**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed identify, evaluate and intervene to prevent or improve a resident with significant weight loss's nutritional status in 1 (R42) of 5 residents reviewed for nutrition in the sample of 30. This failure resulted in R1 continuing to lose weight over the next 9 months. The findings include: R42's admission record notes he was admitted to the facility on [DATE]. The same admission record lists some of his diagnoses as mild protein- calorie malnutrition, Benign Prostatic Hyperplasia without lower urinary tract symptoms. R42's MDS (Minimum Data Set) dated 8/28/24 note that R42 has a BIMS (Brief Interview of Mental Status) of 08 which indicates R42 has moderate cognitive impairment. Section K of the same MDS note that R42 has not had a weight loss of 5% or more in the last month or greater that a 10% weight loss in 6 months. Section K also notes that R42 has had no nutritional approaches provided while a resident at the facility. R42's Care Plan has a focus area of potential for nutritional problems related to dental impairment with date initiated 6/21/23. R42 likely has cavities and broken natural teeth. R42 is able to feed himself with set up and supervision assistance. R42 likes to eat meals in his room mostly, but will eat in the dining room at times. R42 has a fair appetite. He enjoys eating snacks throughout the day and will also keep snacks at the bedside. Some of the interventions listed are: Provide and serve diet as ordered, RD (Registered Dietitian) to evaluate and make diet recommendations prn (as needed). Staff will assist with oral care, monitor/record/report to MD (Physician) prn s/s (signs or symptoms) of malnutrition, emaciation (cachexia), muscle wasting, significant weight loss of 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. All of interventions were initiated on 6/21/23. R42's Order Entry printed 9/26/24 documents, order date 8/21/23 under additional directions: Health Shakes TID (three times daily), double protein all meals. R42's Order Entry printed 9/26/24 documents, order date 5/21/24 under additional directions: health shake BID (may mix with ice cream). R42's Order Entry printed 9/26/24 documents, order date 7/22/24 under additional directions: health shake between meals. Whole milk with meals. snacks TID. R42's Order Summary Report printed 9/26/24 documents, Regular diet, Regular texture, Thin liquids consistency, health shake TID for Diet order date 7/22/24 and start date 7/22/24. The order also documented, regular diet, regular texture, thin liquids consistency, health shake BID (may mix with ice cream) for diet. Discontinued 5/21/24. On 9/26/24, R42's diet card listed shakes and whole milk at breakfast, lunch and dinner. Double protein all meals. Review of document labeled Document profile dated 6/7/23 note under likes and dislikes, there is no answer provided. There were no other Nutritional assessments provided by the facility. Document labeled Clinical Weights and vitals document R42's weight on 1/10/24 as 175.0 lbs (pounds). The same titled document note that on 2/19/24, R42's weight was 148.0 lbs. Facility document labeled Weights and Vital Exceptions note on 3/12/24, R42 weighed 150.0 lbs. Document labeled Facility Progress note *NEW* dated 9/26/24 notes that on 3/13/24, V5 (Registered Dietician) documented the following: High Risk RD note d/t (due to) weight loss 5% x 1 month. CBW (Current body weight) 150# (pounds), BMI (Body mass index) 20.9. Diet: Regular diet, regular texture, thin liquids consistency, Health shakes TID with meals, Double protein at all meals. Meds (medications) include atorvastatin, Vitamin D3, Ca (calcium) - Vit (vitamin) D w/min (with minerals) Remains at risk of weight loss d/t refusing meals at times. Is encouraged to eat in dining room and does refuse at times. Receiving health shakes with varied PO (by mouth) intake. Appropriate to consider appetite stimulant to support improved PO intake. Recommend- consider appetite stimulant. Unlabeled document provided by V1 as IDT/QA notes note for 3/3/24 to 3/9/24, there were no residents with weight losses over 3 pounds. Notes for 3/10/24-3/16/24 note R42's weight as 150 lbs, continue supplements. monitor, poor appetite, refuses supplements at times. There were no other IDT/QA meeting notes provided that mentioned R42's weight loss. Facility document labeled Weights and Vital Exceptions note that R42 was not weighted in April 2024. There was no dietary notes by V5 for the month of April 2024. R42's document labeled Weights and Vital Exceptions note on 5/21/24, R42 weighed 139.0 lbs which notes -10.0% change (comparison weight 12/5/23, 176.0 lbs , -21.0%, -37.0 lbs). There was no dietary note by V5 for the month of May 2024. There was no documentation of progress notes by the Registered Dietician (V5) for April and May 2024. R42's document labeled Weights and Vitals Exceptions document R42 weighed 137.0 lbs on 6/10/24 which notes a -7.5% change (comparison weight 3/12/24, 150.0 lbs, -8.7%, -13.0 lbs), -10.0% change (Comparison weight 1/10/24, 175.0 lbs, -21.7%, -38 lbs). R42's Dietary note dated 6/12/24 note high risk RD note d/t weight loss -5% in 1 month. The same document notes a CBW (current body weight) 150#, diet: Regular diet, regular