**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of R72's diagnoses from the Electronic Health Record (EHR) included dementia (progressive mental disorder characterized by failing memory, confusion) and vitamin deficiency (is the condition of a long-term lack of a vitamin). The Annual Minimum Data Set (MDS) dated [DATE], documented R72 had moderately impaired cognition. The resident had a total mood severity score of 00, which indicated no depression. R72 displayed no behaviors and the resident required maximum assistance with activities of daily living (ADLs), to include eating, oral care, toileting, dressing, footwear, and personal hygiene. The MDS indicated R72 had no weight loss. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 08/23/24, documented R72 required two staff assistance with most of her ADLs. R72 required one staff assistance with meals and noted R72's intake would vary. At times R72 was alert and able to eat some and at times it was difficult to wake R72 up enough to eat. The Nutritional Status CAA dated 08/19/24, documented R72 was at a high risk for weight loss due to being a new admission and the change in lifestyle. The CAA noted the facility would proceed to care plan for monitoring of nutritional status and for monitoring of weight. The Quarterly MDS dated 11/14/24, documented R72 had moderately impaired cognition. The resident had a total mood severity score of 00, which indicated no depression and no behaviors. R72 was totally dependent for all ADLs and had no weight loss. The Care Plan dated 08/06/24, revealed R72 required staff assistance to go to and from meals. The staff were to assist the resident as needed with eating. R72's morning routine included to get up around 07:00 AM, staff were to assist R72 with ADLs, encourage R72 with oral intake of food and fluids, and offer R72 snacks in between meals and at bedtime, as she was often hungry. Review of the Physician Orders documented R72 with a regular, no added salt diet, and finely chopped meats, dated 08/06/24. Review of weights in the EHR from 08/06/24 until 12/02/24 documented the following weights for R72: 08/06/24 at 03:39 PM weighed 93 pounds (lbs.). 08/19/24 (13 days since prior weight) at 01:09 PM weighed 94.8 lbs. 08/26/24 at 10:10 AM weighed 93.2 lbs. 09/02/24 at 03:43 PM weighed 89.8 lbs. 09/09/24 at 08:57 AM weighed 104 lbs. 09/10/24 at 09:15 AM weighed 103 lbs. 09/16/24 at 01:01 PM weighed 85.6 lbs. 09/23/24 at 10:46 AM weighed 94.6 lbs. 09/30/24 at 02:18 PM weighed 86.8 lbs. 10/14/24 (14 days since prior weight) at 03:39 PM weighed 86.6 lbs. 10/21/24 at 10:09 AM weighed 89.6 lbs. 10/28/24 at 03:30 PM weighed 85.4 lbs. 11/04/24 at 10:23 AM weighed 94.2 lbs. 11/18/24 (14 days since prior weight) at 11:19 AM weighed 92.6 lbs. 12/02/24 (14 days since prior weight) at 12:19 PM weighed 83.1 lbs A review of weights in EHR on 12/09/24 at 02:07 PM revealed on 08/06/2024, the resident weighed 93 lbs. On 12/02/24, the resident weighed 83 pounds which indicated a 10.75 % loss of weight. The 08/15/24 at 11:58 AM Dietary Progress Note revealed R72 received a regular diet, no added salt with finely chopped meats. R72 required assistance with meals. R72's weight was 93 pounds. The 12/01/24 at 12:17 PM Progress Note revealed staff reported R72 had a decrease in food intake. According to the report, R72 ate only jelly at lunch on 11/30/24. R72 slept all morning and was assisted up at lunchtime, where the resident consumed ice cream and a few bites of apples. During an observation on 12/09/24 at 07:53 AM and 09:07 AM, R72 remained in bed, and was not assisted to the dining room for breakfast. During an observation on 12/09/24 at 10:13 AM, R72 remained in bed, eyes open and she reported she was thirsty. During an observation on 12/09/24 at 01:35 PM, R72 sat in the dining room and Certified Nurse Aide (CNA) S assisted the resident with eating. During an observation on 12/10/24 at 07:48 AM, and 08:36 AM, R72 was in her bed that was positioned low to the floor, both of her legs were hanging over the edge of the bed with feet on the floor mat, both of her eyes were closed. During an observation on 12/10/24 at 09:06 AM, CNA S entered R72's room to assist her. During an observation on 12/10/24 at 11:05 AM, R72 was in dining room eating her breakfast independently. During an interview on 12/11/24 at 02:46 PM, Licensed Nurse (LN) U reported staff assisted the residents up when they were awake, and the residents were not made to get up for meals. However, if the resident was not up for breakfast and lunch, they would be assisted up for the supper meal. During an interview on 12/11/24 at 03:31 PM, Administrative Nurse B reported R72 was discussed at the 12/05/24 risk meeting about the weight loss and reported no progress note was written. Administrative Nurse B was not sure why no new orders were obtained for her weight loss of 10.75%. Administrative Nurse B reported that was a significant weight loss and that was a concern. The facility's policy Weight Policy and Protocol dated 02/2018 documented the following: All elders of the facility will be evaluated for weight stabilization for timely identification of weight loss and treatment. Significant weight loss would be defined as five percent loss in 30 days and 10 percent loss in 180 days. The provider, elder, and or surrogate decision maker would be notified of the significant weight loss and would be referred to the Registered Dietitian immediately for assessment and recommendations. The