**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accident hazards out of three sample residents remained free from accident hazards. On 2/27/24, just before 2:00 p.m. certified nurse aide (CNA) #1 was providing care to Resident #1. The resident was rolled on her side during the care and the resident slid off the side of the bed, fell to the floor and sustained a left hip fracture. The resident was sent to the hospital for treatment and underwent surgical repair of the left hip fracture. Through a facility investigation, it was found that CNA #1 had not followed the resident individualized care plan accurately when she made the decision to provide care without a care partner to ensure proper technique for safety and appropriate bed mobility. The facility failed to ensure that Resident #1 received appropriate care per her comprehensive care plan for two staff members to assist with bed mobility and incontinent care which resulted in the resident falling out of bed and sustaining a hip fracture that required surgical intervention. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 11/14/24, resulting in the deficiency being cited as past noncompliance with a correction date of 2/28/24. I. Incident on 2/27/24 CNA #1's failure to follow the resident' s care plan to provide bed mobility with the assistance of two staff members led to the resident falling out of a high bed and sustaining a major injury (hip fracture). II. Facility plan of correction Interviews and record review during the onsite investigation on 11/14/24 revealed the facility investigated this singular event and implemented corrective actions to prevent the recurrence of the incident. A. Immediate action to correct the deficient practice for Resident #1 CNA #1 was suspended during the investigation and, upon her return on 3/1/24, CNA #1 was provided coaching and education on the facility' s policy that the resident' s care plan must be followed at all times. CNA #1 was educated on where to locate a resident' s care plan, the care plan interventions and on the expectation to check each resident' s care plan daily and before the start of care. Additionally, CNA #1 was educated that, per facility policy, the resident' s care plan was to be followed as written and that any concerns about care were to be brought to the attention of the nurse on duty. Resident #1' s care plan was revised with appropriate interventions for all care areas. All facility nurses and CNAs were educated on the facility' s policy for following each resident' s care plan, where to find the care plan and expectations for reporting concerns about care plan interventions. The education was completed on 2/27/24 and 2/28/24. B. Identification of other residents All residents (90) were assessed for ADL level of assistance and care needs and the information was compared to the existing care plan. All discrepancies and conflicting documentation were clarified or corrected to reflect each resident's assessed care assistance needs. This was completed on 2/28/24. C. Systematic changes The facility' s quality assurance performance improvement committee developed a plan of improvement on 2/28/24. The plan included: A root cause analysis of the incident was conducted and it was determined that CNA #1 was not following facility policy for reviewing and following Resident #1' s comprehensive care plan, which led directly to the resident falling off the bed while in the care of a facility staff member causing the resident a significant injury (see above). Staff education was completed with all nurses and CNAs on 2/28/24 and completed with new staff and staff upon their assigned work shift by 2/28/24. Following the provision of staff education, each staff member was required to show a return demonstration that they understood and were capable of accessing resident care plans. This was completed with every staff member by 4/30/24. Observations and interviews during the survey revealed staff were consistently following the care plan interventions of the residents included in the survey process on 11/14/24. An interview with the director of nursing (DON) confirmed the corrective actions, and therefore the facility's substantial compliance, by 2/28/24, at the time of the survey was conducted on 11/14/24. D. Monitoring The DON/designee was tasked with ensuring each resident was assessed for appropriate care needs upon admission, quarterly, and with each change in condition and that the resident' s care plan was updated accordingly. Needs for care plan revision out of sequence (when a change of condition occurred) were to be brought to the attention of the DON and other members of leadership and discussed with the interdisciplinary team ( IDT) and then documented in the resident' s record. II. Facility policy and procedure The Fall Management policy and procedure, revised on 4/7/24, was provided by the DON on 11/14/24 at 3:01 p.m. It read in pertinent part, The facility will assess the resident upon admission/readmission, quarterly, with change of condition and will identify appropriate interventions to minimize the risk of injury-related falls. The resident environment remains as free of accident hazards as is possible. Each resident shall receive adequate supervision and assistance to prevent accidents. III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and was discharged to the hospital on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included a fracture to the left femur (hip), a history of stroke, muscle weakness and Alzheimer' s disease. The 9/16/24 minimum data set (MDS) assessment revealed Resident #1 had short-term and long-term memory impairment, severely impaired daily decision-making skills and continuous symptoms of inattention, per staff assessment. The resident had difficulty focusing attention on tasks, was easily distractible and had difficulty keeping track of what she was told. The resident was dependent on two staff members to complete activities of daily living (ADL), including performing toileting hygiene, shower/bathing, and personal hygiene transferring and repositioning in bed. B. Record review Resident #1' s comprehensive care plan documented the resident had an ADL performance deficit due to Alzheimer's disease, dementia, hemiplegia/hemiparesis (weakness) to the right side and a history of stroke. Interventions included providing assistance of two staff members to turn and reposition the resident (initiated 12/11/2020) and providing assistance of two staff members for incontinence care (initiated 12/11/2020). A progress note, dated 2/27/24 at 2:00 p.m., documented the nurse heard a loud noise and screaming for help from a CNA and Resident #1' s roommate. The nurse went to the room to check on the resident. Resident #1 was found lying on the floor. CNA #1 said she was changing Resident #1 and she fell out of bed. CNA #1 said the resident landed on her right side. Resident #1 was assessed and found to have a hematoma (raised area due to swelling) on her forehead, a laceration on her nose, bruising to her chin, a skin tear to her left lower leg shin area, and a skin tear to her left elbow. The resident had rapid respirations, a very high blood pressure and was complaining of pain to her