texture, thin liquid consistency. Meal intake varied and improving after recent acute illness. Requesting health shakes. Will add and may mix with ice cream to improve acceptance. Recommend: add health shake BID, may mix with ice cream. R42's document labeled Weights and Vitals Exceptions note R42 weighed 134.5 lbs on 7/9/24 which is a -10.0% change (Comparison weight 3/12/24, 150.0 lbs, -10.3%, -15.5 lbs) Dietary note dated 7/24/24 note high risk RD note d/t weight loss >10% x 6 months. CBW: 134.5 Diet: Regular diet, regular texture, thin liquid consistency, health shakes BID. Meal intake varies at times. Typically eats breakfast well. Health shakes added 7/22/24. Appropriate to continue current interventions to support nutrition needs for weight maintenance. Monitor prn (as needed). R42's document labeled Weights and Vitals Exceptions documents no weight for the month of August 2024. There is no progress note by V5 for the month of August 2024. R42's document labeled Weights and Vitals Exceptions documents R42 weighed 131.0 lbs on 9/9/24 which is a -10.0% change (Comparison weight 3/12/24, 150.0 lbs, -12.7%, -19 lbs). Dietary note dated 9/18/24 notes high risk RD note d/t weight loss >10% x 6 months. CBW: 131#. Diet: Regular diet, Regular texture, thin liquid consistency, health shakes BID (twice daily) weight decline continues with recent interventions. Staff reports he typically eats well at lunch meal. Usually skips breakfast and eats light dinner meal. Likes to snack. Appropriate to add snacks between meals and add whole milk. On 9/26/24 at 2:35pm, V5 (Registered Dietician) said that she did not see R42 in April, May and August 2024 due to not being flagged for weight loss. V5 said there were no weights done for him to be flagged. V5 said that R42 tends to skip meals or skip breakfast and also has a tendency to refuse meals. V5 said the fact of him missing her recommendations versus the fact he often refuses meals or skips meals would not really make a difference. V5 said she sends her recommendations to the Administrator, the Director of Nursing and the Dietary manager and they are to speak with the doctor. V5 said she usually sees a resident with significant weight loss monthly. On 9/27/24, V6 (Dietary Manager) said that they do not document when supplements are given. V1 said he could not provide any documentation that they were given. V1 also said that R42 did not have any weekly weights documented from January 2024 to August 2024. R42 was placed on weekly weights on 9/27/24. On 10/3/24 at 12:10pm, V7 (friend/POA/Power of Attorney) said that R42 was not eating good prior to his admission to the facility. R42 said he just didn't really want to get up or eat. V7 said she was not made aware of R42's weight loss until 9/27/24 when the facility called to get her approval for starting an appetite stimulant. R42 said she has not been notified of R42 having any weight loss until then. On 10/3/24 at 11:51am, V5 said she did not know if R42 was being given supplements or not. V5 said she was told he refuses them a lot and in June they were requesting health shakes and said they could add with ice cream. V5 also said they tried other foods. V5 was asked how she knew his preferences since there was no documentation of those and replied she was told he likes snacks and cookies. V5 said that R42 was getting an appetite stimulant and was told he was eating better and was snacking well and since his appetites were improving, she didn't get more aggressive with her interventions. V5 was informed that R42 was not getting an appetite stimulant, however it was begun on 9/27/24. V5 said if she would have known R42 possibly wasn't getting health shakes and the appetite stimulant, her approach would have been more aggressive. On 9/26/24 at 2:00pm, V1 (Administrator) said the Dietician does not have to see a resident monthly. V1 said that R42 refused his weights for the month of August and April. V1 said she did not have any documentation for refusals by R42. V1 said that R42 was getting his health shakes with meals. V1 said that the team meets every morning and discusses weight loss/gains and wounds. V1 said she does receive the Dietary recommendations from V6 each month. V1 said that is a residents weight is off from the last weight, they weigh the resident again, but can not provide any documentation to that. On 9/27/24 at 1:00pm, V1 also said that the IDT (Interdisiplinary Team) meet weekly and discuss weight loss on all of the residents. V1 was asked should R42 have been put on weekly weights and she replied Yes, I guess he should have. V1 said they had a problem with scales and felt that was the problem with weights being off. V1 said she bought new scales in January of 2024. V1 was asked if they calibrated them and she replied yes. V1 said she don't know why the doctor didn't order the stimulant since they always agree with the dietary recommendations. V1 said the called the previous physician's office and they sent a copy to them that said she did not want to order the stimulant. V1 said that V6 asks residents about their likes and dislikes of food. V1 could not provide any documentation of where V6 asked about it. V1 said she would think with weight loss, you should ask about the resident's likes