Based on interview and record review the facility failed to assess, intervene and implement treatments in a timely manner for a resident (R2) found to have a new injury/bruising to her left shoulder which resulted in a delay in the diagnosis of and treatment of R2's left shoulder dislocation. This failure applies to 1 of 5 residents (R2) reviewed for the necessary care and services in the sample of 5.The findings include:A facility Incident report dated 9/6/25 showed on 9/5/25 at 4:20 AM, facility staff discovered new bruising to R2's left upper arm. The facility notified R2's hospice agency which subsequently ordered an X-ray of R2's left arm. An X-ray of R2's left arm was performed in the facility which showed R2's left shoulder was dislocated. The report showed R2 was sent to a local hospital on 9/6/25 for an evaluation of her shoulder dislocation. The report showed hospital recommended surgical intervention to reposition the shoulder; however, V8 (Power of Attorney/POA for R2) declined surgical intervention. R2's hospital records dated 9/6/25 showed a repeat X-ray of R2's left shoulder was performed which showed R2's left shoulder was dislocated with a possible glenoid (shoulder bone) fracture. R2 was discharged back to the facility on 9/6/25, on hospice, with orders for R2's left arm to be kept in a sling for comfort and conservative management of R2's shoulder dislocation. R2's current care plan showed R2 was severely cognitively impaired and primarily nonverbal due to her diagnosis of Alzheimer's disease. R2 was unable to verbalize her needs. R2 was dependent on staff for all cares. R2 was unable to move on her own. R2 required two staff members to safely reposition her in bed. R2 was on hospice.R2's progress note dated 9/5/25 showed at 4:20 AM, facility staff discovered new bruising to R2's left shoulder. The note showed R2's hospice agency was notified of the new bruise on 9/5/25. The note showed no documentation facility staffed notified R2's physician or nurse practitioner of the R2's new bruising. The note showed no documentation that facility staff attempted to obtain a physician order to X-ray R2's shoulder. A physician order dated 9/5/25 at 1:23 PM showed an X-ray of R2's left shoulder was ordered/obtained by V14 (R2's Hospice Nurse) after R2 was assessed by V14. R2's progress notes dated 9/5/25 from 4:20 AM to 9/6/25 at 9:30 PM were reviewed and showed no documentation of facility staff attempting to notify R2's physician or nurse practitioner of the new bruising to R2's shoulder. The progress notes showed no documentation of staff reassessing R2's left shoulder bruising at any time after the bruising was found. The progress notes showed no documentation of staff attempting to contact the facility's mobile X-ray company to ensure the X-ray of R2's left shoulder was completed as soon as possible. R2's progress note dated 9/6/25 at 10:21 AM showed an X-ray was completed in the facility of R2's left shoulder; over 24 hours after the new bruising/injury to R2's left arm was found by staff. R2's progress note dated 9/6/25 at 9:40 PM showed the facility was notified, by R2's hospice agency, of R2's X-ray results which showed her left shoulder was dislocated. R2 was sent to a local hospital for an evaluation due to her injury.On 9/10/25 at 10:48 AM, V10 RN stated she was notified of new bruising to R2's left shoulder by V9 CNA on 9/5/25. V10 stated she immediately went to assess R2 and found R2's left upper arm to be purple in color and warm to the touch. V10 stated she did not complete a range of motion assessment on R2's left arm. V10 stated she notified R2's hospice agency of R2's new bruise. V10 stated she did not notify R2's physician or nurse practitioner of the changes noted to R2's shoulder. V10 stated, I notified hospice. They were coming in to see her later that day (9/5/25). I just assumed hospice would follow up on her shoulder and get an X-ray if she needed it.On 9/10/25 at 11:15 AM, V3 Assistant Director of Nursing (ADON) stated he was notified of the new bruising to R2's left shoulder on the morning of 9/5/25. V3 stated when he observed R2's shoulder on that morning, he noted a new. large bruise to R2's left upper arm. V3 stated he did not contact R2's physician or nurse practitioner to inform them of the bruise and/or obtain an order for an X-ray because we were just kind of waiting on direction from her hospice. V3 stated facility staff are to notify a resident's physician or nurse practitioner immediately with any changes