**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure effective services were provided to prevent the development of a facility-acquired stage two pressure injuries for Resident 46 and Resident 9, who were admitted to the facility without pressure injuries, and were identified by the facility upon admission to be at risk to develop pressure injuries. This deficient practice resulted in Resident 46 developing a facility-acquired stage two pressure injury on the coccyx that deteriorated to an unstageable pressure injury with infection and required hospitalization for intravenous antibiotic therapy of wound-based sepsis, and surgical debridement of the facility-acquired unstageable pressure injury to a stage four pressure injury. This deficient practice resulted in Resident 9 developing a facility-acquired stage two pressure injury on the left heel that deteriorated to a stage three pressure injury. Findings include: 1. On 3/27/24 at 1:46 P.M., Resident 46's family member indicated Resident 46 was hospitalized in January 2024 for a pressure ulcer. They indicated they were not told about the pressure ulcer until the resident was transferred to the hospital and they weren't sure how the resident got the pressure ulcer. At the hospital the resident received antibiotics and treatment, and the pressure ulcer started to heal. They indicated that prior to the hospitalization the resident was giving staff a hard time and thought it was because the resident was in pain due to the pressure ulcer. They indicated that the resident was mobile when admitted to the facility but was no longer able to get around on her own. On 3/28/24 at 9:06 A.M., a Hospice Nurse was observed changing the dressing for Resident 46's pressure ulcer on her coccyx. The hospice nurse cleansed and packed the wound with a half sheet of calcium alginate dressing (a highly absorbent dressing). At that time, the Hospice Nurse indicated the resident was admitted to Hospice upon return from the hospital in January. She further indicated the pressure injury was healing nicely. On 3/28/24 at 10:25 A.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and stage 4 pressure ulcer of sacral region, onset date 1/13/24. The admission Minimum Data Set (MDS) Assessment, dated 9/15/23, indicated that Resident 46 had severe cognitive impairment, required extensive assistance of 2 staff for bed mobility, transfers, toileting, and bathing, and supervision of 1 staff for eating. The resident was frequently incontinent of bowel and bladder. No pressure ulcers were present. A formal assessment scale was used that indicated the resident was at high risk for pressure ulcers. The resident had no nutritional or swallowing issues. An admission Braden Scale Assessment (a tool used to assess the resident's risk to develop pressure injuries), dated 9/8/23, indicated the resident was at high risk to develop a pressure injury. The tool did not include documentation related to turning and repositioning interventions. The admission physician orders, dated 09/08/2023, included, but were not limited to, the following orders: Turn and reposition approximately every 2 hours per Braden Scale. Pressure relieving/reducing mattress and device for chair. A late loss ADLs (Activities of Daily Living) care plan, initiated 9/8/23, included an intervention to inspect the resident's skin weekly, observe for redness, open areas, scratches, cuts, and bruises, and report any concerns to the nurse. The comprehensive care plan lacked documentation related to the resident's risk for pressure ulcers. Weekly Skin Assessment every day shift every Friday, dated 9/15/23. Tylenol (a pain reliever) Oral Tablet 325 mg (milligrams) - Give 2 tablets by mouth every 6 hours as needed for pain or temperature, dated 11/15/23. A re-admission Physician's Note, dated 10/10/23, indicated the resident did not have any skin impairments. The Quarterly MDS Assessment, dated 12/16/23, indicated Resident 46 had severe cognitive impairment, was dependent (staff does everything) on staff for toileting and shower, required substantial/maximal assistance (staff does more than half) for bed mobility and transfers, and required supervision/touch assistance for eating. The resident was always incontinent of bowel and bladder. No pressure ulcers were present. A formal assessment scale was used that indicated the resident was not at risk for pressure ulcers. The resident had no nutritional or swallowing issues. A Quarterly Braden Scale Assessment, dated 12/16/23, indicated the resident was at risk for pressure ulcers. The Nursing Skilled evaluation reports, dated 12/16/23 through 01/03/2024, indicated skin assessments were completed by nursing staff twice daily and no skin impairment was observed. A partially-completed