left hip and forehead. Emergency medical services (EMS) was called and the resident was taken to the hospital for assessment and medical treatment. C. Incident investigation The facility fall investigation report, dated 2/27/24, revealed Resident #1 fell out of bed on 2/27/24 at approximately 2:00 p.m. while being assisted by only one CNA (CNA #1). As a part of the investigation, the facility conducted a root cause analysis of the incident and determined CNA #1 was not following the resident' s care plan. When interviewed, CNA #1 was unaware of the resident's care assistance needs, including that the resident was to receive ADL assistance performed by two staff members for proper support and safety. CNA #1' s interview statement documented that she entered Resident #1' s room to assist her with toileting hygiene. CNA #1 said she started to provide care for Resident #1 by wiping her genitalia in the front and then turning the resident on her right side to wipe and cleanse her buttocks. After wiping the resident' s buttocks, the resident slid off the side of the bed to the floor. CNA #1 said the resident did not roll forward but slid off the bed while maintaining a side-lying position landing on her side. CNA #1 told the investigator that she had cared for Resident #1 for the past four years and she thought she was following the resident' s care plan and following interventions for the resident' s current level of care. CNA #1 admitted that she had not reviewed the resident' s care plan recently and believed Resident #1' s care could be provided by one staff member without assistance. -However, the resident' s care plan interventions indicated intervention for the need for two staff members to provide bed mobility assistance had been in place since 12/11/2020. A nurse practitioner exam note, dated 3/11/24 at 11:19 a.m., revealed the resident had been in the hospital since 2/27/24 receiving medical treatment after she fell out of bed during ADL care while in the facility. The note revealed Resident #1 returned that day (3/11/24) after being hospitalized for surgical repair to the left hip after falling out of bed while staff provided care. The note documented that the resident also had ecchymosis (bruising from broken blood vessels to the skin or mucous membranes) on the face resulting from trauma and a hematoma in the middle of the forehead. The resident was able to move all four extremities with decreased movement to both lower legs. A progress note dated, 3/12/24 at 2:03 p.m., revealed the resident moaned in pain when repositioned and was prescribed Tylenol three times a day for the pain. III. Staff interviews The DON and the nursing home administrator (NHA) were interviewed together on 11/14/24 at 3:30 p.m. The DON said CNA #1 had not followed the facility' s policy or the resident' s care plan and that lead to the resident being injured. The DON said CNA #1 was counseled and educated on facility expectations to check each resident' s care plan each shift to be aware of any changes and care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#17) of two out of 40 sample residents was treated with dignity and respect and cared for in an environment that promoted her quality of life. Specifically, the facility failed to ensure Resident #17 did not suffer from emotional distress by registered nurse (RN) #4. The facility failed to provide Resident #17 an environment free to share her concerns without fear of humiliation, retaliation or intimidation. The facility's failure caused continued emotional distress experienced by the Resident #17. Findings include: I. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2022 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease and depression. The 7/29/22 facility assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required supervision with activities of daily living. It indicated the resident did not have any signs or symptoms of depression. The resident did not reject any care during the assessment period. B. Resident interviews Resident #17 was interviewed 10/11/22 at 10:32 a.m. She said about two to three months ago that RN #4 was short with her and embarrassed her in front of other staff members. She said she approached the unit manager, licensed practical nurse (LPN) #1 to make a doctor appointment for the next day regarding a procedure to remove eyelashes on her left eye because the unit manager for her unit was not at work. She said her eyelashes grow inwards and she was experiencing a lot of pain in the left eye. She said RN #4 approached her in the hallway and chewed me out and said that I didn't need to bother anyone else and I had to wait until my unit manager returned to make the appointment. Resident #17 said she approached the unit manager, licensed practical nurse (LPN) #2, upon her return to the facility, about the incident and told her that I felt like I was at fault and wanted to apologize to RN #4. LPN #2 told Resident #17 that she did not have to apologize. Resident #17 said she continued to feel badly and approached RN #4 the next day to apologize. RN #4 told the resident that she had been chewed out by LPN #2 regarding the incident. Afterwards, Resident #17 said that RN #4 was very cold towards her and would only come in to give her medications and leave. She said RN #4 would not speak with her. During the interview, Resident #17 became emotional and had tears in her eyes when speaking of the encounter with RN #4. Resident #17 said, They were supposed to investigate it and write up a report and they never did that. Resident #17 said RN #4 was no longer employed at the facility because she followed a member of the administrative team to another facility. She and there has been a positive change since she has been gone in the attitudes of the CNAs (certified nurse aides) and residents. C. Record review The mood care plan, initiated on 11/11/18, documented the resident had a diagnosis of depression. It indicated the resident had a history of feeling tearful, hopeless and socially isolating. The interventions included administering antidepressant medications as ordered, completing the PHQ-9 (patient health questionnaire for depression) quarterly and as needed, providing the resident time to discuss concerns, feelings and thoughts as needed. -It did not include any person-centered approaches to manage the resident's depression. The impaired visual function care plan, initiated on 10/10/18 and revised on 1/22/2020, documented the resident's vision was severely impaired to the left eye and had right eye blindness related to macular degeneration, [NAME] disease of the eye and corneal ulceration of left eye (from misalignment of eyelashes as they rub against the eyeball). The interventions included consulting with an eye practitioner as required, explaining activities/sounds in the environment as needed and explaining care and services. II. Additional resident interview Resident #28, who was cognitively intact according to the facility assessment, was interviewed 10/17/22 at 10:30 a.m. Resident #28 said that RN #4 was a good nurse but she was abrupt with many residents and her attitude was someone who was not very happy with her job. She said RN #4 had an air about her where