and dislikes. V1 said they do not notify the dietician in writing about a resident's weight loss, she stated they may by phone. On 10/2/24 at 2:35pm, V8 (CNA/Certified Nurse Assistant) said she works the hall R42 was on and she has not given him any health shakes until the other day and now they have a list of names and have to sign them off. V8 said they can not put their weekly weights in the computer and they do them on paper. V8 said she did re-weigh R42 but don't remember when, possibly in the past couple months. On 10/2/24 at 2:45pm, V9 (LPN/Licensed Practical Nurse) said to her knowledge, R42 has not been given any health shakes until last week. On 9/26/24 at 1:45pm, V6 (Dietary Manager) said that the dietician does see residents monthly if they have a significant weight loss. V6 said that R42 has been getting health shakes with his meals and when they are given with meals, they do not sign them off any where and can not provide any documentation that they were actually given. V6 said each month he gives the weights to the DON (Director of Nursing) the weights on each resident. V6 said he does receive the recommendations made by V6 each month. R42's DiningRD Request for Diet Change PCP Fax Report provided by the Facility on 9/26/24 dated 3/13/24 from V5 documents in part, Appropriate to consider appetite stimulant to support improved PO (by mouth) intake. Recommend: -consider appetite stimulant. This document did not have any comments from the physician or a signature. On 9/27/24 at 3:30pm V1 emailed another version of R42's DiningRD Request for Diet Change PCP Fax Report dated 3/13/24 from V5 that now had marked under comments, Do no Change current orders with an unrecognizable signature and a date of 3/15/24. On 9/27/24 at 2:30pm, V2 (DON/Director of Nurses) said that he faxed the unsigned March dietary recommendation for an appetite stimulant to the physician and he ordered Remeron 7.5 mg (milligrams) daily. Facility Document labeled Weight Assessment and Intervention (revised September 2017) note any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. The Dietician will review the unit Weight record by the 15th of the month to follow individual weight trends over time. The same document notes Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the dietician, the Consultant Pharmacist, and the resident or resident's legal surrogate. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss, b. Goals and benchmarks for improvement and c. time frames and parameters for monitoring and reassessment. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choices and preferences c. Functional factors that may inhibit independent eating, d. Environmental factors that may inhibit appetite or desire to participate in meals .g. The use of supplementation and/or feeding tubes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify, assess, and implement treatment and interventions for pressure ulcers for 2 (R1, R2) of 3 residents reviewed for pressure ulcers in a sample of 6. This failure resulted in R1 developing a stage III pressure ulcer area to her left buttock. The findings include: 1. R1's Face Sheet documents that R1 was admitted to the facility on [DATE] with diagnoses of Sepsis, Unspecified Organism, Urinary Tract Infection, Site not specified, Bipolar Disorder, Unspecified, Unspecified Intellectual Disabilities, Unspecified Glaucoma, Acute Embolism, and thrombosis of superior vena cava. R1's Face Sheet documents a discharge date from the facility on 3/25/24. R1's Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score of 13, indicating that R1 is cognitively intact. Section GG, Functional Abilities and Goals, of the same MDS documents that R1 is dependent with all activities of daily living. R1's hospital notes Discharge summary dated [DATE], under Physical Exam documents in part . There was a 2-centimeter (cm) stage III sore on the left heel; No other sores or rashes noted. R1's Physician's Orders dated 2/20/2024 documents weekly skin check every day shift, every Wednesday. R1's admission Braden assessment dated [DATE] documents score of 10. A score of 12 or less indicates a High Risk for skin breakdown. R1's Initial Skin Alteration Record (Admission) dated 2/20/2024 documents in part . small, scabbed area to left buttock noted. There were no measurements or location of the wound on the left buttock noted on this initial admission skin assessment. On 3/28/2024, at 11:15 AM, V2 (Director of Nursing) stated that she completed R1's initial skin assessment on admission and noted a scabbed area to left buttock, the size of a small eraser. V2 stated that no measurements were taken of scabbed area to left buttock and no treatment was obtained for scabbed area to left buttock upon admission assessment. V2 stated that R1 developed another area to her inner buttock that was first identified on 3/03/2024, and an order for a dry dressing to her left buttock area was obtained and R1 saw V13 (primary physician) on 3/5/2024 and he referred R1 to the local wound clinic. V2 stated that it is her expectation of the nursing staff to complete weekly skin checks as ordered, initiate a skin alteration record for all new wound areas, and notify the physician to obtain any new treatments. R1's Treatment