness and was up in his wheelchair most of the time which put him at risk for skin injury or further skin injury. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., LN 1 confirmed Resident 1 spent more time up in his wheelchair than in bed. LN 1 stated there was no documentation to verify that Resident 1 was being repositioned in his wheelchair or in bed. LN 1 confirmed Resident 1's Roho cushion and LAL mattress were not added to a care plan. LN 1 added care plans were the documented plan of care the resident should receive. Prior to 8/10/23, LN 1 verified Resident 1 did not have any other pressure relieving devices to help prevent pressure ulcers except for the same mattress every resident had in the building. A review of Resident 1's change in condition nurse's note, dated 9/12/23, indicated, .Resident [1] presented with .foul odor from wound to R [right] ischium, lethargic [drowsy], pale and clammy .MD advised to send resident to acute for further evaluation for .sepsis [your body's extreme reaction to an infection. Without prompt treatment, it can lead to organ failure, tissue damage and death] . 2. Resident 2 was admitted to the facility in mid-2023 with diagnoses which included diabetes (an abnormal amount of sugar in the blood which can affect the eyes, kidneys, and nerves of the body), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs which can cause fatigue, constipation, and dry skin), overactive bladder (causes a frequent and sudden urge to urinate that may be difficult to control), and had a history of urinary tract infections (UTI, a common infection which happens when bacteria, often from the skin or rectum, enter the urinary system.) A review of Resident 2's Quarterly MDS, dated [DATE], revealed a score of 4 on the BIMS which indicated significant cognitive impairment. Further review of the MDS indicated Resident 1 was at risk for developing pressure ulcers, had a stage two pressure ulcer (developed three months after admission), and was not on a turning/repositioning program. Resident 2's mobility documented on the 8/13/23 MDS indicated Resident 2 needed the assistance of one person for bed mobility and transfers and used a wheelchair. The MDS also revealed Resident 2 was frequently incontinent of bowel and bladder and was not on a toileting program. A review of Resident 2's assessment titled, .Bowel and Bladder Screener ., dated 8/10/23, revealed a score of 9 which indicated Resident 2 was a .good candidate for retraining . During a concurrent interview and record review on 11/10/23, at 12:38 p.m., LN 1 confirmed Resident 2 had not been on a toileting program and incontinence was a risk factor for pressure ulcers. A review of Resident 2's assessment titled, BRADEN SCORE FOR PREDICTING PRESSURE SORE RISK, dated 5/17/23, revealed it was blank (not done on admission to the facility.) The next Braden was completed on 8/10/23 and revealed a score of 16 which indicated Resident 2 was at risk for developing pressure ulcers. During a concurrent interview and record review on 10/26/23, at 4:49 p.m., LN 1 confirmed Resident 2's 5/17/23 Braden assessment was incomplete. LN 1 stated the Braden should be completed upon admission to the facility, so staff are able to properly identify pressure ulcer risk for each resident. LN 1 stated the Braden should be done on admission and quarterly thereafter. A review of Resident 2's nurse progress note dated 8/5/23, indicated, .coughing and fine crackles [a series of short, explosive sounds that can also sound like bubbling, rattling, or clicking] noted during shift. Resident appears to have increased confusion .MD notified of findings .This writer requested order for chest x-ray . During an interview on 10/4/23 at 11:47 a.m., CNA 3 stated she could not remember the exact date but when she took over care for Resident 2 one morning, she was soaked with urine and her bed was wet. CNA 3 added Resident 2 had a rash on her bottom, and she notified the nurse. CNA 3 went on to say Resident 2 would not drink much water. During an interview on 10/31/23 at 2:44 p.m., LN 4 stated he witnessed Resident 2 up in her recliner a couple times on the PM shift (shift between AM shift and Night shift.) LN 4 added Resident 2 was not eating well, would not drink enough water, and stayed in bed while she was sick. LN 4 stated these factors contributed to Resident 2 developing a pressure ulcer. During an interview on 11/1/23 at 11:29 a.m., the DON stated Resident 2 developed a pressure ulcer because Resident 2 was not repositioned frequently or often enough. The DON added Resident 2's nutrition was not good. During an interview on 11/10/23 at 12:38 p.m., LN 1 stated Resident 2 would get up to her wheelchair for meals then transfer to the recliner in her room each day. LN 1 confirmed Resident 2 did not have any other pressure relieving devices to help prevent pressure ulcers except for the mattress every other resident had in the building. LN 1 verified there was no documentation to indicate Resident 2 was on a turning/repositioning program. A review of Resident 2's care plans indicated, .Focus .[Resident 2] has bladder incontinence and requires extensive assistance with toileting .She is at risk for skin breakdown .date initiated 5/25/2023 .Interventions .Briefs [used for incontinence in adults] .encourage fluids . An additional care plan indicated, .