resident shower sheet/skin concern document, dated 12/26/23, did not include documentation to indicate skin issues were present. A Pressure Wound Weekly assessment, dated 12/28/23, identified a new stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister) on the coccyx (the area that articulates with the sacrum at the top of the buttocks) that measured 2.2 cm (centimeters) in L (length) by 0.5 cm W (width) by 0.2 cm D (depth). The assessment indicated the wound bed contained no epithelial tissue, no granulation, no slough, no necrotic tissue, no drainage, no odor, and normal per-wound tissue. The Nurse Practitioner (NP) and the facility's wound nurse were notified on 12/28/23, and orders were received to cleanse the wound with Anasept (an antimicrobial skin and wound cleanser) and apply a foam dressing. The December 2023 TAR (treatment administration record) indicated that a weekly skin assessment was conducted on 12/1, 12/8, 12/15, 12/22, and 12/29 and that the resident's skin was intact with no new or existing skin issues. The December 2023 TAR indicated that the pressure wound was cleansed with Anasept and a foam dressing was applied once daily on day shift from 12/28/23 to 12/31/23. The December TAR did not include sufficient documentation to show the facility-acquired stage two pressure ulcer was effectively assessed by nursing staff daily between 12/28/23 and 01/03/24. The IDT (Interdisciplinary Team) progress notes, the plan of care, the nursing progress notes, and the wound nurse progress notes dated from 12/29/23 through 1/3/24, did not include documentation of the facility-acquired stage two pressure injury on the coccyx. On 4/2/24 at 12:28 P.M., assessments of the specific characteristics of the facility-acquired stage two pressure injury on the coccyx between 12/29/23 and 1/03/24 were requested. The facility was unable to provide documentation to determine that staff assessed the facility-acquired stage two pressure injury on the coccyx between 12/29/23 and 1/3/24. The January 2024 TAR indicated that a weekly skin assessment was conducted on 1/5/24 and that the resident's skin was intact with no new or existing skin issues. The record did not include documentation related to the specific characteristics facility-acquired stage two pressure injury on the coccyx initially identified on 12/28/23. The January 2024 TAR indicated that the facility-acquired stage two pressure wound was cleansed with Anasept and a foam dressing was applied once daily on day shift from 1/1/24 to 1/4/24. It did not include an assessment of the wound. A resident shower sheet/skin concern document, dated 1/2/24, indicated the resident had an open area, but did not include a nurse assessment related to the open area. The nursing progress notes did not include sufficient documentation to show the facility-acquired stage two pressure ulcer was effectively assessed by nursing staff daily between 12/28/23 and 01/03/24. A Pressure Wound Weekly assessment, dated 1/4/24, indicated the pressure ulcer on the coccyx was worsening and measured 2.5 cm in length, 2 cm in width, and 0 cm in depth. The assessment indicated the wound bed contained 100% epithelial tissue, no granulation, no slough, no necrotic tissue, no drainage, no odor, and normal per-wound tissue. The NP was notified and orders were given to cleanse the wound with wound cleanser, pat dry, apply Medihoney (a gel used to treat wounds), and apply a bordered foam dressing A care plan, initiated 1/4/24, indicated the resident had a facility-acquired stage 2 pressure ulceration to inner buttocks with interventions to implement treatment as ordered, update the facility wound nurse, PCP (primary care physician), or NP of benefit of treatment plan or worsening with routine treatments, and weekly skin assessments. A Nursing Skilled Evaluation, dated 1/4/24 at 2:03 A.M., indicated Moisture Associated Skin Damage (MASD) was newly identified on the coccyx above the buttocks measuring 2 cm in length and 20 cm in width with slough in the wound bed and minimal bloody drainage on the dressing. The assessment indicated the resident experienced episodic pain. Pain relieving interventions were not given at that time. A nursing progress note, dated 1/4/24 at 10:36 A.M., indicated the resident was lethargic and not eating, and the NP saw the resident and gave new orders to obtain labs for CBC (complete blood count), CMP (complete metabolic panel), TSH (thyroid-stimulating hormone), and T4 (thyroxine) the next morning. A Nursing Skilled Evaluation, dated 1/5/24 at 1:27 A.M., indicated the MASD on the coccyx above the buttocks measured 2 cm in length and 20 cm in width with slough in the wound bed and minimal bloody drainage on the dressing. The assessment indicated the resident