she felt RN #4 thought she was better than the residents and other staff members. III. Staff Interviews LPN #2 was interviewed on 10/13/22 at 5:00 p.m. LPN #2 said she was the unit manager of the unit where Resident #17 resided. She said that RN #4 butted heads with a lot of residents and was no longer employed at the facility. She said she followed the former NHA to another facility. LPN #2 said, in early July 2022, she had to take a day off of work. She said when she returned, Resident #17 said she went to LPN #1 to make an appointment for her to remove the eyelashes for her left eye, because she was experiencing pain. She said Resident #17 told her RN #4 accosted (approached aggressively) her in the hall and told Resident #17 that she did not need to bother anyone about her appointment and that she needed to speak with LPN #2 when she returned to work. LPN #2 said Resident #17 felt bad and wanted to smooth things over with RN #4. She said Resident #17 wanted to write an apology note to RN #4. LPN #2 told Resident #17 apologies were not necessary and that she should not feel bad about asking for the appointment. Resident #17 wrote the note and left it for RN #4 on the medication cart. She said she saw RN #4 take the note, unopened, to Resident #17's room. She said Resident #17 told her she found the note she had written RN #4 in her nightstand, unopened. LPN #2 said it was the ultimate (expletive) to someone who was just trying to offer an apology. LPN #2 said Resident #17 continued to feel badly and was emotional about the incident. LPN #2 said she reported this incident, in writing, to the former nursing home administrator (NHA) along with many other complaints from family, staff and residents regarding RN #4. LPN #2 said the former NHA was always smoothing things over and making excuses for RN #4. LPN #2 said the complaint was not addressed and felt the grievance, along with all the other grievances about RN #4, probably ended up in the shredder. LPN #2 said the former NHA and RN #4 were now employed at another facility. The NHA was interviewed on 10/17/22 at 8:15 a.m. He said he was unable to find an investigation regarding the incident between Resident #17 and RN #4. He said he interviewed Resident #17 that day (10/17/22) and she was very tearful and upset when recounting the incident regarding RN #4. He said he was not the NHA at the facility when this event occurred. LPN #2 was interviewed on 10/17/22 at 2:30 p.m. She said the issue regarding Resident #17 not feeling like RN #4 had been giving her the antidepressant medication (which had happened the weekend before the incident, see the former NHA interview below) and the issue with making the appointment were two separate instances. She said she was not aware of the incident with the medications. She said Resident #17 had come to her, the day she returned to work, and told her about the incident with RN #4. She said she immediately informed the former NHA that same day. LPN #6 was interviewed on 10/17/22 at 2:35 p.m. She said any allegations of abuse should be reported immediately to the unit manager, the director of nursing (DON), supervisor on duty and the executive director. She said the types of abuse reported were physical, mental, verbal and neglect. The NHA and former nursing home administrator (FNHA) were interviewed on 10/17/22 at 11:00 a.m. The FNHA said she had completed an investigation regarding Resident #17 reporting RN #4 had not been giving her the antidepressant medication she was prescribed, which was the weekend before the incident with RN #4. She said she had conducted an investigation and resolved the concern with the resident by ensuring the medications were shown to the resident prior to being crushed and mixed with applesauce. She said LPN #2 had not reported the incident between Resident #17 and RN #4 to her, however she was able to recount the entire event between Resident #17 and RN #4. She said that event had not been included in the investigation she completed about the medication concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#17) of two out of 40 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #17 did not suffer from emotional abuse by registered nurse (RN) #4. The facility failed to provide Resident #17 an environment free to share her concerns without fear of humiliation, retaliation or intimidation. The facility's failure caused continued emotional distress experienced by the Resident #17. Findings include: I. Facility policy and procedure The Reporting Alleged Abuse policy and procedure, revised February 2017, was provided by the nursing home administrator on 10/10/22 at 8:30 a.m. It revealed, in pertinent part, This facility does not condone resident abuse and/or neglect by anyone. This includes but is not limited to: staff members, other residents, consultants, volunteers, staff from other agencies serving out residents, family members, the responsible party, sponsors, friends, or other individuals. All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin. II. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2022 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease and depression. The 7/29/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required supervision with activities of daily living. It indicated the resident did not have any signs or symptoms of depression. The resident did not reject any care during the assessment period. B. Resident interviews Resident #17 was interviewed 10/11/22 at 10:32 a.m. She said about two to three months ago that RN #4 was short with her and embarrassed her in front of other staff members. She said she approached the unit manager, licensed practical nurse (LPN) #1 to make a doctor appointment for the next day regarding a procedure to remove eyelashes on her left eye because the unit manager for her unit was not at work. She said her eyelashes grow inwards and she was experiencing a lot of pain in the left eye. She said RN #4 approached her in the hallway and chewed me out and said that I didn't need to bother anyone else and I had to wait until my unit manager returned to make the appointment. Resident #17 said she approached the unit manager, licensed practical nurse (LPN) #2, upon her return to the facility, about the incident and told her that I felt like I was at fault and wanted to apologize to RN #4. LPN #2 told Resident #17 that she did not have to apologize. Resident #17 said she continued to feel badly and approached RN #4 the next day to apologize. RN #4 told the resident that she had been chewed out by LPN #2 regarding the incident. Afterwards, Resident #17 said that RN #4 was very cold towards her and would only come in to give her medications and leave. She said RN #4 would not speak with her. During the interview, Resident #17 became emotional and had tears in her eyes when speaking of the encounter with RN #4. Resident #17 said, They were supposed to investigate it and write up a report and they never did that. Resident #17 said RN #4 was no longer employed at the facility because she followed a member of the administrative team to another facility. She and there has been a positive change since she has been gone in the attitudes of the CNAs (certified nurse