facility failed to initiate weight loss interventions for cognitively impaired R72, who had an identified weight loss of 10.75% in four months. This deficient practice had the potential to negatively affect the resident's physical well-being. The facility had a census of 73 residents, with 18 sampled, and four reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene for Resident (R)20, which placed R20 at risk for poor personal hygiene and related complications. The facility also failed to assist R72 to the dining area for meals or provide assistance with meals in her room, to help prevent the 10.75% weight loss over four months. Findings included: - Resident (R) 20's Electronic Health Record (EHR) included the following diagnoses: idiopathic peripheral neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet, caused by an unknown cause), pressure ulcer (any localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) to right plantar (walking surface) foot, venous hypertension (high blood pressure) with ulceration of right lower extremity, dementia (a progressive mental disorder characterized by failing memory, confusion), Methicillin-Resistant Staphylococcus Aureus (MRSA-a type of bacteria resistant to many antibiotics), excoriation (skin-picking [a mental disorder characterized by the repeated urge to pick at one's own skin]) disorder, anxiety (a mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), ataxia (inability to walk), and Wernicke's encephalopathy (presence of neurological symptoms related to depletion of thiamine [a B-vitamin] from excessive alcohol consumption). The Significant Change Minimum Data Set (MDS), dated 08/17/24, documented a Brief Interview of Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The assessment documented R20 was dependent on staff for assistance with lower body dressing and required substantial/maximal assistance with all other cares except eating which required setup or clean-up assistance and was frequently incontinent of bowel and bladder. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 08/17/24, documented the resident required assistance of two staff for most ADLs and R20 was no longer able to stand or ambulate (walk). The Quarterly MDS dated 11/07/24 documented a BIMS score of six, which indicated severe cognitive impairment. The assessment documented R20 was dependent on staff for all cares except eating, which required setup or clean-up assistance and was frequently incontinent of bowel and bladder. The 08/28/24 Care Plan documented R20 had impaired mobility due to recent hospitalization and included the following dated interventions: 03/06/23, R20 had incontinence if unable to make it to the bathroom on time and staff would utilize briefs to maintain personal hygiene and dignity. 08/08/24, R20 would be assisted to utilize bedpan and/or urinal or transfer to rolling shower/commode chair with two assist and split leg sling. 08/08/24, R20 would utilize a full lift with two staff assistance and would be mobile with a wheelchair. 08/09/24, R20 would utilize a geri-chair for positioning. The Electronic Health Records (EHR) Physician Orders lacked active orders specific to ADL cares. During an observation on 12/11/24 at 08:20 AM, R20 sat in a geri-recliner in the dining area at a table with the morning meal present. R20 called out to the staff in the area and stated he needed assistance to the bathroom so he could move his bowels which was unacknowledged by any staff present in the area. At 08:25 AM, R20 called out to the staff in the area stating he had soiled his brief, which was unacknowledged by any staff present in the area. At 08:35 AM, an unknown staff member assisted the resident from left leaning to an upright position and placed a pillow between R20 and the left arm rail of the geri-recliner. R20 stated to the staff that his buttocks hurt, and he needed to utilize the bathroom, and the unknown staff did not acknowledge the resident's statement. At 08:50 AM, R20 sat in a geri-recliner and cried out to alert staff. Administrative Staff A sat with resident and was told by R20 that he needed to go to the bathroom. Administrative Staff A then told an unknown staff member that R20 had stated that he needed to go to the bathroom. Observation on 12/11/24 from 08:50 AM to 09:46 AM, R20 sat in a geri-recliner and cried out to alert staff and staff responded by asking R20 if he was hungry and provided additional food. R20 continued to state that he needed to go to the bathroom but was unacknowledged and unassisted by staff. Observation on 12/11/24 at 09:46 AM, Certified Nurse Aide (CNA) E approached R20 when he cried out for assistance. R20 told CNA E that he needed to go to the bathroom. CNA E alerted CNA F for assistance and assisted R20 to his room with his geri-recliner which was one hour and 26 minutes after R20 was first observed stating that he needed to go to the bathroom and one hour and 21 minutes after R20 stated that he had soiled his brief. CNA E and CNA F utilized the mechanical lift to assist R20 from his geri-recliner to the bed and performed incontinence care and discovered that R20 had a large BM and the intragluteal cleft was reddened. CNA staff alerted Licensed Nurse (LN) G to perform skin assessment and observed moisture-associated skin damage (MASD - an area of inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva or mucous to both inguinal (crease where the leg bone is joined to the trunk) folds and genitals and inside