[Resident 2] has potential for pressure ulcer development r/t [related to] bowel and bladder incontinence, immobility and she requires extensive assistance with bed mobility .date initiated 5/23/2023 .Interventions .Encourage and assist patient to turn and reposition frequently .monitor nutritional status .provide good .care with each incontinent episode . A review of Resident 2's change of condition nurse's note, dated 8/8/23, indicated, .pressure ulcer on [tailbone] . A subsequent review of Resident 2's care plans revealed staff did not initiate a care plan for Resident 2's pressure ulcer with interventions to treat/heal the pressure ulcer. During an interview on 11/1/23 at 11:29 a.m., the DON stated staff should have initiated a care plan after the pressure ulcer was identified. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 2's nurses notes were reviewed with LN 1. LN 1 confirmed there was not a progress note, a change of condition note, or any other type of entry from a nurse that verified Resident 2's pressure ulcer to her tailbone was assessed for cause, location, stage, size (length, width, depth), odor, or necrotic/eschar tissue (dead skin tissue) but should have been. A review of Resident 2's Physician Assistant's (PA) note indicated the PA examined Resident 2 on 8/9/23 (one day after the pressure ulcer was discovered) which read, .complaints: none .Skin .exam .yes . Further review revealed under the area for the PA to write a Plan the area was blank. A review of the facility's policy and procedure titled, Prevention of Pressure Injuries, revised 4/2020, indicated, .Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable .Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment [The facility uses the Braden Scale] weekly and upon any changes in condition .inspect the skin on a daily basis .identify any signs of developing pressure injuries .inspect pressure points .[tailbone] .ischium .reposition resident as indicated on the care plan .Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team [team of professionals providing day to day care of the resident] .Choose a frequency for repositioning based on the resident's risk factors .Evaluate, report and document potential changes in the skin .Review the interventions and strategies for effectiveness on an ongoing basis . A review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, Revised 4/2018, indicated, .The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example immobility, recent weight loss .Full assessment of pressure sore [ulcer] including location, stage, length, width and depth, presence of .necrotic tissue .pain assessment .mobility status .current treatment, including support surfaces .all active diagnoses .The physician will help identify factors contributing .to skin breakdown .medical instability .friable [fragile] skin .the physician will order .pressure reduction surfaces .During resident visits, the physician will evaluate and document the progress of wound healing .The physician will guide the care plan as appropriate .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 made by the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain acceptable parameters of nutrition for one of three sampled residents (Resident 1) when Resident 1's decreased food intake and 18-pound weight loss was not recognized, addressed, or reported to the physician in a timely manner. This failure resulted in a delay of treatment and Resident 1 being hospitalized . Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included tongue cancer and dysphagia (difficulty swallowing). Review of Resident 1's POLST (Physician Orders for Life Sustaining Treatment: care directives during life threatening situations) dated 9/6/22, indicated, .Attempt Resuscitation/CPR [cardiopulmonary resuscitation, an emergency lifesaving procedure performed when the heart stops beating] . was checked. A review of Resident 1's electronic health record titled, Weight Summary, indicated the following: 12/1/22-118.2 Lbs (pounds) 12/5/22-100 Lbs During a concurrent interview and record review on 12/22/22, at 3:41 p.m., Certified Nursing Assistant (CNA) 1 reviewed Resident 1's medical record for meal intake, Task:Nutrition-Amount Eaten . and confirmed Resident 1 refused all his meals from 11/25/22 through 12/4/22, with the exception of one meal on 12/2/22, when Resident 1 ate 0-25% of the morning meal. CNA 1 stated it was dangerous to Resident 1's health to continuously refuse his meals, and this was an important issue to report to the nurse. During a concurrent interview and record review on 12/22/22, at 4:55 p.m., Resident 1's medical record was reviewed with Licensed Nurse (LN) 1. LN 1 stated she did not know the resident had refused his meals during this time period, and she expected the CNA to report it to the nurse. LN 1 further stated she did not know about Resident 1's weight loss, but 18 pounds lost in four days was a lot and the physician should have been notified by the nurse. LN 1 stated there was no documentation to indicate the physician was notified about Resident 1's refusals to eat or his 18-pound weight loss. During a concurrent interview and record review on 12/22/22, at 5:49 p.m., Resident 1's medical record was reviewed with the Director of Nursing (DON). The DON acknowledged Resident 1's weight loss of 18 pounds and stated Resident 1 was dehydrated. The DON stated she considered it a significant weight loss. The DON stated she was unaware Resident 1 refused his meals between 11/25/22 and 12/4/22. The DON further stated there was no documentation to show if the physician was notified about Resident 1's weight loss and his refusal of meals. The DON stated she expected the CNA to report it to the nurse and the nurse should have reported it to her. The DON further stated Resident 1's refusals to eat should have been addressed and better coordination of care should have been provided. The DON reviewed Resident 1's medical record and stated a