aides) and residents. C. Record review The mood care plan, initiated on 11/11/18, documented the resident had a diagnosis of depression. It indicated the resident had a history of feeling tearful, hopeless and socially isolating. The interventions included administering antidepressant medications as ordered, completing the PHQ-9 (patient health questionnaire for depression) quarterly and as needed, providing the resident time to discuss concerns, feelings and thoughts as needed. -It did not include any person-centered approaches to manage the resident's depression. The impaired visual function care plan, initiated on 10/10/18 and revised on 1/22/2020, documented the resident's vision was severely impaired to the left eye and had right eye blindness related to macular degeneration, [NAME] disease of the eye and corneal ulceration of left eye (from misalignment of eyelashes as they rub against the eyeball). The interventions included consulting with an eye practitioner as required, explaining activities/sounds in the environment as needed and explaining care and services. III. Additional resident interview Resident #28, who was cognitively intact according to the facility assessment, was interviewed 10/17/22 at 10:30 a.m. Resident #28 said that RN #4 was a good nurse but she was abrupt with many residents and her attitude was someone who was not very happy with her job. She said RN #4 had an air about her where she felt RN #4 thought she was better than the residents and other staff members. IV. Staff Interviews LPN #2 was interviewed on 10/13/22 at 5:00 p.m. LPN #2 said she was the unit manager of the unit where Resident #17 resided. She said that RN #4 butted heads with a lot of residents and was no longer employed at the facility. She said she followed the former NHA to another facility. LPN #2 said, in early July 2022, she had to take a day off of work. She said when she returned, Resident #17 said she went to LPN #1 to make an appointment for her to remove the eyelashes for her left eye, because she was experiencing pain. She said Resident #17 told her RN #4 accosted (approached aggressively) her in the hall and told Resident #17 that she did not need to bother anyone about her appointment and that she needed to speak with LPN #2 when she returned to work. LPN #2 said Resident #17 felt bad and wanted to smooth things over with RN #4. She said Resident #17 wanted to write an apology note to RN #4. LPN #2 told Resident #17 apologies were not necessary and that she should not feel bad about asking for the appointment. Resident #17 wrote the note and left it for RN #4 on the medication cart. She said she saw RN #4 take the note, unopened, to Resident #17's room. She said Resident #17 told her she found the note she had written RN #4 in her nightstand, unopened. LPN #2 said it was the ultimate (expletive) to someone who was just trying to offer an apology. LPN #2 said Resident #17 continued to feel badly and was emotional about the incident. LPN #2 said she reported this incident, in writing, to the former nursing home administrator (NHA) along with many other complaints from family, staff and residents regarding RN #4. LPN #2 said the former NHA was always smoothing things over and making excuses for RN #4. LPN #2 said the complaint was not addressed and felt the grievance, along with all the other grievances about RN #4, probably ended up in the shredder. LPN #2 said the former NHA and RN #4 were now employed at another facility. The NHA was interviewed on 10/17/22 at 8:15 a.m. He said he was unable to find an investigation regarding the incident between Resident #17 and RN #4. He said he interviewed Resident #17 that day (10/17/22) and she was very tearful and upset when recounting the incident regarding RN #4. He said he was not the NHA at the facility when this event occurred. LPN #2 was interviewed on 10/17/22 at 2:30 p.m. She said the issue regarding Resident #17 not feeling like RN #4 had been giving her the antidepressant medication (which had happened the weekend before the incident, see the former NHA interview below) and the issue with making the appointment were two separate instances. She said she was not aware of the incident with the medications. She said Resident #17 had come to her, the day she returned to work, and told her about the incident with RN #4. She said she immediately informed the former NHA that same day. LPN #6 was interviewed on 10/17/22 at 2:35 p.m. She said any allegations of abuse should be reported immediately to the unit manager, the director of nursing (DON), supervisor on duty and the executive director. She said the types of abuse reported were physical, mental, verbal and neglect. The NHA and former nursing home administrator (FNHA) were interviewed on 10/17/22 at 11:00 a.m. The FNHA said she had completed an investigation regarding Resident #17 reporting RN #4 had not been giving her the antidepressant medication she was prescribed, which was the weekend before the incident with RN #4. She said she had conducted an investigation and resolved the concern with the resident by ensuring the medications were shown to the resident prior to being crushed and mixed with applesauce. She said LPN #2 had not reported the incident between Resident #17 and RN #4 to her, however she was able to recount the entire event between Resident #17 and RN #4. She said that event had not been included in the investigation she completed about the medication concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide the necessary treatment and services to prevent the development of pressure injuries for one (#42) of two residents reviewed for pressure injury out of 40 sample residents. Resident #42 was identified by the facility as a high risk for developing pressure injuries upon his admission to the facility. On 9/13/22, the resident developed a pressure injury to the right trochanter (hip). The facility failed to ensure an initial assessment of the pressure injury was completed upon the residents admission, The physician was not notified timely and a treatment order was not put into place until 9/26/22; 13 days after the pressure injury was identified. A treatment note dated 9/27/22, by the wound physician, documented the resident had a stage 3 facility acquired pressure injury to her right hip. The facility failed to take sufficient steps to promote wound healing and prevent further skin breakdown. Additionally, the facility failed to ensure that repositioning and incontinence care were provided to the resident in a timely manner. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: [NAME] Park, Western Australia; 2018, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 10/27/22, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Ulcer Prevention policy and procedure, last reviewed April 2022, was provided by the nursing home administrator (NHA) on 10/18/22 at 3:41 p.m. It revealed, in pertinent part, To provide associates and licensed nurses procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPUAP (national pressure injury advisory panel) and WOCN (wound, osteomyelitis, continence nurses society). Based on the comprehensive assessment of a resident the facility must ensure that a resident receives care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individuals clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. A skin assessment/inspection occurs on admission/readmission. Skin observations also occur throughout point of care provided by CNA's (certified nurse aide) during ADL (activities of daily care) care (bathing, dressing, incontinent care, etc.). Any changes or open areas are reported to the nurse. A risk assessment tool, Braden scale or Norton Scale, determines the residents risk for pressure injury development. The scores documented on the tool and placed in the resident's medical records using the appropriate form. Certain risk factors have been identified that increase a resident's susceptibility to develop or impair healing of pressure injuries. Examples include but are not limited to: impaired/decreased mobility and decreased functional ability, comorbid conditions, cognitive impairment, exposure of skin to urinary and fecal incontinence, and the history of healed injury. A skin assessment/inspection should be performed weekly by a licensed nurse. Measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care. All residents upon admission are considered to be at risk for pressure injury development due to medical issues requiring nursing care related to disease process and illness or need for rehabilitation services. Upon admission and throughout stay at a minimum a pressure redistribution surface is in use with turning and repositioning as needed with ADL care/assistance incontinent care if needed to include skin barriers application as needed, preventative wheelchair cushion is indicated, etc. Skin inspections with particular attention to bony prominences, skin cleansing with appropriate cleanser at time of swelling and routine intervals, treat dry skin with moisturizers, minimize skin exposure to incontinence using devices ( i.e. briefs) and skin barriers, minimize injury due to shear and friction through proper positioning, transfers and turning schedules, improve residents mobility in activity when potential exists(restorative). Measures to protect the resident against adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: reposition at least every two to four hours (per NPIAP standards) as consistent with overall patient goal in medical condition; utilize positioning devices to keep bony prominences from direct contact; ensure proper body alignment when side-lying; heel protection/suspension if indicated; maintain HOB (head of bed) at the lowest degree of elevation consistent with medication conditions;, a pressure redistribution mattress service is placed under the resident; when positioned in a wheelchair, the resident is to be placed on a pressure reduction device and repositioned; when positioned in a wheelchair, consideration is given to postural alignment, distribution weight, balance, and stability. The Documentation and Assessment of Wounds policy and procedure, reviewed April 2022, was provided by the NHA on 10/18/22 at 3:41 p.m. It revealed, in pertinent part, To guide the associates and licensed nurse in the assessment of the wounds to include pressure ulcer/injuries, venous, arterial, diabetic, dehisced surgical wounds, and other (not otherwise specified). Based on the comprehensive assessment of a resident, the facility must ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. A wound assessment/documentation is required to occur at a minimum weekly. Nurses performing the treatment would perform an prn (as needed) assessment/documentation if noted change has occurred i.e. wound has healed/resolved, appears infected, or appears to have declined. It may not be practical for the weekly assessment to occur on the 7th day deadline due to dressing not required to be changed on due date, wound round or MD (medical doctor) schedule changes, follow-up appointments, or resident's refusal. For those purposes would obtain wound assessment/documentation prior to if able or within the calendar week to maintain assessment and documentation compliance. Documentation is located in the EHR (electronic health record) progress notes, wound observation tool and/or skin integrity data collection tools. Additional documentation from MD office visits or wound clinic notes may be located in the hard copy medical record. III. Failure to provide the necessary treatment and service to prevent the development of pressure injuries for Resident #42 A. Resident #42's status Resident #42, age [AGE], was admitted on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis (paralysis) affecting right dominant side, unspecified dementia with behavioral disturbances, contracture of muscle of left ankle and foot, contracture of right shoulder right elbow and right hand and specified depressive episodes. According to the 8/16/22 minimum data set (MDS) assessment, the resident had short-term and long-term memory impairment with severe impairment in making decisions regarding tasks of daily life. The resident required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. The MDS documented the resident was incontinent of bowel and bladder and did not have any unhealed pressure ulcers. The resident was on hospice care. B. Observations On 10/12/22, during a continuous observation, beginning at 2:06 p.m. and ended at 3:18 p.m., Resident #42 was observed laying in the supine position (laying on his back) with his feet directly onto the mattress. -At 2:55 p.m. Resident #42 remained in the same position. -At 3:18 p.m. Resident #42 was laying in bed, awake. He attempted to sit up in bed but was unable to reposition himself. On 10/13/22, during a continuous observation, beginning at 8:30 a.m. and ended at 1:25 p.m. Resident #42 was observed sitting in the day room, in front of the television, in a Broda chair. -At 8:48 a.m. the resident was observed eating breakfast in the day room, in the Broda chair. -At 9:10 a.m. Resident #42 remained in the day room, in the Broda chair. -At 9:34 a.m. licensed practical nurse (LPN) #2 and LPN #5 took Resident #42 to his room and helped him to bed by standing the resident and doing a pivot transfer. They placed a pillow behind his head and positioned him supine. The resident's feet were placed directly on the mattress. Certified nurse aide (CNA) #4 came into the resident's room, put his oxygen on, lowered the bed and positioned the resident at 45% angle. -At 9:45 a.m. CNA#4 brought the resident a blanket and put it on him. The resident's feet remained directly on the bed. -At 10:08 a.m. the Resident #42 remained in the same position. -At 11:05 a.m. LPN #5 checked to ensure dressing was on his pressure ulcer. She did not check the resident's incontinence brief or offer to reposition the resident. -At 11:18 a.m. hospice agency staff went in but left because the resident was asleep. The hospice agency staff did not provide the resident care. -At 12:14 p.m. Resident #42 remained in the same position. -At 12:22 p.m. CNA #4 closed the resident's door. She did not enter the resident's room. -At 12:34 p.m. LPN #5 entered the resident's room and gave the resident his medication. She did not offer or provide repositioning to the resident. -At 12:35 p.m. CNA #4 brought the resident his lunch tray, set it on the