the intergluteal cleft (area of the body between the buttocks). CNA E and CNA F performed incontinence care and applied a white barrier cream to the areas of MASD and placed a clean brief on R20. During an interview on 12/11/24 at 10:10 AM, LN G stated R20's groin and intergluteal fold redness appeared to be blanchable MASD. During an interview on 12/11/24 at 10:35 AM, LN G confirmed R20 was in the dining area attempting to alert staff for over an hour and stated that R20 should have been assisted to the restroom as quickly as possible once R20 alerted staff that he needed to go to the bathroom. LN G said prolonged exposure of the skin to urine and or stool would contribute to skin breakdown as well as a negative effect on R20's dignity as this was not providing appropriate ADL care to a resident who was dependent on staff for cares. During an interview on 12/11/24 at 11:15 AM, Administrative Nurse B stated the observations of R20 (documented above) was an unacceptable delay in providing ADL care to a resident who was dependent on staff for assistance. Administrative Nurse B stated the prolonged exposure of urine or stool would contribute to skin breakdown and would have a negative affect on R20's dignity. Administrative Nurse B expected staff to assist residents to the bathroom as soon as possible, when alerted to the need. The facility's Pressure Ulcer Treatment and Prevention Policy, dated 10/2013 documented that all residents would be assessed for risk of and have interventions initiated to prevent impaired skin integrity that included to reduce or minimize excessive moisture on the skin by implementation of a toileting program and utilizing measures to contain incontinence. The facility lacked a policy related to ADL care of dependent residents as requested on 12/12/24. The facility failed to ensure staff provided prompt ADL care to dependent R20, when R20 requested toileting, and the staff did not provide the requested toileting care for one hour and 26 minutes. This failure placed R20 at risk for poor personal hygiene and at risk for skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 73 residents, with 18 residents sampled, and four residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to prevent the development of pressure ulcers and failed to provide treatment to promote healing for two residents, Resident (R) 24 and R14, who both developed pressure ulcers while a resident at the facility. Findings included: - Resident (R) 24 's Electronic Health Record (EHR) revealed diagnoses of fractures (broken bones) to both upper arms, depression, Mantle cell lymphoma (a rare, aggressive type of blood cancer that affects the lymphatic system), abnormal weight loss, schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) spectrum disorder, and unspecified dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. The MDS noted R24 had no behaviors and was dependent on staff for all activities of daily living (ADL). The assessment documented she did not have a pressure ulcer, but also documented she had one stage I pressure ulcer. The assessment documented the resident had a surgical wound, a pressure reducing device for her bed, pressure ulcer/injury care, surgical wound care, a non-surgical dressing, and ointments or creams other than to feet. The Pressure Ulcer CAA dated 11/10/24 documented R24 had a stage one pressure area to her coccyx that healed and returned. She sat or laid on her bottom frequently and chose not to reposition. The CAA documented the skin was red and blanchable. The Cognitive Loss/Dementia CAA dated 11/10/24 documented R24 had a BIMS score of 15 which indicated no cognitive impairment. She required two or three staff for assistance and two staff to assist her with bed mobility. She was not able to walk and required two to three staff to assist her with transfers. She was incontinent of bowel and had a foley catheter. She exhibited signs and symptoms of pain with movement due to a left wrist and left humerus fracture and a right humerus fracture. The 12/09/24 Care Plan documented the following dated interventions: 12/17/21, staff were to provide incontinence care after incontinence episodes and use moisture barrier and incontinence pads. The staff were to use heel protectors on the resident. The staff were to report any signs of skin breakdown like sore, tender, red or broken areas; avoid shearing skin during repositioning, transfer, and turning; and keep boney prominences cushioned with pillows, foam wedges, etc. 07/07/22, the care plan documented the resident sat for long periods of time in her recliner and refused to be repositioned. The staff were to ensure memory foam was on R24's bed. 11/18/24, staff would add padding to the resident's chair or the wheelchair as needed when the resident was seated and use a gel cushion as needed. The resident was unable to fully reposition due to fractures on both arms and unable to shift her lower body, and she refused at times. R24 was to be up in her chair. The Physician Order dated 10/24/23, included a weekly skin assessment, vital signs, and charting once a week. The Physician Orders reviewed for 10/28/24 to 12/09/24 lacked any treatments for skin issues or pressure area. The Final Discharge Summary from the hospital dated 10/28/24 documented Follow wound care instructions per Physician CC]. The Braden with Skin Risk Assessment dated 10/28/24 revealed the resident required the application of nonsurgical dressings (with or without