**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, staff interview, and record review, it was determined the facility failed to prevent the development of avoidable pressure ulcers. This was true for 2 of 2 residents (#3 and #28) reviewed for pressure ulcers. Resident #3 was harmed when she developed a suspected deep tissue injury that worsened to a Stage IV (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) pressure ulcer to her sacrum (bottom of the spine). Resident #28 was harmed when she developed an unstageable pressure ulcer to her sacrum and suspected deep tissue injuries to her right heel and left calf. Findings include: The facility's policy for Pressure Ulcer Assessment Guidelines, dated 9/5/17, documented: *To ensure a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the resident's clinical condition demonstrated they were unavoidable; and a resident having pressure ulcers received necessary treatment and services that promoted healing and prevented new ulcers from developing. *All new developing pressure ulcers must be measured and graded according to acceptable definitions of pressure ulcers. The website www.healthline.com, dated 6/15/18, documented, A Kennedy ulcer, also known as a Kennedy terminal ulcer (KTU), is a dark sore that develops rapidly during the final stages of a person's life. Kennedy ulcers grow as skin breaks down as part of the dying process. The National Pressure Ulcer Advisory Panel, dated March 2017, described a [NAME] pressure ulcer as pear shaped, always on the coccyx or sacrum, red, yellow, and black, sudden onset, and death is imminent. 1. Resident #3 was admitted to the facility on [DATE], with diagnoses that included legal blindness and chronic pain. The annual Minimum Data Set (MDS) assessment, dated 3/6/19, documented Resident #3 was moderately cognitively impaired and required extensive assistance with two staff members for bed mobility, dressing, toileting, and personal hygiene. Resident #3 required limited assistance for eating and was dependent on two staff members for transfers. The MDS assessment documented Resident #3 was at risk for pressure ulcers and had one Stage II (Partial-thickness loss of skin with exposed dermis, presenting a shallow open ulcer) pressure ulcer. A Wound Assessment, dated 8/16/18 at 11:21 AM, documented Resident #3 had an in-house acquired [NAME] pressure ulcer over the sacral/buttock area. The assessment documented the sacral/buttock area did not have drainage, odor, and no tunneling or undermining. The surrounding tissue was normal. The weekly wound summary documented, large purple/maroon area, very slow to blanch, open area still noted to the center of the gluteal fold and measurements are unchanged from last assessment . The treatment was for staff to apply, copious amounts of vaseline several times a day. The assessment did not include measurements of the wound or when the pressure ulcer was first identified. A Wound Assessment, dated 10/26/18 at 12:32 PM, documented Resident #3 had an in-house acquired [NAME] pressure ulcer with an open area in the center above the gluteal fold (where the top of the thigh meets the buttock). The wound edges were defined and flushed, the wound bed was pink and white, no tunneling or undermining, and with minimal clear drainage. The surrounding skin tissue was red. Pressure ulcers are measure by length, width, and depth, in that order. The assessment documented The ulcer in the center of the wound has now divided in half with new epithelial growth the left side measures 1 cm x 0.5 cm x 2 mm, and the right side measures 3 cm x 1 cm x 2 mm. The additional comments documented, Overall appearance of this areas looks to be a [NAME] (ulcer) as the area about 11 cm x 10 cm is maroon in color, does blanch with open ulcer in the center of the proximal gluteal fold, there is sloughing noted on the right buttock that is very superficial and dry . The assessment documented the wound status had improved. The wound care treatment was for staff to apply Medifil paste (wound healing treatment) in the wound bed and cover with an adhesive dressing. A Wound Assessment, dated 12/11/18 at 2:15 PM, documented Resident #3 had acquired an in-house [NAME] pressure ulcer to her sacrum/buttocks, and the entire reddened area measured 9 cm x 10 cm. Another wound measurement documented on the assessment was 26 x 3 x 2. The measurement did not include how the wound was measured, in centimeters or millimeters. The assessment documented the wound edges were defined and flushed, the wound bed was beefy red, and no tunneling or undermining. There was no drainage or odor and the surrounding skin tissue was normal. The assessment documented the wound continued to improve each week. The additional comments documented the small pressure ulcer to the left was closed, leaving only the ulcer on the right after the one ulcer divided about 2 months ago. The wound care treatment was for staff to apply Medifil paste in the wound bed and cover with an adhesive dressing. A Wound Assessment, dated 2/26/19 at 10:24 AM, documented Resident #3 had an in-house acquired [NAME] pressure ulcer to her sacrum. The measurements were documented 17 x 8 x 5. The measurements did not include how the wounds were measured, in centimeters or millimeters, and did not specify if the measurement was that of the entire reddened area or the open ulcer. The assessment documented the wound edges were defined and the wound bed was