in resident condition. When asked why the facility did not order any X-ray of R2's shoulder themselves and why it took over 24 hours for R2's X-ray to be completed, V3 stated, I believe we could have ordered the X-ray ourselves if we had contacted the physician. I don't know how the X-ray was ordered by hospice. I don't know why it took so long to get it.On 9/10/25 at 11:19 AM, V14 (R2's Hospice Nurse) stated she was notified of the new bruising to R2's shoulder on 9/5/25. V14 came to the facility on 9/5/25 to assess R2. V14 stated, I found bruising to (R2's) left lateral arm and posterior shoulder area. (R2) didn't appear to be in pain. It was her bath day. My hospice CNA went to bathe her and called me immediately. She said that something was wrong with (R2's) shoulder because she said (R2's) shoulder was floppy and seemed unstable. That is when I ordered the X-ray. When asked if she ordered R2's X-ray to be done STAT (immediately), V14 stated she didn't know if it had been ordered STAT. V14 stated, We (hospice and the facility) should have collaborated better and ordered the X-ray sooner. V14 stated the facility could have contacted V15 (R2's Nurse Practitioner) directly when they found the new bruising to R2's shoulder to obtain an order for an X-ray. On 9/10/25 at 11:40 AM, V15 (R2's Nurse Practitioner/NP) stated she never received a call from the facility on 9/5/25 or 9/6/25 informing her of and/or updating her on the new bruising found to R2's left shoulder. V15 stated, The first I learned of the injury was on 9/5/25 when (V14 R2's Hospice Nurse) called me and got an order for the X-ray. V15 stated either V15 or R2's physician should have been notified immediately by the facility when the new bruising to R2's shoulder was found by facility staff. On 9/10/25 at 1:00 PM, V2 Director of Nursing (DON) stated she examined R2's left shoulder on 9/5/25 after she was notified of the new bruising. V2 stated she noted a large bruise to R2's left upper arm. V2 stated she did not complete a full assessment of R2's left arm at that time. V2 stated she did not contact R2's physician or NP to notify them of R2's new bruising or attempt to obtain an X-ray order. V2 stated, We were just waiting to see what hospice would say. The facility is responsible for all patient care and general treatment even with hospice residents. Hospice is kind of a second set of helping hands. We should have called (V15 R2's NP) ourselves to inform her of the bruising and to get the X-ray order. I am not sure why we didn't. V2 DON stated facility staff are to immediately report any changes in a resident's condition to the resident's physician or NP to ensure treatments are implemented as soon as possible.The facility's Responding to an Acute Change of Condition policy dated August 2025 showed, Residents who experience an acute change in condition will have their condition monitored, the attending physician notified, and the responsible party informed when the condition changes and as follow up actions occur. GOAL: 1. To ensure the resident changes are identified, communicated, and addressed timely. 2. To ensure that the attending physician of a resident is notified of changes in condition. The licensed nurse will evaluate the resident to determine the status of the condition change. If the resident is not presenting with a medical emergency but presents with an acute condition that requires prompt care and treatment, the licensed nurse will obtain a baseline assessment. and then contact the physician for further follow up and orders. The medical record should reflect the nurse's observation and assessments, physician notification, and follow-through, including updated plan of care.

Based on observation, interview and record review the facility failed to care for a resident (R2) in a safe manner which resulted in R2 sustaining a left shoulder dislocation. The facility failed to ensure a resident (R2) was safely repositioned in bed, as directed per the resident's care plan. These failures apply to 1 of 5 residents (R2) reviewed for resident safety and supervision in the sample of 5.The findings include:A facility Incident report dated 9/6/25 showed on 9/5/25 at 4:20 AM, facility staff discovered new bruising to R2's left upper arm. The facility notified R2's hospice agency which subsequently ordered an X-ray of R2's left arm. An X-ray of R2's left arm was performed in the facility which showed R2's left shoulder was dislocated. The report showed R2 was sent to a local hospital