overbed table and assisted him with eating. -At 12:52 p.m. CNA#4 was finished assisting the resident with his lunch. CNA #4 lowered Resident #42's bed and kept the resident at a 45 degree angle. CNA #4 did not offer to reposition the resident or provide incontinence care. -At 1:17 p.m. Resident #42 remained in the same position. -At 1:25 p.m. CNA #4 entered the resident's room and provided Resident #42 with incontinence care. CNA#4 said the resident was incontinant with urine and the brief was wet. The soiled brief was observed in a trash bag. The brief was heavy, sopping wet, and the moisture could be felt with a gloved hand. CNA #4 said she had not provided Resident #42 incontinence care since the resident was transferred to the Broda chair for breakfast. After providing incontinence care, CNA#4 did not float the resident's heels. The resident was still laying in the supine position. Cross-reference F677: the facility failed to provide incontinence care and repositioning timely for Resident #42. C. Record review The cognition care plan, revised 10/5/22, documented the resident had impaired cognitive skills related to dementia, had trouble word findings and had short-term and long-term memory loss. The activities of daily living (ADL) care plan, revised on 10/11/22, documented the resident had a self-care deficit related to a CVA (cerebral vascular accident) with subsequent impaired mobility. It indicated the resident required one person assistance with bed mobility and totally dependent upon staff for personal hygiene and toileting. The interventions included providing the resident with body pillows for positioning while in bed, encouraging the resident to participate in ADLs as he was able, floating the resident's heels while in bed, repositioning the resident in bed as tolerated, placing the resident's call light on the left side of the resident due to visual impairments. The skin integrity care plan, revised on 10/10/22, revealed Resident #42 was at risk for an alteration in his skin integrity due to impaired mobility, incontinence and a right hand contracture. The interventions included placing an arm rest pad on the left side for skin integrity, applying lotion to the resident's bilateral upper and lower extremities daily, cleaning and drying the resident's skin after each incontinent episode with barrier ointment being applied, completing the Braden scale assessment quarterly or as indicated, checking for proper positioning when the resident was up in the Broda chair, following wound care orders, a pressure reducing mattress to the bed and cushion for the wheelchair and weekly skin checks. The skin impairment care plan, revised on 10/11/22, documented the resident had a stage three pressure injury to the right trochanter (any of two bony protuberances by which muscles are attached to the upper part of the thigh bone). The interventions included assessing the location, size, and treatment of the skin injury, cleaning and drying the resident's skin after each incontinent episode, identifying and documenting potential causative factors and resolving where possible, using a draw sheet or lifting device to move the resident and documenting weekly treatments to include the measurements of each area of skin breakdown with any notable changes or observations. The 10/6/22 Braden assessment documented the resident was at a high risk for pressure ulcers with a score of 11 out of 23. A lower score indicates more risk. III. Failure to assess, notify the physician and put a treatment in place timely upon the identification of a pressure injury A. Record review The 9/13/22 weekly skin integrity data collection documented the resident's skin was intact, however the 9/13/22 nursing progress note documented the resident had an open area to the right hip, was improving in size and condition, and it did not have any signs and symptoms of infection. It indicated the nurse applied skin prep to the open area. The September 2022 medication administration record (MAR) and the treatment administration record (TAR) did not reveal documentation of a treatment of the pressure injury to the resident's right trochanter until 9/26/22, 13 days after the pressure injury was identified, according to the 9/13/22 nursing progress notes. The wound physician note dated 9/27/22 documented that resident had a stage three pressure ulcer located on the right hip, that was acquired at the facility. The 9/27/22 weekly skin integrity data collection documented the resident sustained friction/shearing to the right hip. The 9/27/22 wound observation tool assessment documented Resident #42 acquired a stage three pressure injury to the right trochanter on 9/21/22. It revealed the wound was unchanged with 20 % (percent) slough (part of the inflammatory process consisting of fibrin, white blood cells, bacteria and debris, along with dead tissue and other proteinaceous material) The wound observation document revealed the wound was 2 cm (centimeters) length x 1.7 cm width x 0.2 cm depth. The treatment order was to apply Medihoney with a foam dressing every day. A review of the resident's medical record revealed the wound was not thoroughly assessed until 9/27/22, when the wound was identified on 9/13/22. A wound physician note dated 10/4/22 documented that resident had a stage three pressure ulcer located on the right hip. The wound physician used an anesthetic instrument 2% lidocaine intervention used as an anesthetic to numb sensation of pain. Also in place was an alternating pressure mattress. A wound physician note dated 10/11/22 documented that resident had a stage three pressure ulcer located on the right hip, the progress was better, complexity was high. Preventive measures care in place, offloading heels and plan in care. -The physician did not give any other details for preventative measures. B. Observations -On 10/13/22 at 11:00 a.m. LPN #2 was observed providing a treatment to Resident #42's stage three pressure injury to the right trochanter. -LPN #2 removed the treatment dressing and a small amount of light yellow purulent (pus) drainage was observed on the dressing. The wound edges appeared pink and the wound bed was difficult to visualize due to residual slough and drainage in the wound. -The measurements were: 0.5 cm length x 0.3 cm width x 0.1 cm depth. IV. Staff interviews LPN #4 was interviewed on 10/17/22 at 1:30 p.m. LPN #4 said Resident #42 had a pressure ulcer to the right hip that was being monitored daily. LPN #2 said Resident #42 was a high risk for developing pressure injuries and should be repositioned every two hours. When a new wound was identified, the registered nurse (RN) should be notified to perform an assessment and physician to obtain treatment orders. The director of nursing (DON) was interviewed on 10/17/22 at 7:00 p.m. The DON said that skin observations should be conducted every day during ADL care. She said any indication of skin breakdown should be reported to the nurse and an assessment should be completed. She said the physician should notify the physician to obtain a treatment order as soon as a wound was identified. She said she and the unit manager observed all wounds in the facility with the wound physician every Tuesday. She said the wound physician would assess the wound, provide treatments and document any changes to the treatment orders. The DON said any skin breakdown observed should be reported to the physician and a treatment should be put in place immediately. The DON said Resident #42 required assistance from staff for bed mobility and repositioning. She said repositioning should be provided or offered to Resident #42 approximately every two to three hours. She acknowledged the MAR and TAR did not reveal a treatment had been put into place until 9/26/22, 13 days after the nurse documented the wound to the right hip.