pale pink with minimal clear drainage, no tunneling or undermining, and the surrounding skin tissue was normal. The additional comments documented to continue with the treatment for staff to apply Medifil paste in the wound bed and cover with an adhesive dressing. A Physician's order, dated 3/26/19, directed the application of Medifil paste to the right lateral lip of Resident #3's wound bed, to pack the deeper center of the ulcer with sterile gauze lightly soaked in normal saline and covered with Medifil, and to change the dressing every Tuesday, Friday, and as needed. A Physician Visit Note, dated 5/2/19, documented Resident #3 was thin and had a stable sacral wound. A Wound Assessment, dated 5/3/19 at 11:59 AM, documented Resident #3 had an in-house acquired [NAME] pressure ulcer to her sacrum. The wound measurements were 18 x 18 x 5. The measurements did not include how the wounds were measured, in centimeters or millimeters. The assessment documented the wound edges were defined and jagged and the wound bed was pale pink and had about 2 mm of undermining (destruction of tissue or ulceration extending under the skin edges) around entire ulcer, with minimal red drainage, and the surrounding skin tissue was red. The assessment documented the surrounding tissue was 10 cm x 10 cm with red area around the ulcer. The assessment documented the wound status was unchanged. A Wound Assessment, dated 6/7/19 at 12:37 PM, documented Resident #3 had an in-house acquired [NAME] pressure ulcer that presented as a Stage IV pressure ulcer. The wound measurements were 25 x 15 x 10. The measurements did not include how the wounds were measured, in centimeters or millimeters, or indicate if the measurements related to the entire reddened area or the open ulcer. The assessment documented the wound edges were defined and the wound bed was beefy red, no tunneling or undermining with a moderate amount of clear and red drainage. The surrounding skin tissue was red. The assessment documented the wound status was unchanged and to continue with the same wound care treatment of Medifil paste and cover the wound with an adhesive dressing. Resident #3's Risk for Skin Alterations Related to History of Pressure Ulcers Care Plan, dated 3/10/18 and revised on 6/7/19, documented a decline in skin condition was anticipated related to her failure to thrive and interventions would be in place to help maintain her comfort. The care plan did not identify a current pressure ulcer. The interventions on the care plan directed staff to reposition Resident #3 every 30 minutes during the day and evening, to use an air overlay on the bed, and a pressure relieving mattress. Resident #3's care plan also directed a scoop mattress (mattress with heightened or beveled edges) be placed over the mattress air overlay to keep the air overlay centered and to keep it from sliding off the bed. RN #2 stated a scoop mattress was not in place. An air overlay was in place which she stated had been utilized for residents for 10 years. A Physician Visit Note, dated 6/6/19, documented Resident #3 was well-nourished. The pressure ulcer was not addressed in the note. At 11:00 AM on 6/18/19, the Administrator provided the Physician Visit Note, dated 6/6/19, with the following addendum: Pt's (Patient's) nutritional status fluctuates but is generally poor. Staff, including dietician, have exhausted avenues to improve beyond current situation. Pt declines aggressive measures. This in turn will affect the ability for pressure ulcer to heal. It is anticipated that it won't heal but will try to keep it stable. Well-nourished was still checked on the assessment. On 6/17/19 at 10:30 AM, Resident #3 permitted LPN #1 to look at her mattress. An air-overlay mattress was over a pressure relieving mattress. A scoop mattress was not on the bed. On 6/19/19 at 5:00 PM, the DNS stated the wound/skin nurse, RN #2, worked in the adjoining hospital at the dialysis center. The DNS stated RN #2 completed the dressing changes and obtained and updated wound care orders. The DNS stated RN #2 determined Resident #3's pressure ulcer was a Kennedy ulcer. The DNS was unable to describe a Kennedy ulcer or the characteristics of one. On 6/20/19 at 8:57 AM, RN #2 stated her position at the hospital was the Facility Administrator over dialysis and chemotherapy. She stated she also provided wound care to the residents in the skilled nursing facility. RN #2 stated Resident #3's wound started about a year ago. She identified it as a Kennedy ulcer because at that time Resident #3 was not expected to live. RN #2 stated terminal ulcers, though not expected to, could improve. RN #2 stated Resident #3's physician saw the [NAME] pressure ulcer, but it had been a little while, probably a few months. RN #2 stated the physician completed rounds in the facility on Thursdays. Resident #3's bath days were Tuesdays and Fridays, so the wound was usually covered when the physician made rounds. RN #2 stated she told the physician what she saw, and he told her what she should do. RN #2 stated on occasion the facility sent residents to the wound clinic, but the wound clinic was not in the local area and sometimes the health of the residents did not allow that. RN #2 stated the pressure ulcer was almost completely closed, then got worse, and now it was better. RN #2 stated treatment should be changed if the wound did not improve over two weeks. RN #2 reviewed Resident #3's assessments and stated using the