experienced episodic pain. Pain relieving interventions were not given at that time. A nursing progress note, dated 1/5/24 at 2:15 A.M., indicated the dressing on the coccyx was intact and there were no signs of discomfort. A resident shower sheet/skin concern document, dated 1/5/24, indicated the resident had an open area, but did not include a nursing assessment related to the open area. A nursing progress note, dated 1/6/24 at 12:48 A.M., indicated the wound was cleaned, and the dressing was changed and was intact. A Nursing Skilled Evaluation, dated 1/6/24 at 12:52 A.M., indicated the MASD on the coccyx above the buttocks measured 2 cm in length and 20 cm in width with slough in the wound bed and minimal bloody drainage on the dressing. The assessment indicated the resident experienced episodic pain. Pain relieving interventions were not given at that time. A nursing progress note, dated 1/6/24 at 3:17 P.M., indicated the dressing to the coccyx was clean, dry, and intact. The nursing progress notes and skilled nursing evaluation reports, dated from 01/05/2024 at 1:28 A.M. through 01/06/2024 at 4:22 P.M., did not include sufficient documentation to determine the specific characteristics of the facility- acquired stage two pressure injury that deteriorated to an unstageable pressure injury. A nursing progress note, dated 1/6/24 at 4:23 P.M., indicated the resident had vomited on her gown and was observed having shallow breathes with a low blood pressure of 60/40 and a thready slow pulse at 26 beats per minute. The doctor was notified, and new orders were given to send the resident to the hospital for treatment and evaluation of the significant change in condition. A hospital admission summary, dated [DATE], indicated Resident 46 was admitted to the hospital for treatment of dehydration, acute hypernatremia (high sodium), acute kidney injury, altered mental status, and sepsis. It was noted that the resident had a large decubitus ulcer (pressure ulcer) with eschar (dead tissue) that was unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.) The summary indicated new areas of pressure-related skin impairment, on the left shoulder, left ear, and right hip, were identified by hospital staff during a physical exam. The resident was admitted to the general medical floor to await transfer to another hospital and was started on IV (intravenous) Zosyn (an antibiotic medication). A laboratory report, dated 1/6/23, included, but was not limited to, the following blood level results: -Lactic Acid (a blood test to determine sepsis): 2.3 mmol/L (millimoles/Liter) therapeutic range: 0.5-2.0 mmol/L -Albumin (a blood test to determine liver and kidney function): 3.0 g/dL (grams/deciliter) therapeutic range: 3.4-4.8 g/dL -Sodium (a blood test to determine fluid and electrolyte balance): 157 meQ/L (milliequivalent/liter) therapeutic range: 136-145 meQ/L -Troponin (a blood test to determine heart damage): 203 ng/L (nanogram/Liter) therapeutic range: 0-13 ng/L A laboratory report, dated 1/7/23, included, but was not limited to, the following blood level results: -Lactic Acid (a blood test to determine sepsis): 2.3 mmol/L therapeutic range: 0.5-2.0 mmol/L -Albumin (a blood test to determine liver and kidney function): 2.8 g/dL therapeutic range: 3.4-4.8 g/dL -Sodium (a blood test to determine fluid and electrolyte balance): 157 meQ/L therapeutic range: 136-145 meQ/L -Troponin (a blood test to determine heart damage): 231 ng/L therapeutic range: 0-13 ng/L A hospital admission summary, dated [DATE], indicated Resident 46 was transferred to another hospital and admitted to the ICU (intensive care unit) with diagnoses of severe sepsis with the source of decubitus wound and decubitus ulcer. A hospital Discharge summary, dated [DATE], indicated the resident's discharge diagnoses included, but were not limited to, sepsis due to decubitus ulcer and decubitus ulcer present on admission. The resident had a surgical debridement of the ulcer on 1/8/24 with a wound vac placed that was removed prior to discharge. The resident was discharged back to the facility and was admitted to hospice on 1/13/24. During an interview on 4/1/24 at 12:13 P.M., the Director of Nursing (DON) indicated Resident 46 developed a pressure ulcer on 12/28/23 that continued to worsen until she was transferred to the hospital on 1/6/24. She indicated that pressure ulcers were measured weekly but assessed daily during the dressing change and should be documented in the progress notes or the TAR. She indicated that the assessment in the Skilled Nursing Evaluations between 12/28/23 and 1/3/24 were not correct and most likely copied and pasted. At that time, she indicated that care plans were updated each morning during Interdisciplinary Team (IDT) meetings and when new orders were added. 