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure one (#36) of four residents reviewed for nutrition out of 40 sample residents received the care and services necessary to meet their nutritional needs to maintain their highest level of physical well being. Resident #36 was admitted on [DATE] with diagnoses including depression, congestive heart failure, and hypertension. Dietary interventions included snacks in the evening, two proteins during meals, 2% milk served with meals, and fortified foods when possible. Since admission on [DATE] it was documented that Resident #36 was losing weight with variable meal intakes. A nutritional supplement was added on 3/23/22 and discontinued on 4/28/22 due to the resident's preference. The resident continued to lose weight and on 6/16/22 other interventions were put in place including additional proteins at meals, 2% milk served with meals, and fortified foods when possible. The 8/15/22 quarterly nutrition assessment documented that the resident had a significant weight loss of 15.8% over the past 180 days (since admission) and this was an unplanned weight change. No additional interventions were put into place. On 8/20/22 orders were placed for the resident to not be weighed for comfort. Meal intakes continued to be variable, interviews and observations during the survey indicated the resident said she did not like the food served and was not provided with milk (cross-reference F803 for menus). The care plan did not include nutritional interventions and just addressed weight fluctuations despite the resident's significant weight loss. Findings include: I. Facility policy The Hydration and Nutrition policy, revised 7/14/21, was provided by the director of nursing (DON) on 10/18/22 at 3:33 p.m. It read, in pertinent part, Adequate nutrition and hydration are essential for overall function. Each resident receives a sufficient amount of food and fluids to maintain acceptable parameters of nutritional and hydration status. A minimum of three meals are provided each day. If a meal or particular food is refused, the resident is offered a substitute of a similar nutritive value. Snacks are given between meals and at bedtime according to the resident desire and/or need. An ongoing assessment of the ability to consume and assimilate food and fluid is conducted by nursing personnel and all concerns are reported to the nurse. II. Resident status Resident #36, age [AGE], was admitted on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses included depression, congestive heart failure, and hypertension. The 8/15/22 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. It indicated the resident required set up assistance for eating. It indicated the resident did not have difficulty swallowing. It indicated the resident had weight loss and was not on a physician prescribed weight loss regimen. The section related to dental status was incomplete. III. Resident interview Resident #36 was interviewed on 10/11/22 at 10:20 a.m. She said the food at the facility was not good. She said she had complained about the food to the staff but she was unsure who and they did not do anything. She said she did not try to get a different meal if she did not like what was served. She said she was independent with eating and preferred to eat in her room. She said she had lost about 25 pounds since admission and was not on any supplemental nutrition. She said she usually ate about 50% of her meals. Resident #36 was interviewed again on 10/12/22 at 1:00 p.m. She said she ordered a cobb salad for lunch and it was good. The resident had eaten 50% of her salad and no milk was on her tray. The resident had two drinks. Resident #36 was interviewed again on 10/13/22 at 9:05 a.m. She said breakfast was good that morning and she had eaten about 50%. She said no milk was served with breakfast but she did not like milk. The resident had eaten 50% of her breakfast and no milk was on her tray. IV. Record review Weights since admission revealed the following: -On 2/10/22 the resident weighed 173.4 pounds; -On 2/12/22 the resident weighed 173.6 pounds; -On 2/13/22 the resident weighed 173.3 pounds; -On 2/18/22 the resident weighed 170.0 pounds; -On 2/24/22 the resident weighed 168.7 pounds; -On 3/4/22 the resident weighed 165.1 pounds; -On 3/15/22 the resident weighed 162.4 pounds; -On 3/26/22 the resident weighed 159.8 pounds; -On 4/3/22 the resident weighed 160.1 pounds; -On 5/1/22 the resident weighed 157.1 pounds; -On 6/6/22 the resident weighed 156.8 pounds; -On 6/12/22 the resident weighed 155.1 pounds; -On 6/26/22 the resident weighed 155.1 pounds; -On 7/1/22 the resident weighed 155.6 pounds; -On 7/25/22 the resident weighed 151.7 pounds; -On 8/1/22 the resident weighed 149.8 pounds, a 23.6 pound weight loss over six months, which was 13.6%. The nutrition care plan, revised 6/1/22, indicated Resident #36 was at risk for weight fluctuations related to current health status. Interventions included assistance with meals as needed, education with resident and family on storage and preparation of outside food, education with resident and family on potential weight fluctuations, and encouraging and providing diet order. -No interventions or food preferences were included in the care plan until 10/13/22 (during survey). The updated nutrition care plan, initiated 10/13/22 (during the survey), indicated Resident #36 was at risk for poor nutrition related to being a selective eater, history of weight loss, and declining nutritional interventions. Interventions included encouraging fluids between meals, offering choices and honoring preferences, offering snacks in between meals, and providing tray set up. The October 2022 CPO revealed the following: -Evening snack at bedtime for nutrition support and document percentage consumed, ordered 7/27/22; and, -Resident on palliative care, do not weigh for quality of life, ordered 8/20/22. The initial nutritional assessment was completed on 2/14/22. It indicated Resident #36 was on a regular diet with regular texture and thin liquids. It indicated the resident was not on nutritional supplements. It indicated the resident's intake for breakfast and lunch was 76-100% and dinner was 51-75%. It indicated the resident had her own teeth, had no difficulty swallowing, and required set up assistance with meals. It indicated the resident's current intake was meeting their estimated protein and caloric needs. It indicated no nutritional diagnosis and interventions related to nutrition included encouragement and fluids in between meals. The 3/9/22 a nutrition progress note indicated Resident #36 had a 3% weight loss