same treatment was not the reason the ulcer did not heal over the past year. She stated the lack of healing was not related to Resident #3's positioning. RN #2 said it was the nutritional aspect that determined whether the wound improved or not. RN #2 said the treatment of Resident #3's pressure ulcer had been constant and only changed if the dressing requirements changed, such as if the ulcer got deeper and needed to be packed. Resident #3's weight records for the past 6 months were documented as follows: *1/29/19 119.5 pounds *3/26/19 117.5 pounds *4/30/19 119 pounds *5/28/19 116 pounds *6/11/19 112.5 pounds Resident #3's weight was relatively stable over 5 of the 6 months, ranging from 119.5 pounds to 116 pounds between 1/29/19 and 5/28/19. Resident #3's 8/16/18 through 6/7/19 (10 months) wound assessments defined her pressure ulcer as a Kennedy terminal ulcer. As previously stated, the National Pressure Ulcer Advisory Panel, dated March 2017, describes a [NAME] pressure ulcer as pear shaped, always on the coccyx or sacrum, red, yellow, and black, sudden onset, and death is imminent. Resident #3's ulcer was not pear shaped and her death was not imminent (likely to occur at any moment) for 10 months. The facility failed to ensure: *Measurements of Resident #3's open ulcer and surrounding area were consistently and thoroughly documented. *Resident #3's pressure ulcer was monitored by a physician. *Alternate treatment options were considered for Resident #3's pressure ulcer when interventions were not effective. *Resident #3's care plan was updated to address her pressure ulcer and changes in its status. 2. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses which included dementia, anxiety, and depression. A quarterly MDS assessment, dated 5/3/19, documented Resident #28 had moderately impaired cognition, did not reject care, and required extensive assistance of 2 plus staff for bed mobility, transfers, dressing, and toileting. Resident #28 was frequently incontinent of bowel and bladder. The assessment documented she was not at risk of pressure ulcers. A care plan, dated 1/25/19, documented a focus related to Resident #28's limited physical mobility. The care plan did not describe what the limited physical mobility was. A new intervention, dated 5/7/19, directed staff to ensure Resident #28's brace was in place. The care plan did not direct staff to assess the skin under the brace. A care plan, dated 1/25/19 and revised on 5/24/19, documented Resident was at risk of skin alterations related to incontinence and decreased mobility. The interventions documented Resident #28 repositioned herself independently and staff were to ensure a gel cushion was in her wheelchair and recliner, and an air overlay on her bed. A nursing progress note, dated 4/25/19, at 5:22 PM, documented Resident #28 fell in the bathroom and was diagnosed with a left tibial plateau fracture (a crack or break in the upper most portion of the shin bone that attaches to the knee joint). A nursing progress note, dated 4/25/19 at 7:50 PM, documented the placement of a universal knee immobilizer to Resident #28's left leg. The physician entered orders for non-weight bearing, may transfer to commode, chair, and knee immobilizer on at all times. A follow up 3 view x-ray of left knee was ordered for 5/6/19. A Physician's Order Summary Report documented Resident #28 was to wear a knee immobilizer at all times, every day and night shift, dated 4/26/19. The order did not direct staff to check the skin under the brace. A Skin/Wound Note, dated 5/21/19 at 12:51 PM, documented a 5 cm by 6 cm red area on Resident #28's sacrum with 3 small purple non-blanchable areas, and in the center there was an area that looked like it may open but was closed. A gel cushion was to be used in the wheelchair and the recliner, an air overlay was placed on Resident 28's bed, and staff were directed to reposition her every hour. Wound Assessments, dated 5/24/19, documented: *The presence of an in-house acquired pressure ulcer. The assessment documented Resident #28 had an open area to the center of her gluteal fold and the surrounding tissue was red. On the right side there was a 1.3 cm x 0.5 cm area that was fading in color. Resident #28 had an air overlay on her bed and a gel cushion to her wheelchair and recliner. The wound measurements were documented as 15 mm in length x 4 mm in width x 1 mm in depth. *The presence of an in-house acquired pressure ulcer to Resident #28's right heel. The assessment documented there was a 1 cm x 0.5 cm light purple area to the center of the heel that did not blanch and a heel elevator boot was placed on 5/23/19 when staff reported concern. The wound measurements were documented on the assessment to be 17 mm in length x 13 mm in width x 0 mm in depth. A Physician Visit Note, dated 5/28/19, did not address Resident #28's sacral pressure ulcer. A nursing note, dated 6/5/19 at 6:20 PM, documented the immobilizer was to be off while Resident #28 was in bed and when sitting. The note directed staff to use the immobilizer with ambulation for 2 weeks and then it may be removed. A Physician Visit, dated 6/6/19, documented Showed RN #2 a picture of the right heel and she will assess in the morning. Feels as long as it is not open, to leave it for now. Consider a better heel protector and ? dressing. Mepilex with border to left calf. Keep brace off when not walking/transferring. The note did not address the sacral/gluteal