on 9/6/25 for an evaluation of her shoulder dislocation. The report showed hospital recommended surgical intervention to reposition the shoulder; however, V8 (Power of Attorney/POA for R2) declined surgical intervention. R2's hospital records dated 9/6/25 showed a repeat X-ray of R2's left shoulder was performed which showed R2's left shoulder was dislocated with a possible glenoid (shoulder bone) fracture. The X-ray results showed no findings of osteopenia or osteoporosis. R2 was discharged back to the facility on 9/6/25. R2's current care plan showed R2 was severely cognitively impaired and primarily nonverbal due to her diagnosis of Alzheimer's disease. R2 was unable to verbalize her needs. R2 was dependent on staff for all cares. R2 was unable to move on her own. R2 required two staff members to safely reposition her in bed. R2 was on hospice related to her diagnosis of Alzheimer's disease. R2's progress note dated 9/5/25 showed at 4:20 AM, facility staff discovered new bruising to R2's left shoulder. The note showed the area of bruising to R2's left shoulder was warm to the touch. R2 was noted to be sleeping, looks comfortable. The note showed R2's hospice agency was notified of the new bruise on 9/5/25. A physician order dated 9/5/25 at 1:23 PM showed an X-ray of R2's left shoulder was ordered. R2's progress note dated 9/6/25 at 10:21 AM showed an X-ray was completed in the facility of R2's left shoulder. R2's progress note dated 9/6/25 at 9:40 PM showed the facility was notified, by R2's hospice agency, of R2's X-ray results which showed her left shoulder was dislocated. R2 was sent to a local hospital for an evaluation due to her injury.On 9/10/25 at 8:30 AM, R2 was asleep in a high-back wheelchair on the facility's memory care unit. A sling was noted around R2's left arm. The sling held her arm in place, close to R2's chest. On 9/10/25 at 11:04 AM, V11 Certified Nursing Assistant (CNA) stated she provided cares to R2 from 2 PM-10 PM on 9/4/25. V11 stated R2 had no bruising to her left shoulder during that time. V11 stated R2 did not have any falls or sustain any injuries during her shift on 9/4/25.On 9/10/25 at 10:28 AM, V9 CNA stated he provided cares to R2 on 9/4/25, from 10 PM - 6 AM. V9 stated from 10 PM on 9/4/25 to approximately 3 AM on 9/5/25, he repositioned R2 in bed and provided her with incontinence care, by himself, two different times. V9 stated R2 was nonverbal and totally dependent on staff for cares but that he always provides these cares, including bed mobility and repositioning, to R2 by himself. V9 stated R2 was dressed in a sweater when he provided cares to R2 from 10 PM-3AM so he was not able to visualize her left shoulder during that time. V9 stated around 4 AM on 9/5/25, he again provided cares to R2, by himself, which included repositioning her in bed, incontinence care, and getting her dressed. R2 stated, When I took her sweater off, I noticed her (left) shoulder was bruised and swollen. It looked abnormal. V9 stated R2 did not appear to be in pain and was not wincing or crying with movement of her left arm. V9 stated he immediately reported the new bruise to V10 Registered Nurse (RN). V9 stated R2 had no falls or injuries while being cared by V9. V9 stated, I don't know what happened to her. I just assumed something happened to her when someone was moving her or removing her shirt. On 9/10/25 at 10:48 AM, V10 RN stated she was notified of the new bruising to R2's left shoulder by V9 CNA on 9/5/25. V10 she immediately went to assess R2 and found R2's left upper arm to be purple in color and warm to the touch. V10 stated R2 did not appear to be in pain as V10 had administered hospice pain medications to R2 one hour prior. V10 stated she had no idea what caused the injury to R2's arm stating R2 was unable to move her extremities on her own. V10 stated she notified R2's hospice agency of R2's new bruise. V10 stated she did not notify R2's physician, nurse practitioner, or V8 (R2's POA) of the changes noted to R2's shoulder. On 9/10/25 at 11:19 AM, V14 (R2's Hospice Nurse) stated she was notified of the new bruising to R2's shoulder on 9/5/25. V14 came to the facility on 9/5/25 to assess R2. V14 stated, I found bruising to (R2's) left lateral arm and posterior shoulder area. (R2) didn't appear to be in pain. It was her bath day. My hospice CNA went to bathe her and called me immediately. She said that something was wrong with (R2's) shoulder because she said (R2's) shoulder was floppy and seemed unstable. That is when