Administration Record (TAR) for February 2024 documents weekly skin check not being completed for 2/28/2024. There was no Braden assessment noted in R1's Electronic Health Record or provided for review upon request for the week of 2/28/2024. R1's TAR for February and March 2024 documents left heel wound, cleanse with normal saline and apply topical ointment with moist dressing and wrap with another dressing every day shift with a start date of 2/21/2024. R1's TAR for 2/25/2024 and 2/28/2024 does not document the treatment as being completed. R1's Skin Monitoring: Shower Sheets dated 2/23/2024 documents an area to left heel (nurse aware); 2/29/2024 documents an area to left heel; 3/01/2024 documents an area to left heel; 3/7/2024 documents an area to left buttock, left heel (nurse notified); 3/14/2024 documents an area to left buttock and left heel; 3/17/2024 documents self-inflicted scratches to chest area, an area to left buttock and left heel; 3/19/2024 documents self-inflicted scratches to chest, and area to left buttock and left heel. R1's TAR for March 2024 documents cleanse wound to left heel, apply foam dressing, wrap with dry dressing, every day shift with a start date of 3/07/2024 and a discontinued date of 3/19/2024. R1's Progress Notes dated 3/01/2024, at 10:39 AM by V12 (Licensed Practical Nurse/LPN) documents in part . Wound to left buttock dry dressing applied. R1's Progress Notes dated 3/03/2024 at 2:28 PM by V12 documents During personal care, 3.5 centimeters (cm) x 4.5 cm area with eschar found on left buttocks; V13 (primary physician) notified; orders to cover area with dry dressing and change daily. R1's TAR for March 2024 documents Place dry dressing on open area to left buttocks daily with a start date of 3/04/2024, 7:00 AM. On 3/26/2024, at 10:20 AM, V10 (CNA) stated that when R1 was admitted she noticed little sores all over her body. V10 stated that she remembers R1 having an open area to her buttock and reported to it to V12 (LPN). On 3/26/2024, at 10:45 AM, V12 (LPN) stated that she reported to V13 (primary physician) on 3/03/2024 that R1 had an area to her left buttock and he ordered a dry dressing and referred her to the wound clinic. V12 stated that R1 went out to the wound clinic on 3/12/2024 and saw V31 (wound physician) and came back with new orders. V12 stated that she updated V30 (guardian) about this area. R1's physician's notes dated 3/05/2024 at 5:30 PM by V13 documents in part . pressure sores to left buttock . left buttock acquired since admission .4 centimeter (cm) soft eschar left buttock . refer to wound clinic for left buttock. R1's Weekly Skin Alteration Record dated 3/06/2024 documents left gluteal fold, 4 cm x 3 cm, open area with eschar); Type of Wound: Pressure, wound margins/edges document irregular, erythema; Peri-Wound area intact; Healing process: new wound; Comments: R1 will see local wound physician at local wound clinic. R1's Braden assessment dated [DATE] documents a score of 11, indicating that R1 is a high risk for skin breakdown. R1's Wound notes dated 3/12/2024 by V31 (wound physician) documents in part .Pt (patient) presents for evaluation of left buttock pressure ulcer. The wound note documents a location of left buttock unstageable pressure ulcer and documents measurements of 3.7cm x 4.5cm. Post debridement measurements are documented as 3.7 cm x 4.5 cm x 5 mm (millimeters) full thickness to adipose tissue. Under the Assessment/ Plan it documents in part .eschar and nonviable tissue was debrided from the wound . Under the section Plan it documents wash wound daily with soap and water; pack with polymen silver; secure with 4 x 4 and medipore tape; will call with culture results; follow up in one week. R1's Weekly Skin Alteration Record dated 3/13/2024 documents in part . Weekly skin check completed . R1 has a red area to back of left foot with daily treatment . R1 has a discolored area to back of left foot . R1 has an unstageable area of 3.7cm x 4.5cm to left lower buttock . R1 is seeing local wound clinic for these wounds. No measurements noted for left heel for weekly skin alteration dated 3/13/2024. R1's Braden assessment dated [DATE] documents score of 11, indicating that R1 is a high risk for skin breakdown. R1's Wound notes dated 3/19/2024 by V31 (wound physician) documents Pt (patient) presents for follow up of stage III left buttock pressure injury and new left heel ulcer stage II. Wound #1 is documented as a left buttock unstageable pressure ulcer with measurements of 4.0 cm x 3.9 cm x 6 mm. Wound #2 is documented with a location of left heel with measurements of 2 cm x 2 cm x 1 mm. Under Assessment/Plan it documents in part .last visits cultures revealed proteus mirabilis in the wound. A topical compound was prescribed . Under the section Plan it documents the following: wash wound daily with soap and water, apply wet to dry dressing BID (twice a day) to both wounds until the compound topical antibiotic arrives, secure with 4 x4 and medipore tape, when topical compound arrives, stop wt to dry, apply topical compound antibiotic as prescribed, secure with telfa and medipore tape, turn q (every) 2 hours, do not apply direct pressure to wounds, increase protein intake, follow up in 1 week, watch for signs of infection, fever, chills, redness, excessive