**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify a pressure injury prior to becoming a deep tissue injury, failed to obtain treatment orders for a new pressure injury, and failed to implement pressure relieving interventions for a resident with multiple pressure injuries for 1 of 7 residents (R117) reviewed for pressure injury in the sample of 31. These failures resulted in R117 suffering a deep tissue injury to the right heel, a Stage 2 pressure injury to the right buttock, and a Stage 1 to the left lateral ankle. The findings include: R117's face sheet showed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of fracture of the right femur, weakness, polyneuropathy, heart failure, foot drop of the left and right feet, and chronic obstructive pulmonary disease. On 03/05/24 at 12:21 PM, R117 was in a wheelchair in his room. There were ace wraps to both legs and feet. R117 had black shoes on his feet and his feet were on the foot pedals. V15 Certified Nursing Assistant-CNA and V12 CNA transferred R117 from the wheelchair to bed using a mechanical lift. R117 grimaced in discomfort during the transfer and his right leg rotated internally. V12 stated he fractured his right hip about 2 months ago and doesn't think he had surgery. V12 and V15 discussed if heel boots should be on when he was in the chair or in the bed. They were uncertain. At 2:21 PM, V41, R117's son in law stated R117 fell at home on 2/4/24 and fractured his right hip. V41 stated R117 was not a candidate for surgery to repair the fracture due to the location of a plate in his leg. V41 stated R117 did not have any skin breakdown at the time of admission and cannot lift his leg. 03/06/24 12:25 PM, V2 Director of Nursing- DON stated if a new skin condition is found the nurse should obtain treatment orders and notify the provider and family. Pressure interventions should be put into place as soon as we can but getting a treatment started is more important. The provider determines if the resident is referred to wound care. It's important that interventions are in place to avoid new injury and prevent worsening of current pressure wounds. On 3/5/24, this surveyor requested to observe R117's wounds with wound rounds on 3/6/24. On 3/6/24, R117's wound round was completed when this surveyor arrived at the facility. On 3/6/24, this surveyor asked V42 wound doctor to speak with this surveyor when his rounds were done and before he left the facility. V42 left the facility without speaking to this surveyor. At 1:08 PM, V2 assisted to observe R117's right heel wound. R117 was in bed with heel boots on, and both feet resting on the mattress. The offloading pillow was on the floor. V2 asked staff why the heels were not offloaded; they responded because he was eating. R117's right lateral heel had a non-blanchable red purple irregularly shaped area approximately the size of a quarter. On 3/7/24 at 10:00 AM, V17 Unit Coordinator and V18 Registered Nurse-RN assisted to observe R117's left lateral ankle wound. R117 was in a wheelchair in his room. R117 had bilateral foam heel boots on with both feet resting on the foot pedals of the chair. There were inflatable boots with the heels open on the top shelf of the closet. V17 said those were from the hospital. R117's left foot was positioned outward allowing the left lateral ankle to rest on the heel boot. The left lateral ankle had non-blanchable red-purple area approximately the size of a dime. R117's (late entry) skin concern notes effective 3/4/24 at 1:16 PM showed discoloration to bilateral heels. This note showed to float heels when in bed, ace wraps to bilateral legs, apply in the morning and remove at night, medical doctor will be in the facility tomorrow to assess wounds and power of attorney gave consent for wound care to follow. R117's 3/4/24 wound weekly observation tool showed a right heel suspected deep tissue injury measuring 3 centimeters (cm) X 4 cm. Float heels in bed/chair, wound care to see 3/6/24. R117's wound doctor notes showed no mention of the heel wound being assessed. The note showed a Stage 1 pressure injury to the left lateral ankle measuring 2.5 X 0.6 cm and a Stage 2 pressure wound to the right upper medial buttock measuring 0.9 X 1.1 X 0.1 cm. This note showed to offload the wounds. A 3/5/24 nursing note showed the medical doctor ordered heel lift boots while in wheelchair and a wedge when in bed. R117's physician order sheet printed 3/6/24 at 1:10 AM showed orders dated 3/5/24 to float heels while in bed at all times and heel lift boots while up in wheelchair for pressure relief. An order for a gel dressing to the right upper medial buttock was ordered on 3/6/24 and to start on 3/8/24. An order for skin prep to the left lateral ankle was dated 3/6/24 and to start 3/8/24 (wound found 3/4/24). There were no treatment orders for the heel wound found 3/6/24 until 3/7/24. The facility's 4/12/2021 Pressure Ulcer Prevention Policy showed interventions necessary to maintain skin integrity or promote healing will be incorporated into the plan of care based on each resident's individual needs and risks. This policy was less than a page and a half in length. Additional pressure injury policies and/or procedures was requested twice, and none was received. The facility's 10/12/2023 Wound Treatment Management Policy showed wound treatments will be provided in accordance with physician's orders. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. Treatments will be documented on the Treatment Administration Record or in the electronic health record. R117's 2/9/24 pressure injury risk assessment showed he was bedfast and completely immobile (does not make even slight changes in body or extremity position without assistance). R117's care plan showed impaired mobility related to cognitive loss, incontinence, pain, visual deficit, inconsistent motivation to participate in his care, and required hands on assist with repeated verbal directions to participate in and to complete bed mobility and repositioning. R117's care plan showed he required assistance from 2 staff members using a total mechanical lift for all transfers, was non-weight bearing and non-ambulatory. R117's 2/9/24 care plan showed a closed right hip fracture related to a fall. The 2/16/24 potential for pressure development related to decreased mobility care plan was updated 3/4/24 to show 2 new bilateral heel deep tissue injuries. Interventions dated 3/5/24 showed to apply heel lift boots and off load heels while in bed. R117's 2/15/24 facility assessment showed severe cognitive impairment and bilateral lower extremity range of motion impairment. This assessment showed dependence for toileting, bathing, lower body dressing, putting on and taking off footwear, roll left and right, sit to lying, and lying to sitting on side of bed.

Based on observation, interview, and record review the facility failed to identify decreased food intake for residents and implement interventions to prevent a significant weight loss for 2 of 6 residents (R50 & R87) reviewed for nutrition in the sample of 31. These failures resulted in a 5% weight loss in one month for R50 and R87. The findings include: 1. On 3/5/24 at 10:03 AM, R50 was in bed with the head of her bed raised. R50 had her tray table in front of her with her breakfast tray sitting on it. R50 had a sausage patty, hardboiled egg, roll, french toast, water, and chocolate milk. The french toast was cut in half and did not have any syrup on it. R50 picked up the hardboiled egg, looked at it and sat it back down on the tray table. R50 did not eat any of her breakfast. R50 was talking gibberish to herself and when asked questions. No staff were observed assisting R50 with breakfast. On 3/5/24 at 1:06 PM, R50 was sitting in her bed with the head of her bed elevated. R50 had her tray table in front of her with her lunch sitting on it. R50 had au gratin potatoes, broccoli, cake, beef a Roni, water, and juice. R50 did not eat any of her food; lunch was served at around 12:15 PM. R25 CNA (Certified Nursing Assistant) came into the room to assist R50's roommate and stated R50 hasn't been eating but will drink her fluids and then left the room. The Care Plan dated 2/7/24 for R50 showed, R50 has an ADL (activity of daily living) self-care performance deficit related to cognitive loss, episodes of impaired balance, resistive with staff during care, bi-lateral lower extremity edema, incontinence, alteration in endurance, new to facility, and requires repeated verbal directions, coaxing, encouragement and hands on assist to participate in and to complete daily care and tasks. Eating: R50 is able to feed herself after staff assist with set up of meal. Provide finger foods when R50 has difficulty using utensils. Provide milkshakes or liquid food supplements when R50 refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or a mug where appropriate. R50 has potential nutritional problem. Provide, serve diet as ordered. Monitor intake and record every meal. Registered dietician to evaluate and make diet change recommendations as needed. The Nutrition/Dietary Note dated 2/15/24 for R50 showed, Diet: Regular with regular texture and thin liquids. Per Nursing notes, resident requires cues and intermittent 1:1 assist to stay on task with meals. The weights for R50 documented in the electronic medical record as of 3/6/24 showed on 2/1/24 her weight was 163. 