I ordered the X-ray. V14 stated R2 was nonverbal and dependent on staff for cares. V14 stated R2 did not have a diagnosis of osteoporosis or osteopenia. V14 stated she was unsure what caused the injury to R2's shoulder but stated, This is not an injury she could have done to herself. She has no physical behaviors and cannot move on her own. This injury will contribute to her decline.On 9/10/25 at 11:40 AM, V15 (R2's Nurse Practitioner/NP) stated R2 is unable to move on her own. V15 stated R2's left shoulder injury was caused by some sort of trauma or force. This is not an injury that spontaneously happens. V15 stated R2 had no underlying diagnoses of osteopenia or osteoarthritis that she was aware of. On 9/10/25 at 1:00 PM, V2 Director of Nursing (DON) stated R2 was nonverbal and fully dependent on staff for all ADL (activity of daily living) cares. V2 stated staff are to refer to the resident's care plan to verify the level of assistance a resident required for cares. V2 stated if R2's care plan showed R2 required the assistance of two staff to be safely repositioned in bed, then two staff members should be repositioning R2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to put interventions in place after a resident fall to protect the resident from future falls. This failure resulted in R1 falling in his room and sustaining 4 fractured ribs on 5/27/25. This applies to 1 of 3 residents (R1) reviewed for fall interventions in the sample of 7. The findings include: R1's EMR (Electronic Medical Record) dated 5/21/25 states, Resident observed laying on the floor next to his bed on his right side. Resident tried to get self up from his bed and slid to the floor. No injuries noted, no pain or discomfort verbalized or demonstrated . Resident transferred back to bed .R1's Care Plan dated 12/17/24 states, Potential for falls, Resident at risk for injury from falls, history of falls. The intervention UA sent to rule out infection shows a date initiated as 5/23/2025. No other interventions were put in place to prevent R1 from falling after the fall on 5/21/25. An incident report dated 5/29/25 states, On 5/27/25 at approximately 6:40PM the resident was reported to have an unwitnessed fall in the resident's room when attempting to self transfer to the restroom. This same report states, On 5/28/25 the resident was noted to be complaining of mild-moderate pain to the right side. An X-ray was ordered and performed on 5/28/25. X-ray results showed acute appearing right lateral 8-11 rib fractures with displacement and mild soft tissue swelling. NP (Nurse Practitioner) updated with results and order was given to transfer resident to the ED (Emergency Department) for further evaluation and treatment. This report also states, The resident has a BIMS (Basic Interview for Mental Status) of 12 on 12/13/24 (mild cognitive impairment). At the time of the resident's fall, the resident stated he was attempting to walk to his bathroom .R1's Radiology Report dated 5/28/25 states, Acute appearing right rib fractures. R1's Hospital admission Report dated 5/28/25 states, He had a mechanical fall- tripped and fell- about 2 days ago. Hitting his right side chest. He was discovered to have 4 broken ribs 8-11. He was brought to the ED tonight for further evaluation. He is complaining of pain onto his lateral right chest and right back. He is having difficulty breathing .Upon arrival in the ED he was hypoxic at 89% on room air at rest. He was tachypneic. Blood pressure was borderline low. On 7/21/25 at 2:30PM V2 (Director of Nursing) stated, (R1) was more confused than normal on the 21st after his first fall. He was with it and could answer questions but something was just off. The (V6- Nurse Practitioner) ordered a UA (Urinalysis). I didn't talk to any of the family before that. We did the UA and we could have started antibiotics based on that but (V6) waited for the culture. The UA looked bad but some of the doctors wait for the culture- I think we should start the antibiotic and change it if we need to when the culture arrives. The UA was done to try to clear up some of the confusion to prevent falls. On the second fall on the 27th the granddaughter came in right after it and thought he was a little confused and I told her that is how he has been and then we sent him out the next day for the rib fractures. I remember he told me that some guys had come into his room and he had to chase them out and then he had to go to the parking lot to get his truck. V2 did not know of any