or foul drainage, increase in pain. There was no order documented in the Electronic Health Record of R1's protein intake being increased as recommended on the wound notes by V31. R1's Weekly Skin Alteration Record dated 3/20/2024 documents in part .Weekly skin completed .R1 has an area to the back of the left foot that has opened up .See TAR for new order from wound doctor .R1 has a discolored area to back of left heel .R1 has unstageable pressure area of 3.7cm x 4.5cm to left lower buttock .R1 is seeing wound clinic for these wounds .New treatment orders on TAR. R1's hospital notes dated 3/21/2024 under Assessment documents in part . R1 has dressing to top of left foot, dressing to left buttock, dressing to right upper arm, scab to the back of neck, rash like area to center of chest and what appears to be an old ligature/scabbed area to left forearm; All areas are old and scabbed. There was no documentation of a wound to the left heel. On 3/26/2024, at 2:17 PM, V13 (Primary Physician) stated that he has been involved in R1's care for years, he was her medical provider at her previous facility she lived at for many years. V13 states that R1 is severely, cognitively impaired and has had a severe physical decline over the past year and prognosis has not been great. V13 recalls being informed of open area to left buttock on 3/03/2024 and giving treatment orders for it. V13 stated that R1 was being followed by an outside wound clinic for area to left buttock. V13 commented that the staff know the importance of notifying V13 of any new and changing skin conditions. On 3/27/2024, at 8:45 AM, V29 (LPN) stated that he works for this facility and also the previous facility that R1 was at. V29 stated that back in January 2024, R1 lost mobility of her right side. V29 stated that R1 would not cooperate fully but it is possible she had a stroke. V29 stated that he remembers R1 having an open area to her left heel and left buttock. V29 stated that she had a treatment for both and those treatments were done on day shift. On 4/01/2024, at 9:35 AM, V31 (wound physician) stated that he saw R1 in the clinic on 3/19/2024 for a follow-up to her stage III left buttock pressure ulcer and for her stage II left heel pressure ulcer. V31 stated that R1 was not a mobile resident and would need to be turned and repositioned on a regular schedule at least every two hours. V31 stated that it does not take a long time to develop a pressure area, could be less than two hours if not consistently turned and repositioned. On 4/01/2024, at 1:45 PM, V31 (wound physician) stated that he was only made aware of R1's left buttock wound when she first came to the clinic on 3/12/2024. V31 stated that they did not do a whole-body assessment on R1 that day. V31 stated the skin assessment was a focused skin assessment on just the left buttock. V31 stated that he saw R1 again on 3/19/2024 and the left heel area had been added to that appointment. V31 stated that only those two areas were the ones assessed for the 3/19/2024 appointment. On 4/01/2024, at 1:50 PM, V13 (primary physician) stated that he was not made aware of a scabbed area to the left buttock when R1 was admitted on [DATE] and no treatment was ordered at that time. V13 stated that he came to see R1 on 3/05/2024 and assessed her left buttock that showed dry eschar, not particularly affecting her general health. V13 stated that he referred R1 to the wound clinic so it could be debrided. V13 stated that he did not refer R1 to the wound clinic for her left heel wound. V13 stated that her left heel had good, granulating tissue and did not feel she needed to be referred to the wound clinic at that time. R1's Baseline Care Plan, dated 2/22/24, documents no wounds or interventions to prevent skin breakdown. R1 was sent to the hospital on 3/21/2024 with no interventions for pressure ulcers or to prevent skin breakdown in place. R1's Comprehensive Care Plan was not initiated until 3/25/2024. 2. R2's Face sheet documents admitted to the facility on [DATE] with diagnoses of Encephalopathy, Urinary Tract Infection, Chronic Kidney Disease, Type 2 diabetes, unspecified, Type 2 Diabetes Mellitus without complications, essential (Primary) Hypertension, unspecified Atrial Fibrillation, Fibromyalgia, morbid (severe) obesity, Arthropathy, unspecified. R2's Minimum Data Set (MDS) dated [DATE] documents Section C, documents a Brief Interview for Mental Status (BIMS) score of 13, indicating that R2 is cognitively intact. Section GG, Functional Abilities and Goals, documents that R2 requires setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, dependent with toileting hygiene, showering, upper/lower body dressing, putting on/off footwear, personal hygiene, bed mobility and transfers. R2's Treatment admission Record documents the following orders related to wound care: Silvadene External Cream 1 % (Silver Sulfadiazine)(SSD) Apply to left buttock topically every day shift for wound apply SSD, collagen powder, calcium alginate pad, and dry dressing daily and as needed. -Start Date 3/13/2024 0700 (7:00 AM); Weekly Skin Check on Friday 7A-7P every day shift every Fri for skin integrity. -Start Date 3/08/2024 0700 (7:00 AM); Weekly Skin Check on Mondays 7A-7P every day shift every Monday