4 pounds and on 3/1/24 her weight was 152.4 pounds. R50 had an 11-pound weight loss in one month = 6.7% weight loss. On 3/6/24 at 3:30 PM, V40 RN (Registered Nurse/Unit Coordinator) stated, significant weight changes come up in the weights section of the computer charting. V40 stated they meet every Thursday for a meeting to discuss weight changes. V40 stated she did want to get a re-weigh for R50 to see if the weight was accurate. V40 stated if there was a weight loss the doctor and power of attorney would be notified. V40 stated she would discuss the weight change with the registered dietician, and she will see the resident and make recommendations. V40 stated she believes R50's weight is accurate because she looks like she has lost some weight. Staff should be encouraging her to eat. V40 stated she thinks R50 might be needing more help and that it hasn't been brought to her attention yet by staff. V40 stated if a resident refuses to eat staff can offer a supplement, come back later, and try to get the resident to eat, and try to find out why the resident is not eating. V40 stated that no one has said anything to her about R50 not eating. On 3/7/24 at 8:37 AM, V23 CNA (Certified Nursing Assistant) stated, if the resident is not eating, we will let the nurse know. We assist if they need help eating. If not eating with assistance, then let nurse know. V23 stated she would offer the resident something else like fruit or if they can tell her what they want she will get that. V23 stated they can offer supplement shakes. V23 stated if there were a big weight change for a resident, she would let the nurse know. On 3/7/24 at 9:18 AM, V20 RD (Registered Dietician) stated she is at the facility 8 times per month so usually twice per week on Mondays and Thursdays. V20 stated she was on vacation and had V21 RD filling in for her remotely this last Monday. V20 stated she typically is the one that goes through the weights to look for weight changes. V20 stated the facility has weekly weight meetings and will bring stuff to her attention as well. V20 stated she printed off a list of residents and weight concerns from home and circled the residents that she needs reweighs on and have questions about. V20 stated she would talk to the unit coordinator to see if they thought the weights in question were legitimate or not. V20 stated V21 listed R50 as needing to be re-weighed on Monday (3/4/24) to make sure the weight was accurate. As of last night (3/6/24) she did not see that R50 had been reweighed. V20 stated typically when she asks for a reweigh, she would have to wait for the new weight to know if it is accurate before she makes recommendations. V20 stated if the reweigh is not in there then apparently nothing was done. V20 stated she would have looked through R50's notes to see if she was refusing to eat and/or not feeding herself. If R50 was not feeding herself then staff could assist her. Staff could do verbal cueing. V20 stated she would expect a note in R50's chart saying she prefers liquids over food. V20 stated if the staff know R50 is declining in eating then they should be there to assist the resident with eating and verbal cues. V20 stated R50 eating in her room alone would not be good; it would be better to be out at a table. The Nutrition/Dietary Note dated 3/7/24 at 9:49 AM for R50 showed, RD Weight Review; Principal diagnosis: unspecified dementia, severe, with other behavioral disturbances. Comfort care in place & do not hospitalize per family preference. Notified of reweigh per unit coordinator of 154.2#. Weight reflecting a significant weight loss of 5.6% (9.2 pounds) x/times 30 days. Meal intake remains variable, however, appears to have declined. Per records, resident requires cues and intermittent 1:1 assist to stay on task with meals. Noted Resident was fed per staff times 1 meal on 2/10, 2/17, 2/18, 2/29 & 3/2 per records. No labs to review. Discussed weight loss with unit coordinator and she will notify the power of attorney and primary care physician. Unit coordinator reports resident likes milk and has been taking fluids well. Will recommend supplement shakes twice a day to assist with calorie & protein needs. Monitor acceptance of supplement. Continue to cue & assist resident at meals as needed. Recommend weekly weight monitoring. Monitor intake & weight. The Face Sheet dated 3/8/24 for R50 showed medical diagnoses including unspecified dementia, severe, with other behavioral disturbance, macular degeneration, history of anxiety disorder, hypertension, unspecified psychosis, polyneuropathy, hypothyroidism, hypercholesterolemia, vitamin D deficiency, and gastroesophageal reflux disease. 