other interventions put in place after R1's first fall while they were waiting for the results of the UA. On 7/21/25 at 2:45PM V6 stated, If the resident is stable and there is no fever, chills, lethargy etc. then we wait for the culture. If the nurse would have told me there were other symptoms than confusion then I may have started the antibiotic before the culture. I could do a UA and start antibiotics on every resident up there just based on confusion. I like to wait for the culture so we are not giving antibiotics unnecessarily to all these elderly people.R1's Physician's Order Sheet for May 2025 shows that R1 has diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Difficulty Walking, Unsteadiness on Feet, Depression, History of Falling and Metabolic Encephalopathy. This form also shows that R1 was started on antibiotics for a Urinary Tract Infection on 5/25/25. R1's Fall Risk assessment dated [DATE] shows that he is a High Risk for Falls.

Based on interview and record review the facility failed to identify pressure injuries prior to a stage 3 for a resident at risk for pressure with a history of pressure (R1). This failure resulted in a delay in assessing and obtaining treatment orders to prevent pressure injuries from worsening for R1. The facility failed to ensure pressure interventions were in place for a resident with a left heel pressure injury (R72). This applies to 2 of 5 residents (R1, R72) reviewed for pressure injuries in the sample of 18. The findings include: 1.) R1's self -care deficit care plan initiated on 6/5/23 shows R1 requires extensive to total staff dependence with incontinence care, personal hygiene, bed mobility, and transferring. R1's skin integrity care plan initiated on 6/29/24 and revised on 9/27/24 shows she is at risk for impaired skin integrity due to cognitive impairment, immobility and nutrition. The care plan identified that R1 currently has pressure injuries to her left buttock, left hip and left shoulder. R1's Pressure Risk Assessment (Braden scale) completed on 8/12/24 by V12 (former Wound Care Nurse) shows R1 scored a 12 and is at high risk for pressure. The assessment shows that skin should be observed and assessed regularly. A Wound Evaluation and Management Summary completed by V7 (Wound Care Physician) on 9/13/24 shows R1 had a stage 3 pressure injury to her left hip which was healed on 9/13/24. The summary does not show any additional pressure injuries for R1 on 9/13/24. A Wound Care noted completed on 9/21/24 shows that R1 was assessed head to toe and had no acute skin alterations. A nursing progress notes for R1 completed by V13 (LPN) on 9/24/24 states, This nurse observed an open skin area to the hip on the resident. Open sore to hip dark discolored area in center, beefy red tissue surrounding. Acute skin alteration noted to right/left buttocks. Area assessed and foam dressing per wound care nurse. A Wound Assessment Details Report for R1 completed on 9/25/24 by V12 (former Wound Care Nurse) shows R1 had the following new pressure injuries identified: 1. Right Buttock- Stage 2 measuring 1.00 cm. (Centimeters) x 1.00 cm x 0.10 cm. (LxWxD/length width and depth) 2. Left Buttock- Stage 2 measuring 1.0 cm. x 1.5 cm.10 cm. 3. Left Buttock- unstageable measuring 0.5 cm. x 0.5 cm. x unknown depth 4. Right Trochanter (hip)- unstageable measuring 1.50 cm. x 3.40 cm. x .10 cm. this wound is described as 80% pink or red tissue with non-granulating to the skin and 20% of the wound bed necrotic (dead tissue). The picture on the wound assessment clearly shows the black center of the wound bed. 5. Right hip- Stage 1 measuring 7.00 cm. x 5.00 cm. x 0.00 cm. 6. Left Shoulder- Stage 1 measuring 3.00 cm. x 3.00 cm. x 0.00 cm. On 9/27/24 V7 (Wound Care Physician) saw R1 and documented the following pressure injuries with his revised/current stages and additional wounds identified. 1. Left hip a full thickness pressure injury (no left hip pressure injury was documented by V12 on 9/25/24) identified as a stage 3 measuring 3.0 cm x 1.9 cm. x 0.2 cm. This wound is described as having 20% thick adherent devitalized necrotic tissue to the wound bed that required debriding and removal on 9/27/24 by V12, and 20% slough tissue with 60% viable tissue. 2. Left lower medial buttock a full thickness pressure injury a stage 3 measuring 1.0 cm. x 0.6 cm. x 0.2 cm. this wound also required debridement by V12 on 9/27/24. 