Skin and Nutrition review was held to address Resident 1's weight loss on 12/9/22 and confirmed Resident 1 was hospitalized as of 12/5/22 and was not in the facility on 12/9/22. During an interview on 12/28/22, at 3:15 p.m., Medical Doctor (MD) 1 stated he was not notified Resident 1 had refused to eat from 11/24/22-12/4/22 and was also unaware Resident 1 had lost 18 pounds. MD 1 further stated the nursing staff should have notified him, so he could have addressed these issues. MD 1 explained it was not acceptable for a resident to lose 18 pounds in 4 days. MD 1 stated the risk of this decline in food intake and weight was serious including metabolic (chemical reactions in the body that breakdown food into energy) problems, dehydration (body loses too much water) and the resident would suffer serious medical problems. During an interview on 1/4/23, at 4:33 p.m., LN 2 stated she was aware Resident 1 was refusing meals but did not know he had an 18-pound weight loss. LN 2 further stated she did not address Resident 1's refusal to eat or weight loss to the physician. LN 2 stated Resident 1 experienced a significant change of condition with refusals of all meals and a further assessment of Resident 1 should have been completed. LN 2 stated Resident 1 had an appointment on 12/5/22 with an Oncologist (cancer doctor). LN 2 indicated she should have sent Resident 1 to the hospital for an evaluation, rather than to his appointment on 12/5/22, and indicated it was not safe for Resident 1 to be sent out of the facility for his appointment. During a concurrent interview and record review on 1/5/23, at 11:06 a.m., the Registered Dietician (RD) confirmed she was not notified by the facility about Resident 1's 18-pound weight loss. The RD stated nursing should have called her in order to address the weight loss. The RD further stated Resident 1's 18-pound weight loss was considered a significant weight loss because the resident had lost 15 percent in four days. The RD explained significant weight loss could be harmful because Resident 1 was losing weight drastically. During an interview on 1/23/23, at 12:37 p.m., the Oncology Nurse (ON) 1 stated Resident 1 arrived for his oncology appointment from the facility on 12/5/22. ON 1 further stated Resident 1's eyes were closed, he was cyanotic (bluish discoloration of the skin from poor circulation or lack of oxygen in the blood), his nail beds were gray, and all his extremities were cold. ON 1 explained she could not get any vital signs on him and considered Resident 1 in an unstable condition. During an interview on 1/23/23, at 12:44 p.m., the Oncologist (ON MD) stated Resident 1 arrived for his appointment on 12/5/22 and was found to be unresponsive. A sternal rub (the application of a painful response with the knuckles of closed fist to the center chest of a person who is not alert and does not respond to verbal commands) was performed with no response. The ON MD further stated he ordered Resident 1 to be taken to the emergency room. The ON MD explained he did not understand why Resident 1 was brought to his office when Resident 1 looked out of it and needed to go to the hospital. The ON MD stated he was not notified about Resident 1's weight loss and expected the facility to communicate with him. The ON MD further stated Resident 1 was at risk for malnutrition (lack of proper nutrition), dehydration, delirium (a disturbed state of mind or consciousness), and kidney failure. A review of the hospital document titled, History and Physical, dated 12/5/22, indicated, .REASON FOR ADMISSION/ CHIEF COMPLAINT: Worsening mentation [mental activity] .In the ER [emergency room] the patient [Resident 1] has been unresponsive. He is hypothermic [the body gets very cold and can't warm up on its own], hypotensive [low blood pressure]. Lab work shows severe hyponatremia [sodium level in the blood is low] . A review of the hospital document titled, Emergency Department Reports, dated 12/5/22, indicated, .[Resident 1] presents for evaluation of worsening mentation. Over the past few days the patient's become increasingly less interactive and nonverbal. They note he has not been eating and has had weight loss. He was at the infusion center here and directed here because he was looking more ill per staff .I spoke with [Resident 1's responsible party] who would like to continue fluids and antibiotics but agrees would not be appropriate for dialysis [a process by which blood is filtered to remove toxins when kidneys don't work properly]. I explained that the patient is gravely ill and will likely likely [sic] not survive this. [RP] voiced good understanding of this and would like the patient to be admitted here . A review of the hospital document titled, Discharge Summaries Notes, dated 12/8/23, indicated, HOSPITAL COURSE .The patient [Resident 1] was admitted to the hospitalist service. He was given IV [intravenous, in the vein] fluid hydration and antibiotics without improvement in his sodium level or mentation. Given his advanced age, protein, nutrition with cachexia [weakness and wasting of the body] acute kidney injury, I discussed the patient's prognosis with his son and decision was made to transition [Resident 1] to comfort measures . Review of the facility policy titled, Resident Rights . dated July 2018, indicated, .The facility will promptly inform the resident, consult with the resident's physician .when there is .A significant change in the resident's physical, mental, or psychosocial status . Review of an undated facility policy titled, Nutrition and Hydration, indicated, .Residents who experience weight loss will be reviewed during the Skin and Nutrition meeting .