2. During record review on 4/1/24 at 11:45 A.M., Resident 9 diagnoses included, but were not limited, to type II diabetes, dementia, heart failure, and chronic kidney disease. Resident 9's most recent Quarterly MDS (Minimum Data Set) assessment, dated 1/19/24, indicated that the resident had severe cognitive impairment, required extensive assistance with ADL's (activities of daily living) and mobility, was always incontinent of bowel and bladder, and had an unhealed stage III pressure area. A nurse's note dated 10/12/23 at 9:56 A.M., indicated that Resident 9 had arrived at the facility in a wheelchair. Resident 9 was taken to her room and transferred to her bed. A skin assessment was completed, and no open areas were noted. An admission Braden scale completed on 10/12/23 indicated that Resident 9 was at risk for pressure. Resident 9's physician orders included, but were not limited to: Cleanse area on left heel with wound cleanser and apply Medi-honey to wound bed. Cover with dry dressing daily, one time a day for wound (started 10/20/23). Float heels at all times, every shift for wound (started 10/20/23). House supplement 4 ounces three times a day, with meals (started 1/11/24). Left Heel: Cleanse with wound cleanser, pat dry. Pack wound bed with collagen sheet moistened with normal saline. Apply bordered gauze dressing. Secure with Kerlix (gauze bandage) as needed. Initial and date every day shift for wound care and as needed for soiled or dislodged dressing (started 3/13/24). Resident 9's care plan included, but was not limited to: I am at risk for impairment to skin integrity due to fragile skin, incontinence. I will maintain or develop clean and intact skin by the review date (revised 10/19/23). I have a stage 3 pressure area to left heel (initiated 10/20/23). Interventions included weekly skin assessments. A weekly wound assessment dated [DATE] at 1:41 P.M., indicated a facility-acquired stage two pressure ulcer on Resident 9's left heel that measured 3 cm (centimeters) L (length) x 4 cm W (width) x 0.3 cm D(depth) (Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present). The assessment indicated the wound bed contained 100% granulation tissue with no odor and well-defined edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 3 cm L x 3.5 cm W x 0.1 cm D (Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed). The assessment indicated the wound bed contained 10% granulation tissue and 90% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 2.4 cm L x 2.4 cm W x 0.1 cm D. The assessment indicated the wound bed contained 25% granulation tissue and 75% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 2.2 cm L x 2 cm W x 0.1 cm D. The assessment indicated the wound bed contained 25% granulation tissue and 75% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 2 cm L x 2 cm W x 0.1 cm D. The assessment indicated the wound bed contained 25% granulation tissue and 75% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. Weekly wound assessment records, dated between 11/21/23 and 12/26/23 did not contain wound documentation including, but not limited to, measurements and specific wound characteristics to show staff effectively assessed the facility-acquired stage three pressure injury to Resident 9's left heel. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 1.5 cm L x 1.2 cm W x 0.3 cm D. The assessment indicated the wound bed contained 90% granulation tissue and 10% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 1.5 cm L x 1.5 cm W x 0.5 cm D. The assessment indicated the wound bed contained 90% granulation tissue and 10% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 1.5 cm L x 1.3 cm W x 0.3 cm D. The assessment indicated the wound bed contained 90% granulation tissue and 10% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 1.4 cm L x 1 cm W x 0.4 cm D. The assessment indicated the wound bed contained 50% granulation tissue and 50% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 2 cm L x 1.5 cm W x 0.6 cm D. The assessment indicated the wound bed contained 50% granulation tissue and 50% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 2 cm L x 1.6 cm W x 0.4 cm D. The assessment indicated the wound bed contained 75% granulation tissue and 25% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 1.8 cm L x 0.6 cm W x 0.2 cm D. The assessment indicated the wound bed contained 75% granulation tissue and 25% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. Weekly wound assessment records, dated between 2/6/24 and 2/20/24 did not contain wound documentation including, but not limited to, measurements and specific wound characteristics to show staff effectively assessed the facility-acquired stage three pressure injury to Resident 9's left heel. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 0.5 cm L x 0.5 cm W x 0.1 cm D. The assessment indicated the wound bed contained 100% granulation tissue with no odor and no drainage and well-defined wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 0.5 cm L x 0.3 cm W x 0.1 cm D. The assessment indicated the wound bed contained 100% granulation tissue with no odor and no drainage and well-defined wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 0.5 cm L x 0.5 cm W x 0.2 cm D. The assessment indicated the wound bed contained 100% granulation tissue with no odor and no drainage and well-defined wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 0.5 cm L x 0.5 cm W x 0.2 cm D. The assessment indicated the wound bed contained 100% granulation tissue with no odor and no drainage and well-defined wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 0.3 cm L x 0.3 cm W x 0.1 cm D. The assessment indicated the wound bed contained 100% granulation tissue with no odor and no drainage and well-defined wound edges. On 4/2/24 at 12:28 P.M., the DON provided a current Pressure Ulcer Treatment policy, revised 11/1/17, that indicated The pressure ulcer treatment program should focus on the following strategies: Assessing the resident and the pressure ulcer(s). Managing tissue loads. Pressure ulcer care. Managing bacterial colonization and infection. Operative repair of the pressure ulcer(s). Education and quality improvement. The following information should be recorded in the resident's medical record: . Any change in the resident's condition. All assessment data (i.e., color, size, pain, drainage, etc.) when inspecting the wound. On 4/2/24 at 3:04 P.M., the DON provided a current Charting and Documentation policy, undated, that indicated Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 3.1-40(a)(1) 3.1-40(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide nutritional care and services including failure to identify significant weight loss, failure to notify the physician of poor intakes, and failure to be reviewed by the Registered Dietician, for 1 of 4 residents reviewed for nutrition (Resident 46). This deficient practice resulted in the resident experiencing a 20% weight loss in 35 days, developing a facility-acquired stage two pressure injury on the 12/28/23 that deteriorated to an infected unstageable pressure injury, and requiring a hospitalization for sepsis, dehydration, and malnutrition. Finding includes: On 3/27/24 at 1:46 P.M., Resident 46's family member indicated they had not been notified by the facility about Resident 46's weight loss. They indicated the resident was hospitalized in January 2024 and they found out about the weight loss then. They indicated that Resident 46 was able to feed herself when she was admitted to the facility but had since declined and required staff to help her eat. They indicated she was able to eat finger foods easily. On 3/28/24 at 10:25 A.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and stage 4 pressure ulcer of sacral region. The admission Minimum Data Set (MDS) Assessment, dated 9/15/23, indicated that Resident 46 had severe cognitive impairment, required extensive assistance of 2 (two) staff for bed mobility, transfer, toileting, and bathing, and required the supervision of 1 (one) staff for eating. The resident had no nutritional issues, swallowing disorders, and had no weight loss in the past 6 months. The resident weighed 150 pounds (lbs.) and was 61 inches (in) tall. A Dehydration Risk Assessment, dated 9/8/23, indicated Resident 46 was at high risk for dehydration. admission physician orders included, but were not limited to: Regular diet, Regular texture, Regular consistency, dated 9/8/23. Weekly weights x4 weeks every Fri dated 9/15/23. A Nutritional Risk Assessment, dated 9/15/23, indicated Resident 46 was at high risk for malnutrition. A nutrition and dietary note, dated 9/15/23 at 11:49 A.M., indicated Initial nutrition risk assessment complete. High Risk. Dx. [diagnosis] of Alzheimer's. Current diet regimen is appropriate. Will continue to monitor weight, intake. RD [Registered Dietician] available as needed. The clinical record lacked a care plan related to a risk for weight loss or malnutrition. A facility weights and vitals summary report included the following measurements: 9/9/23 at 2:54 A.M. 150.4 lbs. (pounds) 9/11/23 at 2:56 P.M., 61 inches (in) length 9/15/23 at 3:08 P.M., 154.6 lbs. 10/9/23 at 11:30 A.M., 140 lbs. The weight warning indicated the resident had a 6.9% weight loss in a month. (The resident returned from the hospital on [DATE] and was weighed in the facility at 140 lbs. The facility entered the date 10/9/23 in error.) 