3. Left upper medial buttock a full thickness pressure injury a stage 3 measuring 3.0 cm. x 1.1 cm x 0.2 cm. 4. Right upper medical buttock partial thickness pressure injury a stage 2 measuring 0.5 cm. x 0.5 cm. x 0.10 cm. 5. Right lower buttock partial thickness pressure injury a stage 2 measuring 1.4 cm. x 1.0 cm. x 0.10 cm. 6. Right hip partial thickness pressure injury a stage 2 measuring 4.2 cm. x 3.5 cm x 0.1 cm. On 9/27/24, V12 identified treatment orders for all wounds listed above to be leptospermum honey with a gauze island bordered dressing to be changed daily and PRN (as needed). On 10/22/24 at 9:23 AM, V3 (Wound Care Nurse) said the former wound care nurse V12 was let go at the facility on 9/25/24 and she was appointed the facility wound care nurse that same day. V3 said she came into the new wounds with R1 and would do her best to answer questions relative to the wounds. V3 said ideally pressure injuries are discovered as a stage 1 and CNA's (Certified Nursing Assistants) should immediately report skin changes to the nurses who should assess the wounds and immediately call for treatment orders. V3 said skin checks should be completed on shower days, when CNA's provide turning and re-positioning and incontinence care to residents. V3 confirmed R1 is a resident who is completely dependent on staff for her cares including re-positioning and incontinence cares. V2 (Director of Nursing) requested to be and was present and collaborated with V3 during the interview about R1's wounds. V2 verified that 6 new wounds were discovered on R1 between 9/24- 9/27 when V7 saw R1. On 10/22/24 at 12:39 PM, V7 (Wound Care Physician) said pressure injuries found past a stage 2 are a little late to the game being identified, especially wounds with necrotic tissue in the wound beds because these wounds are now advanced and more difficult to heal and don't just happen overnight. V7 said that is on the nurses and CNA's for not identifying these wounds sooner if they are providing care to the patient and doing incontinence cares and turning them regularly they should be noticing the areas sooner, multiple stage 3 pressure injuries being identified and pressure injuries to both sides of the body is concerning. V7 said even though R1 had co-morbidities that would contribute to her developing the wounds since she was on hospice he feels sometimes residents on hospice do not get the same care as non hospice residents because the assumption is they are going to die so additional care and treatment sometimes is not done. On 10/23/24 at 8:44 AM, V6 (CNA) said R1 has been totally dependent on staff for her cares for months. V6 said turning and repositioning and incontinence care should be provided for residents every 1-2 hours and skin should be assessed at that time and any abnormalities including pink or redness should be immediately reported to the nurse. On 10/23/24 at 10:36 AM, V2 said that R1 had tested positive for Covid on 9/16/24 and that staff should have been in the room a lot. V2 also verified that as of 9/13/24 R1 had no active pressure injuries on her body. The facility provided Skin Care Prevention policy revised on 10/16 shows residents will be evaluated daily for changes in their skin condition and dependent residents will be assessed during cares for any changes in skin including redness. 2.) R72's care plan shows she has an active stage 4 pressure injury to her left heel, and requires extensive staff assistance with turning and re-positioning. R72's Pressure Risk Assessment History (Braden Scale) shows she scored a 12 which is high risk to develop a pressure injury. A Wound Assessment Details Report completed by V3 (Wound Care Nurse) on 10/16/24 shows she has a healing stage 4 pressure injury and the plan of care is for protective heel boots to be worn. On 10/21/24 at 9:09 AM, V8 and V9 both (CNA's) put R72 to bed. After they were finished with her care they covered her up and left her heels flat against the mattress with no heel protectors on or pillow under her heels offloading them. On 10/21/24 at 11:18 AM, R72 was still in bed with her heels flat against the mattress and not offloaded. On 10/21/24 at 11:14 AM, V3 said for residents at risk for pressure or who have pressure they use offloading of heels with a pillow or heel protectors. On 10/22/24 at 9:50 AM, V3 said she was not aware of R72 not having her heels off loaded but she should have because she does have a current pressure injury. On 10/23/24 at 8:44 AM, V6 (CNA) said R72 has heel protectors that she should have on when she is in bed or up in her wheelchair. The facility provided Skin Care Prevention policy with a revised date of 10/16 shows residents at risk for skin breakdown will have their heels off loaded off the bed surface.