2. The Weights and Vitals Summary Sheet dated 3/7/24 for R87 showed on 2/1/24 his weight was 202.6 pounds and on 3/1/24 his weight was 186 pounds. R87 had a significant weight loss of 16.6 pounds in one month that equals and 8.2% weight loss. The Face Sheet dated 3/7/24 for R87 showed diagnoses including alzheimer's disease, muscle weakness, protein-calorie malnutrition, generalized arthritis, hypertension, vitamin D deficiency, mixed hyperlipidemia, bilateral hearing loss, atherosclerotic heart disease, paroxysmal atrial fibrillation, cerebrovascular disease, gastro-esophageal reflux disease, benign prostatic hyperplasia, and type 2 diabetes mellitus. The Progress Notes from 2/1/24 through 3/7/24 at 8:57 AM did not show any documentation related to R87's weight loss. The Nutrition Intake Documentation for R87 from 2/7/24 through 3/6/24 showed staff documented the resident ate 76-100% of his meals except for 3 meals where he ate 51-75%. On 3/7/24 at 8:41 AM, R22 LPN (Licensed Practical Nurse) reviewed R87's weights in the electronic medical record and stated usually when the weight loss is like R87's the dietician will come in and see the resident, have the resident re-weighed and go from there. R22 stated R87 eats really well and usually has a weight gain. R22 stated she was not aware of R87's weight loss and would have him re-weighed. On 3/7/24 at 8:59 AM, V3 RN (Registered Nurse/Unit Coordinator) stated they have meetings every week about weights. V3 stated that the dietician was on vacation. V3 reviewed R87's weight in the computer and stated he is going to have R87 re-weighed because doesn't think the weight is accurate. V3 stated R87 usually eats great and has no eating problems that he is aware of. V3 stated the dietician goes through the building. There is a meeting that the unit coordinators go to, to talk about weight losses and gains. They re-weigh residents if needed. V3 stated if the documented weight is something ridiculous then it is brought to his attention. V3 stated R87's weight loss was kind of ridiculous. The Weights and Vitals Summary Sheet dated 3/7/24 for R87 showed at 10:56 AM he was re-weighed, and his weight was 186.4 which was a 16.2-pound weight loss. This was an 8% significant weight loss in one month from his 2/1/24 weight of 202.6 pounds. The Care Plan dated 1/25/24 for R87 showed R87 is able to feed himself independently, staff assist with set up as and if needed. R87 has a potential nutritional problem related to his weight being higher than recommended for his height. Monitor intake and weight. Monitor/record/report as needed any signs/symptoms of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss: 3 pounds in 1 week, >5% in 1 month, >7.5% in 3 months, and >10% in 6 months. The Nutritional Management policy (10/12/23) showed, the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A systematic approach is used to optimize each resident's nutritional status: a. Identifying and assessing each resident's nutritional status and risk factors; b. Evaluating/analyzing the assessment information; c. Developing and consistently implementing pertinent approaches; d. Monitoring the effectiveness of interventions and revising them as necessary. A comprehensive nutritional assessment will be completed by a dietician within 72 hours of admission, annually, and upon significant change in condition. Care Plan implementation: Interventions will be individualized to address specific needs of resident. Examples include but are not limited to iii. Weight related interventions; iv. Environmental interventions; vi. Physical assistance or provision of assistive devices. The physician will be notified of i. significant changes in weight, intake, or nutritional status Nutritional recommendations may be made by dietician based on resident's preferences, goals, clinical condition, or other factors and followed up with the physician/practitioner for orders as per facility policy, if indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary care and services for a resident with a dislocated shoulder for 1 of 3 residents (R1) reviewed for quality of care in the sample of 3. This failure resulted in resident (R1) waiting approximately 12 hours to be transferred to the hospital for acute intervention of a dislocated shoulder. The findings include: On 11/22/22 at 11:21 AM, R1 was observed in a wheelchair at the dining room table with a sling on her right shoulder. R1's right arm was immobilized by the sling. R1 stated she went to the bathroom, washed her hands, and when she came out of the bathroom, she couldn't lift her arm. R1 stated the Certified Nursing Assistant (CNA) was in there with her and nothing happened. R1 stated she didn't fall or bump anything with her arm. R1 stated Oh my God yeah was it painful, the pain was a 10. They told me I had to wait for the X-ray. I had to wait a long time. Why they didn't send me sooner is a good question. I had to wait for X-ray in all that pain. I couldn't lift my arm. On 11/22/22 at 11:45 AM, V4 CNA stated R1 was in the hall in her wheelchair and told her Oh my arm hurts. V4 stated R1 told her that her arm was out of the socket. V4 stated R1 was putting pressure on her right shoulder with her left hand to try to relieve the pain. On 