pressure ulcer. Resident #28's care plan, dated 6/7/19, documented the focus as [specify name] has a pressure ulcer of the [specify location(s)] r/t. The interventions directed staff to assess, record and monitor the wound healing weekly. If there was no improvement in the wound over a two-week period staff were to notify the physician and consider changing treatments. The second intervention was to provide dietary supplements per the physician's order. The care plan did not include the locations of Resident #28's pressure ulcers. A Nutrition/Dietary note, dated 6/12/19 at 5:41 PM, documented acknowledgement of Resident #28's wound to her buttocks (sacral/gluteal), left lower leg, and heel. Wound Assessments, dated 6/7/19, documented: * The assessment described Resident #28's wound bed as a white/grey slough. The note documented the wound was cleansed with wound cleaner, patted dry, dressed using sterile packing and covered with a Mepilex border dressing. The wound measurements were documented on the assessment to be 15 mm in length x 9 mm in width x 3 mm in depth. The assessment documented the wound was declining and was deeper and slightly wider than it was previously. The assessment documented the pressure ulcer as unstageable (full thickness skin and tissue loss in which the extent of the tissue damage cannot be confirmed because the wound bed is obscured with slough or eschar [dead or devitalized tissue].) The assessment did not identify the location of the wound. It was determined the assessment related to Resident #28's sacral/gluteal pressure ulcer as assessments of Resident #28's other two pressures, one on the right heel and another on the back Resident #28's left lower leg, were completed on the same date. *The right heel pressure ulcer measuring larger and was maroon in color, spongy, and had deep purple edges. The assessment documented I talked with MD yesterday about leaving the skin intact for now and using it as a natural band aid. I talked to him about dressing it and advised him that as long as it was not open or draining to leave the dressing off at this time. The wound measurements were documented on the assessment to be 45 mm in length x 45 mm in width x 0 mm in depth. *The assessment documented an in-house acquired pressure ulcer to the back of Resident 28's left lower leg. The assessment documented staff removed the immobilizer a few days ago and noticed discoloration on the left distal calf. The assessment documented the area did not blanch and skin was sloughing in areas causing drainage. The wound measurements were documented on the assessment to be 45 mm in length x 13 mm in width x 0 mm in depth. The immobilizer was assessed, there was a hard metal support that ran down the back of the device, from the top to the bottom and fit right over the ulcer. The assessment documented sheepskin was applied to the brace and Mepilex with border was placed to protect the pressure ulcer. On 6/20/19 at 9:25 AM, RN #2 stated Resident #28's daily skin checks should have been done. The facility was unable to provide documentation of daily skin checks completed for Resident #28. On 6/20/19 at 10:15 AM, RN #1 stated when a resident had a brace, she would check for CMS (Circulation, Motion, Sensation) and document her assessment on the treatment sheets. RN #1 did not specify if she removed the brace to assess the skin under the brace. Resident #28's treatment sheets did not include daily skin checks. The facility failed to ensure Resident #28 was provided the care and services necessary to prevent the development of 3 pressure ulcers, one becoming unstageable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, and review of facility policies and Incident Reports and investigations, it was determined the facility failed to ensure 1 of 8 (#23) sampled residents were free from all forms of abuse, including verbal and mental abuse. Resident #23 sustained psychosocial harm when she was verbally and mentally abused by the LSW, when the LSW coerced Resident #23 to sign a contract stipulating that Resident #23 was responsible for her own falls, and would waive her right to decline a room change if further falls occurred. Following the abuse, Resident #23 and her interested party were afraid she would be discharged from the facility if she did not follow the rules. This deficient practice placed residents residing in the facility at risk of abuse. Findings include: The facility's Abuse Policy and Procedure, revised 9/13/16, defined verbal abuse as use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families . examples include threats of harm, saying things to frighten a resident, such as telling a resident he/she will never be able to see his/her family again. The facility's Abuse Policy and Procedure, revised 9/13/16, defined mental abuse as includes, but is not limited to humiliation, harassment, threats of punishment, or deprivation. Mental abuse may occur through either verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Resident #23 was admitted to the facility on [DATE] with multiple diagnoses, including Parkinson's Disease and Lewy body dementia. Resident #23's annual MDS assessment, dated 6/6/17, and quarterly MDS assessments dated 9/6/17 and 12/7/17 documented Resident #23 was cognitively intact. An Incident and Accident Report, dated 9/23/17 at 10:20 AM, documented Resident #23 fell when attempting to ambulate without assistance. Resident #23 obtained a laceration