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the dietician in a timely manner of a resident with a significant weight loss of 8 lbs. (pounds) 6.2% in one month. This failure resulted in a delay in dietary interventions being implemented and an additional 3.4 lb. 2.81% weight loss in one week. This applies to 1 of 18 residents (R77) reviewed for weight loss in the sample of 18. The findings include: R77's face sheet shows she was admitted to the facility on [DATE] and has diagnoses including cognitive communication deficit, other disorders of the brain, need for assistance with personal cares, and dysphagia. R77's weight summary sheet shows she weighed 129.2 lbs. on 9/21/24 on 10/14/24 she weighed 121.2 lbs. which is an 8 lbs. 6.2% significant weight loss in 24 days. From 10/14/24 she weighed 121.2 lbs. and on 10/21/24 she weighed 117.8 lbs. which was an additional 3.4 lbs. 2.81% weight loss in 7 days. R77's Dietary Review note completed by V4 (Dietician) on 10/22/24 states, I was notified by DON {V2} on the evening of 10/21/24 that resident {R77} has lost weight as of 10/14. Res. latest weight 117.8# does indicate an 8.6% significant weight x 1 month. Interventions added for R77 include a high calorie drink 120 milliliters (ml.) QID (four times a day), and double portions at lunch and dinner. R77's active Physician Order Summary shows an order for dietary consultation as needed and shows the order for double portions at lunch and dinner and a high calorie drink 120 ml four times a day were added on 10/22/24. R77's nursing progress notes do not show that R77's physician was contacted about her weight loss prior to 10/22/24. On 10/22/24 at 9:40 AM, V2 (Director of Nursing) said she notified V4 last evening of R77's significant weight loss. V2 said she is new to the facility and was not sure of the process for nurses reporting weight loss to the dietician. On 10/22/24 at 10:41 AM, V4 said she was not notified about R77's significant weight loss until the evening of 10/21/24. V4 said she pulls the facility weights at the beginning of each month to review weight loss, and ideally the facility should be notifying her immediately of any significant weight loss in between so she can implement interventions. V4 said if she was notified sooner she would have initiated the same interventions. On 10/23/24 at 8:48 AM, V5 (Licensed Practical Nurse/LPN) said when a resident has weight loss the nurse should notify the unit manager and also the Nurse Practitioner. The facility provided Weight Change Investigation policy with a review date of 7/14 shows the purpose of the policy is to investigate significant or insidious weight changes. The weight investigation will be initiated with a significant weight change of 5% or more in one month. Once the weight change is identified the facility will contact the dietician and health care provider for interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify and treat a pressure ulcer for a resident dependent on staff for care. This failure resulted in R1's pressure ulcer to his right heel not being identified until it was necrotic and unstageable on 3/18/24. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 5. The findings include: R1's Face Sheet shows that he was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Atrial Fibrillation, Cellulitis of the Left Lower Limb, Lymphedema, Muscle Weakness, Acute Cystitis and Morbid Obesity. R1's Progress Notes dated 3/17/24 state, Necrotic tissue on bottom of Right heel surrounded by slough. Resident Unaware of wound. Wound care nurse notified. NP notified. POA updated. Foam boots applied. R1's Progress Notes dated 3/18/24 state, Resident was notified by staff regards new skin alteration to left heel, upon assessment noted unstageable to right heel, wound bed necrotic, no exudate noted, resident denies any pain to right heel but complains of pain to right leg. Writer notified NP (V4), per (V4) orders to send out to ER for further evaluations and to rule out DVT. On 6/3/24 at 11:15AM V3 (LPN-Wound Nurse) stated, He came from the hospital. He was resistive to all care, pericare, therapy. On Monday (3/18) morning when I came in he had a new skin alteration, he refused to wear the boots, refused to have heels elevated on a pillow because he said it was uncomfortable. I notified (V4) and she said to send him out. I was doing the