11/22/22 at 12:35 PM, V6 CNA stated she took R1 to the bathroom in the morning and nothing happened out of the ordinary. V6 stated after she wiped R1, pulled up R1's pants, assisted R1 to sit and then R1 washed her own hands in the sink. V6 stated 10-15 minutes after this, R1 was complaining that her arm hurt, and she couldn't lift it. V6 stated she left at 2:00 PM and R1 was still waiting for her X-ray and kept saying she couldn't lift her arm. On 11/22/22 at 1:09 PM, V7 Registered Nurse stated R1 came out into the hallway and said she couldn't move her arm. V7 stated R1 told her this happened to her before when she lived at home. V7 state she asked the CNA what happened and was told nothing happened during care. V7 stated she did an assessment and R1 could squeeze with both hands, but when she barely touched R1's right arm, she cried out Ouch. V7 stated she was unable to do range of motion or any further assessment on R1's right arm due to pain. V7 stated she called the Nurse Practitioner (NP) and relayed her findings. V7 stated the NP ordered and X-ray of the shoulder. V7 stated she called and ordered the X-ray to be done that day. V7 stated R1 acted normal unless R1 tried to move her arm and then she had pain. V7 stated she gave R1 her morning scheduled pain medication and did give R1 Tylenol later on in the afternoon. V7 stated when she left for the day the X-ray still had not been done. V7 said R1 kept her arm by her side and was not moving it. V7 stated had R1 been screaming or looked like she was in agony, I would have sent her out. On 11/22/22 at 1:16 PM, V8 NP stated she received the call from the nurse about R1's shoulder dislocation. V8 stated the nurse did tell her about R1's history of R1's shoulder popping out, R1's pain with palpation, and that the nurse was not able to do a further assessment due to R1's pain. V8 stated she ordered a STAT X-ray to determine if the shoulder was dislocated. V8 stated she didn't receive any results from the X-ray during the rest of her shift, the next NP on call received them. V8 stated if she would have received the results, she would have sent R1 to the ER/emergency room . R1's Minimum Data Set, dated [DATE] shows R1 is cognitively intact. R1's Progress Noted dated 11/19/22: At 8:35 AM, shows resident in hallway, sitting in her wheelchair, yelling out I can't lift my right arm, nurse noted hand grasps strong and equal, attempt to check range of motion (ROM), resident yelled out when nurse held wrist, refused ROM, stated it hurt when she tries to lift her arm. No distress noted with rest, no movement to right upper extremity (RUE), resident stating my shoulder is out of socket, I have to go get it pushed back in like before at the hospital, it happened like that when I lived in town. Resident states she was in the bathroom with CNA without any problems .sat back into her wheelchair, washed her hands, came out of her room and noticed she could no longer lift her RUE. Resident denies injury .states it just happened. At 8:49 AM, shows resident states she is unable to lift RUE, has pain when she tries. Message for on call NP. Awaiting call back. At 9:03 AM, shows V8 NP returned call, reported residents' complaint, and nursing assessment to RUE. New order received, 2 view X-ray to right shoulder, portable. At 9:10 AM, shows spoke with X-ray service, set up portable X-ray for today. At 4:00 PM , shows X-ray of right shoulder taken, 2 views. Resident continues to complain of pain and inability to raise her harm. She is able to move her hand and fingers .Medication given for pain. At 6:55 PM notified family of dislocation and they want her sent to hospital for evaluation and treatment. At 8:30 PM, (approximately 12 hours after the injury was reported) shows transferred by stretcher to local hospital. R1's Physician Orders date 11/9/22 shows X-ray 2 views right shoulder portable (not written as STAT). R1's Radiology Report Shoulder Complete, Right dated 11/19/22 at 5:00 PM shows acute anterior medial dislocation involving the humeral component of the reverse total shoulder arthroplasty. On 11/22/22 at 12:48 PM, V2 Director of Nursing stated if the X-ray is taking too long, they can call back and check the status. V1 Administrator stated she was aware of R1's incident and the ordered X-ray. V1 stated I do agree, it was a long time to wait for the X-ray and they could have sent R1 out without the X-ray or an order. On 11/22/22 at 1:45 PM, R1 stated they should have sent me out to the hospital sooner, it was something else. The pain got worse thru the day. They told me I had to have an X-ray before I go. Now my arm only aches once in a while, I have to follow up with the doctor on Monday. R1's Hospital After Visit Summary dated 11/19/22 shows you were seen .shoulder injury diagnosis: dislocation of prosthetic joint of shoulder.