for skin integrity. Start Date 2/26/2024 0700 -D/C (discontinue) Date 3/06/2024. R2's Baseline Care Plan, dated 2/23/24, under Functional Abilities and Goals-Mobility Substantial/ maximal assistance is marked for roll left to right, sit to lying, lying to sitting in the side of the bed, sit to stand, chair/ bed-to-chair transfer, toilet transfer, and tub/shower transfer. Under Bowel and Bladder documents that R2 is frequently incontinent of bowel and bladder. Under Skin Risk the boxes for current skin integrity issues and history of skin integrity issues are not marked. R2's Braden assessment dated [DATE] documents score is 16, a score of 15-16 indicates a Low Risk. Under the section Moisture, Occasionally moist: Skin is occasionally moist, requiring and extra linen change once a day is marked. Under the section Friction & Shear, Potential Problem: Moves freely or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair most of the time but occasionally slides down is marked. R2's Initial Skin assessment dated [DATE] documents Skin pink, warm & dry. No redness noted to bony prominences. Multiple discolorations noted to BUE (bilateral upper extremities) r/t (related to) IV (intravenous) & blood draws in hospital. Redness/excoriation noted to bottom/peri-area with barrier cream applied. Dry scaly skin noted to bilateral ankles & feet. Bilateral heels intact. No open areas or areas of concern noted at this time. R2's Care Plan dated 3/13/2024 documents a Focus area of: R2 has potential/actual impairment to skin integrity related to pressure injury (stage 2) to left buttock. Goals: R2 has potential/actual impairment to skin integrity related to pressure injury (stage 2) to left buttock with a target date of 6/11/2024. Interventions: Follow facility protocols for treatment of injury. Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to primary physician. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface with a start date of 3/13/2024. On 4/2/2024, at 3:00 PM, V9 (Regional Clinical Reimbursement) stated that if a resident has a pressure relieving mattress or cushion, it should be listed as an intervention in their care plan. R2's Weekly Skin Alteration Record dated 3/13/2024 documents left buttock, small pea size open area with pink wound bed measuring 0.5cm x 0.5cm. On 3/25/2024, at 2:00 PM, R2 stated that they just don't turn you enough here. R2 states that staff are sweet and try their best here, but there just aren't enough people. R2 reports she got in her chair at around 8:00 AM or 9:00 AM and has been in her chair since then. R2 reports that they forgot to put her pressure relieving cushion in her chair. R2 was observed to not have cushion in her chair and the pressure relieving cushion was observed lying on her bed at this time. R2 was observed with the call light around her wrist, she states it is her preference because she needs it and always knows where it is. R2 stated that her bottom hurts at this time, but the incontinence brief she wears does make it worse. On 3/25/2024, at 2:45pm, R2 was observed sitting on edge of chair, restless with expressions of pain. R2 stated that her bottom and legs hurt, and she just wanted to lay down. On 3/25/2024, at 3:15pm R2 was laid down and wound treatment was observed. V5 (Licensed Practical Nurse) performed wound care with the assistance of V7 (Certified Nurse's Assistant). Left buttock wound has pink wound bed with no drainage noted or signs and symptoms of infection noted. V5 performed treatment as ordered with no concerns of infection control noted. R2 tolerated treatment with no complaints of pain or discomfort noted. The facility's Decubitus/Pressure Area policy dated January 2014 documents under Policy: To ensure a proper treatment has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified; Procedure: Upon identification of skin breakdown, the following will be completed: 1. Pressure area will be assessed and documented; 2. Complete all areas of a wound assessment following National Pressure Ulcer Advisory Panel (NPUAP) guidelines: i) Document size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from the physician); 4. Documentation of the pressure area must occur upon identification and at least once each week. The facility's Preventative Skin Care policy dated January 2014 documents under Policy: To provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well-groomed, and free from pressure ulcers; under Procedures: 1. All residents will be assessed using the Braden Pressure Ulcer Scale at the time of admission and weekly x 4, then will be reassessed at least quarterly and/or as needed; 3. After thorough cleaning of the skin, lotion may be applied and observation of any reddened areas will be reported to the Charge Nurse; 5. Any resident identified as being at high risk for potential skin breakdown shall be turned and repositioned at a minimum of every two (2) hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions for self-injurious behaviors and obtain necessary behavioral health services for 1 (R1) of 1 resident reviewed for behavioral health in a sample of 6. This failure resulted in R1 developing cellulitis to a self-inflicted wound to the chest wall. The findings include: R1's Face Sheet documents R1 was admitted to the facility on [DATE] with a diagnosis including Bipolar Disorder, Unspecified, and Unspecified Intellectual Disabilities. R1's Face Sheet documents a discharge date from the facility of 3/25/24. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, indicating R1 was cognitively intact. This same MDS documents R1's Functional Abilities and Goals as Dependent with all activities of daily living. R1's baseline care plan, dated 2/22/24, the section Active diagnoses contributing to admission is left blank. There is no documentation of R1's self-injurious behavioral concerns and the Social Services section is left blank. R1's Care Plan dated 3/25/2024 (date of R1's discharge from the facility per Face Sheet) does not document scratching or self-injurious behaviors. On 3/25/2024, at 8:50 AM, V30 (Guardian) stated that she did not visit R1 while she was at the facility. V30 stated that she visited R1 when she was at the emergency room on 3/21/2024. V30 stated that she did not disclose any self-injurious behavior to the facility when R1 got admitted to the facility. V30 stated that R1 wore mittens at her previous facility to help keep her from scratching herself. On 3/26/2024, at 10:20 AM, V10 (Certified Nurse Assistant/CNA) stated that when R1 was admitted she noticed little sores all over her body. V10 stated that R1 would have repetitive scratching to different areas on her body and had to be redirected multiple times. V10 denies being informed of R1's chronic self-injurious behaviors. On 3/26/2024, at 10:40 AM, V11 (CNA) stated that she remembers seeing multiple scratch areas to R1's chest like she had dug into her chest. V11 stated that the staff would put socks over her hands to help keep her from scratching. V11 denies being informed of R1's chronic self-injurious behaviors. On 3/27/2024, at 8:20 AM, V20 (CNA) stated that she recalled R1 scratching her upper arms first about a week after she got admitted and reported this to V12 (LPN). On 3/26/2024, at 2:05 PM, V12 (Licensed Practical Nurse/LPN) stated that it was reported to her on 3/17/2024, that R1 had scratched her chest area. V12 stated that when she assessed her, she noticed R1 had dug into her chest hard. V12 stated that she notified V13 (Primary Physician) about R1's scratches to her chest. V12 stated that V13 told her that this was a long-time behavior of R1 and that her previous facility used mittens to cover her hands to keep her from scratching herself. V12 stated that she told him that mittens are not available at the facility. V12 stated that after she told him that, V13 hung up on her. V12 stated that she found soft, no-show socks and placed them on R1's left hand. V12 stated that R1 would rub her hand against her to remove the sock and continue to scratch herself. On 3/26/2024, at 2:17 PM, V13 (Primary Physician) stated that he has been involved in R1's care for years and was her medical provider at the previous facility she lived at for many years. V13 confirmed that R1 did have a history of self-injurious behavior including, scratching, picking and occasionally biting. V13 states that R1 was severely cognitively impaired and has had a severe physical decline over the past year and prognosis has not been great. V13 recalls being notified about new area to chest from R1 scratching and that he had advised the facility to use mittens as they have used in the past with R1 at her previous residence. V13 denied being informed that the facility did not have mittens or that they were using socks instead. On 3/26/2024, at 2:50 PM, V9 (Regional Director Clinical Reimbursement) stated that it is not an expectation for the facility to call a resident's previous facility concerning a resident's history, if they were admitted from a hospital and not a facility of residence. Unless a problem would arise, V9 stated the same regarding residents with intellectual disabilities/developmental disabilities or psychiatric diagnosis. On 3/27/2024, at 8:45 AM, V29 (LPN) stated that he works for this facility as well as the previous facility where R1 resided. V29 stated that R1 has a chronic behavior of scratching herself. V29 stated that at her previous facility, they would put mittens over her hands to keep her from scratching. V29 stated that it would not be uncommon for R1 to rub a spot open in two hours, it would happen so quickly at times. V29 stated that he works mainly at night at this facility and while he worked R1 was usually in bed, calm and quiet. On 3/27/2024, at 2:15 PM, V8 (CNA) stated that R1 scratched herself hard one day in the upper chest area. V8 stated that soft, fuzzy socks were placed over her hands to help to keep her from scratching self. On 3/27/2024, at 3:35 PM, V7 (CNA) stated that two weeks after R1 got admitted , she noticed her scratching her stomach, chest, and arms. V7 stated that she reported it to V12 (LPN) and was told they were going to monitor her scratching. On 3/27/2024, at 3:45 PM, V16 (CNA) stated that R1 would scratch herself with her left hand and soft socks were placed over her hands to help keep her from scratching herself. V16 stated that she reported R1's scratching herself to V12 (LPN) and that V12 applied some cream to her scratches. On 4/2/2024, at 10:45 AM, V2 (Director of Nursing/DON) stated that she did