11/3/23 at 8:08 A.M. 144.8 lbs. 12/1/23 at 8:44 A.M., 145 lbs. 1/4/24 at 10:31 A.M. 115.6 lbs., a 20.28% weight loss since 12/1/23. On 9/15/23, Resident 46 was transferred to a psychiatric hospital for treatment and evaluation of behaviors. The resident was transferred back to the facility on [DATE]. Hospital discharge records, dated 10/10/23, indicated Resident 46 was treated for aggression and paranoia. A re-admission Dehydration Risk Assessment, dated 10/10/23, indicated Resident 46 was at high risk for dehydration. The clinical record lacked a Nutritional Risk Assessment and a Clinical readmission Assessment on re-admission to the facility. The clinical record lacked notification to the provider, RD (Registered Dietitian), or family of the 6.9% weight loss. The clinical record lacked an assessment by the RD following this weight loss. A Care Conference Summary, dated 10/16/23 at 1:00 P.M., lacked documentation of a review of Resident 46's significant weight loss. The Interdisciplinary Team (IDT) notes lacked documentation to show that the resident's weight loss was reviewed or effective interventions were implemented to prevent further weight loss. Progress notes, the plan of care, and doctor's orders, dated between 11/3/23 and 11/8/2023, did not include documentation to show an intervention was immediately implemented to prevent further weight loss. The nursing progress notes, dated from 11/8/2023 at 3:38 P.M. through 11/17/2023 at 6:21 P.M, indicated Resident 46 had a poor appetite and food intake, had extremely dark-colored skin in the area below the eyes, and slept most of the time. The notes indicated the facility staff notified the NP (Nurse Practitioner) of the significant changes on 11/15/2023 and the MD (Medical Doctor) on 11/16/23. The notes did not include documentation to show the NP responded to the notification or to show the facility followed-up with the NP between 11/15/2023 and 11/16/2023. A laboratory report, dated 11/18/2023, included, but was not limited to, the following blood level results: -Albumin (a blood test to determine liver and kidney function): 3.7 g/dL (grams/deciliter) therapeutic range: 3.4-4.8 g/dL -Sodium (a blood test to determine fluid and electrolyte balance): 139 meQ/L (millequivalent/Liter) therapeutic range: 136-145 meQ/L The nursing progress notes, dated from 11/18/23 at 12:50 A.M. through 11/28/23 at 1:14 P.M., indicated Resident 46 had a poor appetite and food intake and slept most of the time. The notes did not include documentation to show notification to the provider or RD. The November 2023 Nutritional Intake form indicated the following: Breakfast consumption: 76-100% on 1 of 30 opportunities 51-75% on 7 of 30 opportunities 26-50% on 4 of 30 opportunities 0-25% on 4 of 30 opportunities 4 of 30 opportunities were documented as resident refused. 1 of 30 opportunities was documented as not applicable. 9 of 30 opportunities were not documented. Lunch consumption: 76-100% on 1 of 30 opportunities 51-75% on 3 of 30 opportunities 26-50% on 4 of 30 opportunities 0-25% on 5 of 30 opportunities 5 of 30 opportunities were documented as resident refused. 12 of 30 opportunities were not documented. Dinner consumption: 76-100% on 1 of 30 opportunities 51-75% on 2 of 30 opportunities 26-50% on 2 of 30 opportunities 0-25% on 4 of 30 opportunities 2 of 30 opportunities were documented as resident refused. 19 of 30 opportunities were not documented. The clinical record lacked documentation of notification to the physician or dietitian related to the refusal of meals and poor food intake. The nursing progress notes, dated from 12/1/23 at 1:57 P.M. through 12/14/23 at 2:23 P.M., indicated Resident 46 had a poor appetite and food intake and slept most of the time. The notes did not include documentation to show notification to the provider or RD. A Quarterly MDS assessment, dated 12/16/23, indicated Resident 46 had severe cognitive impairment, required supervision or touch assistance for eating, had no weight loss, no swallowing disorder, and weighed 148 lbs. A Quarterly Dehydration Risk Assessment, dated 12/16/23, indicated Resident 46 was at high risk for dehydration. Nursing progress notes from 12/16/23 to 1/16/24 lacked documentation related to loss of appetite, weight loss, nutritional status, or notification of poor appetite or intake to the physician, RD, or family. The December 2023 Nutritional Intake form indicated the following: Breakfast consumption: 76-100% on 0 of 31 opportunities 51-75% on 1 of 31 opportunities 26-50% on 3 of 31 opportunities 0-25% on 13 of 31 opportunities 3 of 31 opportunities were documented as resident refused. 11 of 31 opportunities were not documented. Lunch consumption: 76-100% on 0 of 31 opportunities 51-75% on 2 of 31 opportunities 26-50% on 0 of 31 opportunities 0-25% on 6 of 31 opportunities 2 of 31 opportunities were documented as resident refused. 