to back of her head and was sent to the emergency room for further evaluation. Resident #23's clinical record had a contract developed by the LSW and signed by Resident #23 and the LSW, dated 10/19/17, documented, I, Resident #23, am entering into a contract of safety with [facility name] as my noncompliance with staff assist transferring has resulted in multiple falls, including a fall with injury. I understand that by continuing to self-transfer, I am putting myself in danger. I, Resident #23, agree to use the call light when I need assistance and wait for the assistance to come. I will not make any attempts to self-transfer. I will not remove my alarms and I understand that the alarms I have in place are related to my noncompliance with transferring and are there for my safety. I understand that my failure to comply with this contract of safety may result in a room change allowing me to be closer to the nurse's station for increased supervision. The LSW's Psychosocial Note, dated 9/19/17 at 1:40 PM, did not document behavioral concerns related to Resident #23 self transferring or falling. The LSW's Psychosocial Note, dated 9/27/17 at 6:30 PM, documented staff reported Resident #23 was depressed. The LSW documented Resident #23 was happy to have the staple removed from the back of her head. The LSW documented she visited with Resident #23 about her tab alarm and Resident #23 stated the tab alarm was a reminder to use the call light for help. The LSW's Psychosocial Note, dated 10/16/17 at 2:59 PM, documented the LSW, DNS, and RN educated Resident #23 on the purpose of the tab alarm and not to remove it to self-transfer. The LSW documented Resident #23 stated after the last fall, she thinks she needs the alarm because she doesn't want to fall again. The LSW validated Resident #23's feelings and encouraged her to use her call light, and not to remove the alarm. The LSW's Psychosocial Note, dated 10/18/17 at 3:24 PM, documented the LSW spent 1:1 time with Resident #23. The LSW documented Resident #23 did not have signs or symptoms of depression. The LSW's Psychosocial Note, dated 10/19/17 at 2:33 PM, documented the LSW provided Resident #23 with a copy of a safety contract. The LSW documented, Res [sic] stated she was okay with interventions being placed and understood it was for her safety. The LSW's Psychosocial Note, dated 10/20/17 at 12:27 PM, documented, LSW followed up res r/t recent fall interventions put in place. Res stated that she thought the seat belt was going to be good. There was no documentation regarding the safety contract that Resident #23 received by the LSW on 10/19/17 and how it made her feel. Resident #23's care plan, dated 1/23/18, documented, Resident #23 is a high risk for falls r/t Gait/balance problems r/t diagnosis of Parkinson's and history of falls at home prior to SNF admission. Interventions included, Has pressure sensitive bed alarm, chair alarm and seat belt alarm to wheelchair as well to alert staff of attempts to stand unassisted. Be aware that alarms will not prevent falls and are only intended to alert staff that she has a need that must be met. Respond promptly to all alarms. The care plan did not document the safety contract. On 1/25/18 at 1:00 PM, Resident #23 stated signing the contract did not make her feel right, but she did not want to lose her private room, so she signed the contract and had been following the rules. Resident #23's interested party stated with the contract, we thought Resident #23 was going to be kicked out of the facility if Resident #23 did not comply with the rules of the contract. On 1/25/18 at 3:15 PM, the Administrator, DNS, and AIT was not aware of the contract in Resident #23's clinical record. The LSW was not available for an interview for the duration of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure residents received nutritional and hydration interventions to prevent unplanned weight loss and dehydration. This was true for 4 of 5 residents (#s 11, 14, 21, and 22) reviewed for weight loss and hydration concerns. a) Resident #14 was harmed when she experienced a 9.3% weight loss in three months, prior to her being placed on comfort care measures, and she was harmed when she experienced dehydration and multiple UTIs; b) Resident #21 was harmed when she experienced a 15.99% weight loss in five months; and c) Resident #'s 11 and 22 had potential for harm when they were not provided with fluids and/or assistance to consume them, and were observed with dry mouths. Findings include: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses, including Vitamin D deficiency, anemia, dementia, and gastroesophageal reflux disease (GERD). A quarterly MDS assessment, dated 12/19/17, documented Resident #14 had a severe cognitive impairment, required extensive assistance with eating, lost food and drink from her mouth while eating, and had significant unplanned weight loss. a. Nutrition concerns: Resident #14's January 2018 Physician's Orders documented Resident #14 was on a pureed diet with thickened liquids, dated 2/11/17. Resident #14's Physician's orders did not contain an order for nutrition supplements. The Nutrition Care Plan, initiated 1/29/16, documented the following interventions for Resident #14: * Resident #14 required a pureed diet with honey thick liquids, initiated 7/22/17. * The Dietitian would review Resident #14's weights weekly and report concerns to the physician, initiated 2/1/16. * Resident #14 