over three weeks and 2Cal Med Pass two times a day was ordered as a supplement. The 4/28/22 a nutrition progress note indicated Resident #36 did not like the 2Cal Med Pass and the order was discontinued. -However, there were no other nutritional supplements offered to the resident or her dietary preferences obtained when she had 3% weight loss. The 5/5/22 a nutrition progress note indicated Resident #36 had a 5% weight loss over ten weeks. It indicated weight continued to trend downward with variable intakes of 25-75%. It indicated no nutritional interventions. The quarterly nutritional assessment was completed on 5/19/22. It indicated Resident #36 continued on a regular diet with regular texture and thin liquids. It indicated no significant weight loss and intakes ranged from 25-100%. It indicated the resident's protein and caloric needs were not being met. It indicated no nutritional interventions were in place due to the resident's dislike for oral nutrition supplements. The 6/16/22 nutrition progress note indicated Resident #36 had weight fluctuations and was down 5% over 12 weeks. It indicated two protein items and 8 ounces 2% milk were added to the tray card. The 6/24/22 a nutrition progress note indicated Resident #36 verbalized she did not want to eat because nothing sounded or looked good to her. It indicated Resident #36 did not like oral nutrition supplements and was not willing to try. It indicated the resident was agreeable to have two protein items and 8 ounces of milk at meals. The 7/28/22 a nutrition progress note indicated Resident #36 had 10% weight loss over 21 weeks. It indicated the addition of an evening snack as a supplement. The quarterly nutritional assessment was completed on 8/15/22. It indicated Resident #36 continued on a regular diet with regular texture and thin liquids. It indicated the resident's weight at admission was 173.4 pounds and current weight was 149.8 pounds. It indicated the resident had a significant weight loss of 15.8% decrease over the past 180 days and this was not a planned weight change. The assessment indicated two protein items, 2% milk, and fortified foods, if possible, would be served at all meals. It indicated an evening snack was initiated as a supplement. The summary of the assessment indicated no change in nutrition intervention and indicated the resident did not like oral nutrition supplements. The 8/15/22 nutrition progress note indicated Resident #36 refused to be weighed. It indicated the resident was on palliative care. It indicated the family was to bring in outside fast food and snacks to increase oral intake. The 9/15/22 physician progress note indicated Resident #36 was seen due to concerns for weight loss. It noted the resident had lost 24 pounds since admission and a hospice consultation was discussed with the resident and family. The 9/22/22 physician progress note indicated the resident was not eligible for hospice. It indicated the resident reported decreased appetite. The meal intake records from 9/18/22 to 10/17/22 indicated the resident's intake was variable and typically between 25-75%. -A request was made for meal percentage intakes since admission but these were not provided. The snack intakes from the medication administration record were reviewed from 7/27/22-10/17/22 and indicated minimal snack intake. July and August 2022 had 0% intake of snacks documented. The September 2022 intake had ten days of 100% intake and two days of 20-25% documented. The October 2022 intake had one day of 100% documented. An order for 2Cal Med Pass twice a day was initiated on 3/23/22 and discontinued on 4/28/22. The medication administration record indicated minimal intake of this supplement with the majority of intake documented as 0%. V. Interviews The registered dietitian consultant (RDC) and licensed practical nurse (LPN) #1 were interviewed on 10/13/22 at 3:27 p.m. The RDC said Resident #36 had weight loss prior to the do not weigh order. She said the do not weigh order was in place for comfort and the family preferred it. She said the resident did not take any nutritional supplements. She said the resident was able to choose her preferred meals and frequently ordered a salad or her family would often bring in food. She said the resident consumed more when family was present. She said the dietary staff could fortify foods such as sauce or gravy and it would be given depending on what the resident ordered and what was on the meal service line. She said the weight loss was expected. She said the resident did not have weight loss interventions because the resident declined the interventions. She said interventions should be included in the care plan such as food preferences, snacks, assessment of chewing and swallowing as needed, and accepting food and fluids as described. She said the resident's care plan should have more interventions than it currently had due to the resident's health status. She said it was expected the resident's weight would decline due to the lack of interventions and the resident not being willing to accept interventions. -However, the interventions were not routinely offered, her dietary preferences were not obtained nor were her complaints addressed regarding the food. LPN #1 said snacks were available to the resident but she did not typically eat them. LPN #1 said the resident did not eat more if staff was present. She said the resident did not complain of the food taste or texture and she could order whatever she wanted. She said her intake was usually 50%. Registered nurse (RN) #1 was interviewed on 10/17/22 at 1:34 p.m. She said Resident #36 ate about 50% of her food during meals. She said the resident did not ask for a different entree if she did not like what was served since she ordered her meals. She said she had not heard the resident complain about the taste or texture of the food. Certified nurse aide (CNA) #2 was interviewed on 10/17/22 at 3:11 p.m. She said the CNAs took the residents' orders before meals to determine if they wanted the main entree or something from the alternative menu. She said snacks were available to the residents but they were only given if the resident requested it. She said the snacks available were string cheese, yogurt, or a peanut butter and jelly sandwich. She was unsure if Resident #36 ever requested a snack. The DON was interviewed on 10/17/22 at 6:56 p.m. She said she was part of resident at risk meetings as well as interdisciplinary team meetings. She said these meetings were weekly. She said the facility's registered dietitian was out on medical leave and the RDC was filling in as needed but was not attending the weekly meetings. She said Resident #36 had an order of do not weigh. She said the last weight that was taken indicated the resident was losing weight. She said Resident #36 did not like supplements. She said the family would bring in snacks or fast food to increase intake and she was unsure if the resident verbalized a dislike of the food at the facility. She said the facility would fortify foods and give milk when possible. She said if milk was on the meal ticket she would expect it to be given. She said she did not see in the resident's chart where a snack would be provided in the evening.