dressing on his legs prior to that and they were weeping. I changed the dressings on Monday/Wednesday and Friday. He would not allow anymore than that, he said he didn't need it. I am here Monday - Friday-. When I saw the wound on the heel (V4) and I wanted to make sure it was not a DVT. I was doing the leg treatments so this had to have happened over the weekend. I do the wound assessments weekly. He tried to reposition himself but he wouldn't let us reposition him. He was admitted with chronic cellulitis and was always in supine position. He refused boots or pillows. On 6/3/24 at 1:32 PM R1 stated, The heel on my right foot got a terrible pressure sore on it that I am still working on healing today (at another facility). I looked at all my records from when I was in the hospital the first time and there was no mention of a pressure sore so I know I got it there. I was able to move my leg but every morning I would wake up in a puddle on the bed because my legs were weeping so much. I begged for a week for wound care to come and take care of my legs. I never had any boots until about 1/2 an hour before I left. Finally when they noticed my heel was black they sent me out right away. On 6/3/24 at 1:24 PM V5(RN) stated, He had been complaining of right leg pain. He had had therapy earlier and (V7-CNA) was getting him ready for bed. He complained of right heel pain. She asked me to come look at it. It was black and full of necrotizing tissue. I was unsure if anyone knew about it so I contacted wound care, the MD and the POA. There was no other documentation about it so I guess no one had noticed it. I never had any issues with him. I heard he was sometimes non-compliant with therapy during the day but I didn't try to get him to therapy. He was cooperative and took his medications . On 6/3/24 at 2:00PM V4 (Nurse Practitioner) stated, I didn't know anything about his heel. He never complained of pain to his heel, the pain was in his hip. The wound nurse called me and said it was black and it wasn't there before so I told her to send him out . With the heel, I wanted to make sure it wasn't circulatory, make sure it wasn't a DVT. On 6/3/24 at 2:30 PM V7 (CNA) stated, He had his call light on and I went in there and he said his leg was hurting- in the groin area. I put him in bed and then a little while later he wanted to get up to the chair and use the restroom again so I helped him and he said his heel was hurting. I looked at his foot and it was all blackish in color. This was my first day on the short hall so I had not really worked with his before. We are supposed to do skin checks on shower days and then document it on the shower sheet. I reported it to the nurse and she came and looked at it. R1's Wound Assessment Details Report dated 3/18/24 shows that R1 had Unstageable Necrotic, hard, Firm, Adherent- 100% Facility Acquired Pressure Ulcer to his right heel. This form shows the wound measured 5.5 x 7.0 cm. R1's Braden Scale for Predicting Pressure Ulcer Risks dated 2/10/24 shows that he scored a 15 (15-18= At Risk) R1's Physician's Order Sheet dated 2/10/24- 3/18/24 shows no orders for heel lift boots or off-loading of R1's heels. R1's Care Plan dated 3/8/24 states, Potential/At Risk for alteration in skin integrity due to risk factors associated with diabetes The interventions include: Reposition/shift weight at frequent intervals to resident's comfort, Remind/ Assist Resident to reposition frequently and Check skin daily. R1's Hospital Discharge summary dated [DATE]- 3/28/24 shows one of R1's admitting and discharge diagnoses as Decubitus Ulcer of right foot- s/p excisional debridement on 3/24/24. This form states, He will be weight bearing as tolerated for transfers and short distances attempting to avoid pressure to the right heel. The facility policy entitled Skin Management Program dated 8/23/23 states, It is the policy of the facility that a guest does not develop pressure injury unless clinically unavoidable. Guests with wounds and/or pressure injury and those at risk for compromise are identified, assessed and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal guest outcomes. A Braden Scale will be completed upon admission, weekly for 4 weeks, quarterly and with a significant change of status by a licensed nurse to determine the risk of pressure injury development. Appropriate preventative measures will be implemented on guests identified as risk (a score of 18 or less on the Braden Scale) and the interventions documented on the care plan.