was dependent on staff for nutritional and fluid intake, initiated 12/20/16. * Resident #14 wore a clothing protector due to excessive loss of foods and fluids during meals, revised 6/27/17. The Nutrition Care Plan's interventions were not updated regarding Resident #14's weight loss. A Weight Flow Sheet, dated 7/20/17 through 9/15/17, documented the following weights for Resident #14: * 7/20/17 - 140 pounds * 7/31/17 - 137.5 pounds * 8/7/17 - 136 pounds * 8/15/17 - 138 pounds * 8/22/17 - 136 pounds * 8/25/17 - 134 pounds * 8/29/17 - 132 pounds * 9/1/17 - 132 pounds * 9/5/17 - 131 pounds * 9/8/17 - 131 pounds * 9/15/17 - 127 pounds A 9/27/17 Physician's order documented Resident #14 was placed on comfort measures. Resident #14 lost 9.3% of her body weight between 7/20/17 and 9/15/17 before comfort measures were initiated. The 6/1/17 through 9/30/17 Activities of Daily Living (ADL) Documentation Survey Report, Nutrition Amount Eaten at meal and Nutritional Supplements, documented Resident #14: * consumed less than 25% of her meals for 80 of 366 opportunities; * refused meals 36 of 366 opportunities; * was not offered a meal 13 of 366 opportunities; * was not offered a supplement 316 of 366 opportunities; * was not offered a meal alternative 129 of 129 opportunities; and * was not offered a snack 366 of 366 opportunities. Resident #14's ADL Documentation Survey Reports, dated 10/1/17 through 1/24/18, documented similar findings in the Nutrition Amount Eaten and Nutritional Supplement sections. Resident #14's Nutritional Risk Assessments (NAR), Weight Change Progress Notes (WCPN), and Nutrition/ Dietary Progress Notes (NDPN) documented the following: * A 3/21/17 WCPN documented Resident #14 had decreased in weight due to problems with swallowing. The note documented the Dietitian would follow up with SLP (Speech Language Pathologist), and suggest that resident have a higher calorie liquids/ nutritional supplements with meals. * A 3/25/17 NDPN documented Resident #14 experienced a significant weight loss in the past 30 days and she required honey thick liquids in a sippy cup. * A 3/25/17 NAR documented Resident #14 was currently receiving a nutritional supplement and the Dietitian recommended nutrition supplements with meals. * A 6/23/17 NAR documented Resident #14 was not receiving supplements and the Dietitian would review her weights weekly. * A 6/27/17 NDPN documented Resident #14 was doing well with her altered texture diet and there were no nutrition related concerns. * A 9/18/17 WCPN documented Resident #14 experienced a 9.3% weight loss over the past 3 months. The WCPN documented Resident #14 had increased difficulty swallowing food, and she required honey thick liquids from a spoon. The WCPN documented Resident #14 did not want tube feeding. * A 9/21/17 NDPN documented Resident #14 experienced weight loss due to problems with swallowing. The note documented comfort measures were initiated. * A 9/26/17 WCPN documented Resident #14 experienced an 8.6% weight loss over the past 3 months. The WCPN documented Resident #14 ate her meals in the dining room, and she was able to take a few bites of her meals. * A 10/1/17 NAR documented Resident #14 choked on thin liquids, and she was not receiving a nutrition supplement. The NAR documented Resident #14 was on comfort measures and tube feeding was not an appropriate intervention. The NAR did not include other nutrition interventions recommended or attempted. A section of the NAR, titled Rate of Unplanned Weight Loss, documented Resident #14 lost less than 7.5% of her body weight over the past 3 months, which was inconsistent with Resident #14's 8.6% weight loss documented in her 9/26/17 WCPN. * A 10/18/17 WCPN documented Resident #14 experienced an 11.8% decrease in her body weight over the past 3 months and related Resident #14's weight loss to her being on comfort measures. Resident #14's clinical record did not contain Nutritional Risk Assessments, Weight Change Progress Notes, or Nutrition/ Dietary Progress Notes between 6/28/17 and 9/17/17 when she experienced a 9.3% weight loss. Resident #14's Nutrition Assessments did not include interventions for the use of fortified foods, snacks, meal alternatives, or consistent use of nutritional supplements. On 1/24/18 at 9:29 AM, Resident #14 was assisted with her breakfast. Resident #14 consumed 3 bites of her pureed eggs and about 1/2 of her cereal. Resident #14 was not offered an alternative or a supplement. On 1/25/18 at 4:11 PM, the Registered Dietitian (RD) stated she did not know what interventions were in place prior to the comfort measure orders. The RD stated Resident #14's orders did not include supplements as snacks, and that Resident #14 did not need them due to her comfort measures order. The RD stated if a resident refused meals or consumed less than 25% of meals, the staff should offer an alternative. The RD stated the facility did not prepare an alternate meal for residents with diet orders of pureed or mechanical soft. The RD stated for these individuals, the facility would provide supplements, such as Ensure, without doctors' orders, when residents refused or consumed less than 25% meals. The RD stated Resident #14 should have received supplements, and did not realize Resident #14 was not consistently provided a supplement, when Resident #14 consumed less than 25% or refused meals. The RD stated Resident #14 should have been offered a snack at night. The RD stated Resident #14's weight loss was gradual did not trigger for weight loss, and when she noticed the weight loss, Resident #14's comfort measures were initiated. The RD stated Resident #14 did not want tube feeding and it did not occur to her to initiate enhanced foods or snacks as interventions. b. Hydration concerns: According to the Nutrition Care Manual Methods for Estimating Fluid Requirements from the Academy of Nutrition and Dietetics, adults within Resident #14's age range should consume 25 ml per kilogram of body weight per day. Using this calculation method, Resident #14 needed a total daily fluid intake of 1397 ml's. Resident #14's clinical record did not include care plans related to dehydration / hydration or Urinary Tract Infections [UTIs]. i. Resident #14 experienced multiple UTIs: * Urinalysis [UA] results from 3/28/17, 9/7/17, and 10/27/17 document Resident #14's urine appeared cloudy and contained blood, nitrite, and bacteria. * Resident #14's culture and sensitivity (C&S) results documented the presence of Escherichia Coli (E. coli) (9/7/17 and 10/27/17) and Gram-Negative Rod (3/28/17). Resident #14's UTIs could be signs and symptoms of dehydration. ii. Resident #14 experienced dehydration: *The 1/1/18 through 1/24/18 ADL Documentation Survey Report, Fluid Intake, documented Resident #14's total fluid intake for each day. Resident #14 received the highest total fluid intake of 667 ml on 1/10/18. Resident #14 received the lowest total fluid intake of 100 ml on 1/1/18 and 1/9/18. Resident #14's average fluid intake for the dates above was 339 ml's. Resident #14 refused some fluid offers 7 of 24 days. * Resident #14's ADL Documentation Survey Reports, dated 6/1/17 through 12/31/17, documented similar findings in the Fluid Intake section. *A Basic Metabolic Panel [BMP] result from 9/17/17, documented Resident #14's Sodium (Na) of 155 milliequivalents of solute per liter (mEq/L), Chloride (Cl) of 116 mEq/L, and Bicarbonate (CO2) of 32 millimoles per liter were elevated. *A BMP result from 1/8/18, documented Resident #14's Na of 149 mEq/L and Cl of 114 mEq/L were elevated. Resident #14's elevated BMP results could be signs and symptoms of dehydration. On 1/23/18 from 9:07 AM to 11:35 AM, Resident #14 was observed in a recliner chair or in her wheelchair in the TV room. Throughout the observation Resident #14 was not offered fluids nor were fluids readily available. On 1/24/18 from 9:04 AM to 11:08 AM, Resident #14 was observed in a recliner chair or in her wheelchair in the TV room, with various staff member contacts. Throughout the observation Resident #14 was not offered fluids nor were fluids readily available. On 1/25/18 at 6:19 PM, the DNS stated Resident #14 had a history of dehydration concerns and the facility ordered IV fluids to correct the imbalance. The DNS stated the BMP results in Resident #14's record demonstrated signs and symptoms of dehydration. The DNS stated UTIs attributed to E. coli was most likely due to a lack of proper peri-care and / or dehydration. The DNS stated staff should have offered Resident #14 fluids minimally every two hours, and ideally after every resident contact. 2. Resident #21 was admitted to the facility on [DATE] with multiple diagnoses, including arthritis, hypothyroidism, and visual impairment. Quarterly MDS assessments, dated 9/4/17 and 12/5/17, documented Resident #21 was cognitively intact, required supervision for eating, and had no weight loss. Resident #21's care plan, dated 6/9/17 and 12/6/17, documented Resident #21 had the potential for weight loss related to arthritis and visual impairment. Resident #21's interventions included, Inform Resident #21 of the location of foods on her plate using the clock method. Provide, serve diet per resident requests and preferences from daily menu . Weights will be reviewed weekly. Dietitian to monitor and report significant wt loss or gain to MD. Resident #21's goals included, Adequate nutrition and fluids to maintain skin integrity, and weight in 150-160 range. A Nutritional Risk Assessment, dated 6/14/17, documented Resident #21's most recent weight was 159 pounds with a nutritional goal to maintain weights between 150-160 pounds. The nutritional interventions documented by the dietitian was to review weights weekly, intakes as needed, and labs when available. Resident #21 was not currently receiving a nutritional supplement. The Weights Summary Report, dated 6/13/17 through 1/23/18, documented Resident #21's weights as follows: * 6/13/17 - 159 pounds * 7/14/17 - 160 pounds * 8/18/17 - 159.5 pounds * 9/8/17 - 149 pounds * 9/19/17 - 151.5 pounds * 10/13/17 - 148.5 pounds * 10/17/17 - 147 pounds * 10/24/17 - 144 pounds * 11/7/17 - 143.5 pounds * 12/8/17 - 143.5 pounds * 12/15/17 - 142 pounds * 12/22/17 - 140 pounds * 12/29/17 - 138 pounds * 1/2/18 - 137 pounds * 1/9/18 - 136 pounds * 1/19/18 - 136 pounds Resident #21 experienced a significant weight loss of 15.00% from 7/14/17 to 1/19/18. There were no Physician Orders for a nutritional supplement for Resident #21 from July 2017 through January 23, 2018. A Nutritional Risk Assessment, dated 9/20/17, documented Resident #21's most recent weight was 151.5 pounds with a nutritional goal to maintain weights between 150-160 pounds. The nutritional interventions documented Resident #21 was receiving Arginaid or Juven supplements to promote wound healing. Resident #21's clinical record did not include Physician Orders for Arginaid or Juven supplements