21 of 31 opportunities were not documented. Dinner consumption: 76-100% on 0 of 31 opportunities 51-75% on 2 of 31 opportunities 26-50% on 1 of 31 opportunities 0-25% on 1 of 31 opportunities 1 of 31 opportunities were documented as resident refused. 26 of 31 opportunities were not documented. A care plan, dated 12/22/23, indicated the resident was at risk for weight loss due to dementia. Interventions included diet as ordered, record intake, labs as ordered, and notify Dr and family of changes. The clinical record lacked a care plan related to the resident's refusal of food or poor intake. A Pressure Wound Weekly assessment, dated 12/28/23, identified a new stage 2 pressure ulcer on the intergluteal cleft that measured 2.2 cm (centimeters) length by 0.5 cm width by 0.2 cm depth. A Quarterly Braden Scale Assessment, dated 12/16/23, indicated the resident was at risk for pressure ulcers. The clinical record lacked referral to the RD for assessment and review. A Pressure Wound Weekly assessment, dated 1/4/24, indicated the stage 2 pressure ulcer was worsening and measured 2.5 cm length by 2 cm width by 0 cm depth. Nursing progress notes and the weight change alert lacked notification to the RD or the family regarding this significant weight loss. The clinical record lacked an assessment by the RD following this weight loss. The Interdisciplinary Team (IDT) notes between 1/4/24 and 1/6/24 lacked documentation to show that the resident's weight loss was reviewed or effective interventions were implemented to prevent further weight loss. A nursing progress note, dated 1/4/24 at 10:36 A.M., indicated the resident was lethargic and not eating, and the NP saw the resident and gave new orders to obtain labs for CBC (complete blood count), CMP (comprehensive metabolic panel), TSH (thyroid-stimulating hormone), and T4 (thyroxine) the next morning. A nursing progress note, dated 1/6/24 at 4:23 P.M., indicated the resident had vomited on her gown and was observed having shallow breathes with blood pressure at 60/40 mm/Hg (millimeters/Mercury) and a thready pulse of 26 beats per minute. The doctor was notified, and new orders were given to send the resident to [name of hospital] for treatment and evaluation. A hospital admission summary, dated [DATE], indicated Resident 46 was admitted to the hospital for treatment of dehydration, acute hypernatremia (high sodium), acute kidney injury, altered mental status, and sepsis. It was noted that the resident had a large decubitus ulcer (pressure ulcer) on the coccyx with eschar (dead tissue) that was unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). A physical exam also indicated the resident had pressure areas on the left shoulder, left ear, and right hip. The resident was admitted to the general medical floor to await transfer to another hospital and was started on IV (intravenous) Zosyn (an antibiotic medication) and given IV fluids for hydration. A second set of labs, dated 1/7/24, included lactic acid at 2.3, troponin at 231, sodium at 157, and albumin at 2.8. A laboratory report, dated 1/6/23, included, but was not limited to, the following blood level results: -Lactic Acid (a blood test to determine sepsis): 2.3 mmol/L (millimoles/Liter) therapeutic range: 0.5-2.0 mmol/L -Albumin (a blood test to determine liver and kidney function): 3.0 g/dL therapeutic range: 3.4-4.8 g/dL -Sodium (a blood test to determine fluid and electrolyte balance): 157 meQ/L therapeutic range: 136-145 meQ/L -Troponin (a blood test to determine heart damage): 203 ng/L (nanogram/Liter) therapeutic range: 0-13 ng/L A laboratory report, dated 1/7/23, included, but was not limited to, the following blood level results: -Lactic Acid (a blood test to determine sepsis): 2.3 mmol/L (millimoles/Liter) therapeutic range: 0.5-2.0 mmol/L -Albumin (a blood test to determine liver and kidney function): 2.8 g/dL therapeutic range: 3.4-4.8 g/dL -Sodium (a blood test to determine fluid and electrolyte balance): 157 meQ/L therapeutic range: 136-145 meQ/L -Troponin (a blood test to determine heart damage): 231 ng/L (nanogram/Liter) therapeutic range: 0-13 ng/L A hospital admission summary, date 1/7/24, indicated Resident 46 was transferred to another hospital and admitted to the ICU (intensive care unit) with diagnoses of severe sepsis with the source of decubitus wound, severe hypernatremia, notable dehydration, acute kidney injury, elevated troponin, and decubitus ulcer. A hospital Discharge summary, dated [DATE], indicated the resident's discharge diagnoses included, but were not limited to, sepsis due to decubitus ulcer, severe hypernatremia due to notable dehydration, decubitus ulcer present on admission, and severe