not receive any information about R1's medical or psychosocial history from V30 (Guardian). V2 stated that she spoke with a staff from her previous facility when she came to visit R1 but did not ask about her previous history at that time. R1's progress notes dated 3/16/2024 at 9:55 PM and written by V32 (LPN) documents in part . R1 has been scratching self to chest, stomach, arms. R1's progress notes dated 3/17/2024 at 2:44 PM and written by V12 (LPN) documents (R1) noted scratching her chest. Area cleansed and cream added. R1 went right back to scratching the area. Called (V13 Primary Physician) and he said she wore mittens at her facility. No mittens available. (R1) was placed in non-latex gloves and could no longer scratch area. R1's progress notes dated 3/19/2024 at 1:35 PM and written by V12 (LPN) documents in part .(R1) has self-inflicted scratches to middle chest. R1's hospital notes dated 3/21/2024 documents in part . Presents to emergency department with complaints of low oxygen .(R1) also has several skin wounds and ulcerations from chronic staph infections .(R1) also has cellulitis and possible aspiration pneumonia . started on intravenous antibiotics . been accepted to another higher level of care hospital and being transferred . Diagnosis - Cellulitis of chest wall. On 4/3/2024, at 1:25 PM, V1 (Administrator) stated that she spoke with V35 (staff form R1's previous facility) about R1's medical history and V1 stated that V35 told her that R1 did not have any behaviors but that she might curse at you occasionally. V1 stated that she always tries to get the previous history on residents from hospitals or other facilities before they get admitted . V1 stated that it is very important to her to know about any resident's behaviors so a decision can be made if the facility can meet their needs or not. On 4/2/2024, at 3:00 PM, V9 (Regional Director Clinical Reimbursement), stated that he was unaware of the staff placing socks on R1's hands to help prevent her from scratching herself. V9 stated that it is his expectation of the nursing staff to perform an assessment, get a consent from guardian, and obtain a physician's order before ever implementing placing a sock or any other restraint device on a resident. V9 stated that the nursing staff should have obtained an order for mittens when V13 (primary physician) suggested it. The facility's Behavioral Assessment, Intervention, and Monitoring policy (revision date December 2016) documents in part under the section Policy Statement, 1. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. Under the section titled Assessment it documents in part 1. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, and mental illness (bipolar, schizophrenia). 2. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: a. The resident's usual patterns of cognition, mood, and behavior; b. The resident's usual method of communicating things like pain, hunger, thirst, and other physical discomforts; and c. The resident's typical or past responses to stress, fatigue, fear, anxiety, frustration, and other triggers. 3. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: a. Onset, duration, intensity, and frequency of behavioral symptoms; b. Any precipitating or relevant factors, or environmental triggers (e.g., medication changes, infection, recent transfer from hospital); and c. Appearance and alertness of the resident and related observations. 4. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. Under the section titled Cause & Identification it documents 1. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition. Under the section titled Management it documents 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm 2. The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice. 3. The resident and family or representative will be involved in the development and implementation of the care plan. Resident and family involvement or attempts to include the resident and family in care planning and treatment, will be documented. 4. The resident and family/representatives will be informed of the resident's condition as well as the potential risks and benefits or proposed interventions .7. Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent, or relieve the resident's distress or loss of abilities. 8. Interventions and approaches will be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. Under the section titled Monitoring it documents 1. If the resident is being treated for altered behavior or mood, the IDT (Interdisciplinary Team) will seek and document any improvements or worsening in the individual's behavior, mood, and function. 2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. 3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment .7. If any devices (restraints) are prescribed, the IDT (Interdisciplinary Team) will monitor the situation to ensure that they are beneficial to the individual (for example, enhancing function and improving symptoms) and are not causing complications or disabling the individual. a. This will be done frequently when such devices are first employed and regularly thereafter for as long as they are used. b. Over time, the staff will reduce the use or remove such devices, or will document why such attempts are not feasible.