to promote wound healing. Resident #21's care plan did not include interventions for nutritional supplements for wound healing. A Dietitian Progress Note, dated 10/18/17, documented Resident #21's current weight was 147 pounds with a 7.5% weight loss. The Dietitian documented, Resident #21 was ill last month and had some weight loss, she has not had continued weight loss. There was no documentation in Resident #21's clinical record that the physician and family were notified of the weight loss. A Dietitian Progress Note, dated 10/25/17, documented Resident #21's current weight was 147 pounds had some weight loss in the past, will review weights, if weight loss continues, then will notify the physician. A Nutritional Risk Assessment, dated 12/20/17, documented Resident #21's most recent weight was 138 pounds with a nutritional goal to maintain weights between 140-150 pounds. The nutritional interventions documented to review weekly weights, labs and intakes as needed, and weights affected at times by edema. The Dietitian documented Resident #21 was receiving Ensure for a nutritional supplement. There was no documentation in Resident #21's clinical record that the physician and family were notified of her significant weight loss. On 1/23/18 at 6:00 PM, Resident #21 was observed eating dinner in her room without a nutritional supplement. On 1/24/18 at 5:52 PM, Resident #21 was observed eating dinner in her room without a nutritional supplement. On 1/24/18 at 2:45 PM, the Dietitian stated Resident #21 had been refusing her dinner meal and her Ensure supplement for the past few months. The Dietitian was unable to provide documentation if Resident #21 was receiving and/or drinking the Ensure supplement. The Dietitian provided a Skilled Nursing Facility (SNF) Resident's Diet Orders Report, dated 1/24/18, from the kitchen that the dietary staff follows. On the Diet Orders Report had a list of seven resident's including Resident #21, who received supplements. Resident #21 was listed to receive a supplement for the pm meal. The Dietitian stated the pm meal was to be served with dinner. The supplement was Ensure, unless it was listed for a specific kind of supplement next to the resident's name. The Dietitian was unable to provide a physician's order or an updated care plan for the Ensure for staff to provide an Ensure supplement with the dinner meal. The Dietitian stated she did not observe Resident #21 receiving the supplement. The Dietitian stated she initiated a high protein jello for Resident #21's 3:00 pm snack on 1/23/18 and will follow up with Resident #21 if she likes on her quarterly nutritional assessment at the end of February or beginning of March. The Dietitian was aware that Resident #21 was a significant weight loss and was unable to provide documentation that she notified the physician and the family. On 1/24/18 at 3:20 PM, Resident #21 stated, she received jello with banana's yesterday and loved it and would eat it everyday. Resident #21 stated she did not receive the Ensure supplement with her dinner meal, unless she asked for it. Resident #21 did not recall when the last time she had an Ensure supplement. On 1/24/18 at 3:30 PM, the Dietitian was notified that Resident #21 enjoyed the jello and banana's. The Dietitian was notified Resident #21 had to request an Ensure and did not recall the last time she had an Ensure. The Dietitian was unable to provide documentation for the staff to offer the high protein jello snack everyday at 3:00 PM. Resident #21's care plan did not include interventions for her significant weight loss. 3. Resident #22 was admitted to the facility on [DATE] with diagnoses, including Alzheimer's disease, hypernatremia, and hyperglycemia. A quarterly MDS assessment, dated 10/12/17, documented Resident #22 had a severe cognitive impairment, and was dependent upon staff for eating and drinking. The Nutrition Care Plan, dated 1/13/17, documented staff were not to place food or fluids within Resident #22's reach, unless staff were present to supervise. According to the Nutrition Care Manual Methods for Estimating Fluid Requirements from the Academy of Nutrition and Dietetics, adults within Resident #22's age range should consume 25 ml per kilogram of body weight per day. Using this calculation method, Resident #22 needed a total daily fluid intake of 1477 ml's. The 12/27/17 through 1/24/18 ADL Documentation Survey Report, Fluid Intake, documented Resident #22's total fluid intake for each day. Resident #22 received the highest total fluid intake of 1001 ml on 1/4/18. Resident #22 received the lowest total fluid intake of 250 ml on 1/7/18. Resident #22's average fluid intake for the dates above was 605 ml's. Resident #22 refused some fluid offers 12 of 29 days. On 1/23/18 from 9:47 AM to 11:33 AM, Resident #22 was observed in a recliner chair near the nurse's station. Throughout the observation Resident #22 was not offered fluids nor were fluids readily available. On 1/24/18 from 9:14 AM to 11:09 AM, Resident #22 was observed in a recliner chair or in his wheelchair near the nurse's station, with various staff member contacts. Throughout the observation Resident #22 was not offered fluids nor were fluids readily available. On 1/24/18 at 3:06 PM, the DNS stated staff should have offered Resident #22 fluids minimally every two hours, and ideally after every resident contact. 4. Similar findings for Resident #22's hydration concerns were true for Resident #11.