malnutrition present on admission. The resident had a temporary weighted feeding tube placed on 1/11/24 for comfort feedings. The feeding tube was removed prior to discharge. The resident also had a surgical debridement of the ulcer on 1/8/24. The resident was discharged back to the facility and was admitted to hospice services on 1/13/24. A clinical readmission assessment, dated 1/13/23 at 12:31 P.M., indicated the resident had a stage 4 pressure ulcer on the coccyx and was taking nutrition and hydration orally. The clinical record lacked a Nutritional Risk Assessment on re-admission to the facility. re-admission physician orders related to nutrition included: Mechanical Soft diet, Mechanical Soft texture, Regular consistency for comfort feeding, dated 1/13/23. On 3/28/24 at 12:23 P.M., Resident 46 was observed sitting in a Broda chair (high backed wheelchair) in her room with a lunch tray on the bedside table in front of her. No bites had been taken of the meal. There were no staff present. 75% of the supplementary shake was gone. At 12:30 P.M., Registered Nurse (RN) 5 entered the room and asked if the resident was done. The resident indicated she was not done yet. RN 5 offered the resident the dessert cup and left the room. The resident picked up the dessert cup and attempted to dump it out onto her plate. The dessert did not come out and the resident put the cup aside. The resident picked up her plastic fork, stabbed the potatoes and salmon onto the fork, attempted to get the fork to her mouth, but was unable, and put the fork down. The resident closed her eyes. In an interview on 4/1/24 at 12:13 P.M., the DON indicated that residents were weighed weekly for four weeks upon admission and then monthly with vitals. Weight reports were generated and reviewed on Tuesdays following completion of weekly weight measurement to determine who had significant weight loss. If a resident had unplanned weight loss, they were referred to the dietician. For residents who were weighed monthly, weekly weights would be started if staff noticed the resident appeared to be losing weight. Families were notified if a resident experienced significant weight loss and those notifications were charted in the weight change note. Significant weight loss would be added to the care plan once it was identified. At that time, she indicated Resident 46 should have been triggered for significant weight loss upon her return from the hospital on [DATE] but didn't see where she was and was not sure how she got missed. She indicated that the weight on 10/9/23 was a data entry error and was intended to read 10/10/23. She indicated that staff in December consistently charted the resident had a poor appetite, but could not find notification to the provider, the RD, or the family. The resident liked to be left alone to eat and often refused meals, but sometimes ate better if staff encouraged her. The resident really liked her supplements, soda, orange juice, and was able to pick up cups on her own. The DON was unable to find a care plan related to the refusal of food or risk of malnutrition and weight loss, prior to 12/22/23. On 4/2/24 at 10:55 A.M., RN 5 indicated that Resident 46 needed setup assistance and encouragement to eat. She liked her shakes and used plastic utensils because they were lighter, and she did not have difficulty using them. She preferred to eat in her room. On 4/2/24 at 9:55 A.M., the DON provided a current Nutritional Assessment policy, undated, that indicated The Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition . The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, the following situations that place the resident at increased risk for impaired nutrition . Increased need for calories and/or protein - onset of exacerbation of diseases or conditions that result in a hypermetabolic state and an increased demand for calories and protein (e.g., .wounds)[sic] . A comprehensive nutritional assessment was requested on 4/2/24 at 9:57 A.M., and the Director of Nursing (DON) indicated a nutritional risk assessment was conducted on 9/15/2023, and no documentation could be provided to show further nutritional risk assessments were performed. On 4/2/24 at 12:28 P.M., the DON provided a current Weight Assessment and Intervention policy, undated, that indicated Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant weight unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant; great than 5% is severe . Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes . the resident's calorie, protein, and other nutrient needs compared with resident's current intake . Care planning for weight loss or impaired nutrition .includes the physician, nursing staff, the dietitian .and the resident's legal surrogate. 3.1-46(a)(1)