topical medications) other than to feet, applications of ointments/medications other than to feet, and noted no current pressure ulcers. It also documented a pressure risk score of 14, which indicated a moderate risk for pressure ulcers. Review of the Progress Notes dated 10/28/24 at 06:29 PM, documented a dressing on her right shoulder with redness to right forearm. She wore slings on both arms for support. Her buttocks had minimal redness and she had a 2 centimeters (cm) by 1 cm sore on her right upper mid back with a foam dressing. Review of the Progress Notes dated 11/01/24 at 05:27 PM, the dressing on R24's right mid back was changed with no drainage. The wound was cleansed, and a foam wound dressing was applied. The Skin Assessment on 11/04/24 documented an open area on the resident's back towards the right side, an incision on her right shoulder with a dressing in place, a left wrist incision with a dressing and wrapped with ace wrap. The assessment documented no ulcers. The Skin Assessment on 11/11/24 documented a reddened non- blanchable area to her lower back with cream applied, and a dressing to her right shoulder. Review of the Progress Notes dated 11/15/24 at 01:42 PM, documented Steri-strips (adhesive wound closures) were in place on the right shoulder and left wrist incision sites and upper left arm. Redness was observed in her mid-back and a foam dressing was applied to relieve pressure on her back. A 1.5 cm by 3.5 cm stage 1 pressure injury was found on her right gluteus maximus. Staff were unable to apply a dressing. The resident had severe skin damage in the vaginal area and inner buttocks, redness and slight bleeding with barrier cream applied. The resident's provider was aware of resident's condition. The Skin Assessment on 11/18/24 documented the resident had no ulcers, documents multiple incisions. The Skin Assessment on 11/25/24 documented the resident had skin tears on the right shoulder and left wrist. The resident had a 1 cm in width and 1.5 cm in length, pressure injury, stage I observed to the mid-back on the side of the spine. with Xeroform (occlusive wound dressing) dressing applied and covered with a foam dressing. Review of the Progress Notes dated 11/25/24 at 10:55 AM documented an excoriation to the resident's buttock with zinc cream applied. Staff observed a stage 1, 1 cm by 1.5 cm pressure injury on the resident's mid-back (spinal cord). Staff used Xeroform and covered the area with a foam dressing. The note documented the resident would be seen by the provider on 12/12/24 for further evaluation. Review of the Progress Notes dated 11/30/24 at 09:43 AM revealed the wound to the resident's mid back measured 0.5 cm in width and 1 cm in length. Redness was observed surrounding the wound. The area was cleansed with NS and patted dry, followed by the application of xeroform, then the wound was covered with a foam dressing. The Skin Assessment on 12/09/24 documented a 1 cm by 2 cm open lesion to the resident's mid back, with Xeroform dressing applied and covered with a non-adhesive dressing and noted no ulcers. During an observation on 12/10/24 at 08:49 AM, Licensed Nurse (LN) AA showed the surveyor the open area to R24's back, adjacent to her spine. The area had white debris covering about 30 percent of the wound bed, and redness around the wound. During an interview with LN AA at the same time, LN AA acknowledged it appeared to be slough (dead tissue, usually cream or yellow in color) in the wound bed and said it was a pressure ulcer. LN AA reported the nurse changed the dressing about every three days and said it was improving. During an interview on 12/11/24 at 09:41AM, Administrative Nurse C reported the facility had no wound nurse, that the household nurse would assess skin concerns weekly, and the physician would prescribe what treatment is to be completed. Additionally, she reported that if a wound treatment was not effective, the resident would receive and order to be assessed at the wound center. Administrative Nurse C could not provide a time frame on how long a resident would have to wait be assessed at the wound center. She reported that would be determined by the physician. Administrative Nurse C reported that when a resident was noted to have a new open area the household nurse would update Administrative Nurse B and physician. She also reported that the facility had standing orders. The Standing Orders policy was requested. During an interview on 12/11/24 at 01:50 PM, LN BB confirmed the staff received no wound care training. LN BB stated the nurse inspected the resident's skin when the resident was in the shower. LN BB stated the pressure ulcer on R24's back was there on reentry. LN BB said the staff had a book to show the (pressure ulcer) stages to assist with documentation. LN BB said it was a stage 3, but now had improved. LN BB stated they changed the dressing whenever it needed it and said it usually came off daily. During an interview on 12/11/24 at 02:35 PM, LN BB confirmed there were no treatment orders or dressing orders for any of the R24's wounds. During an interview on 12/12/24 at 08:51 AM, Administrative Nurse B confirmed there was not a wound nurse. Also confirmed the information provided in the interview on 12/11/24 at 09:41AM with Administrative Nurse C. Administrative Nurse B reported that the nurses really could use updated training on wound care and prevention and had been looking at a program from another company for education. The Pressure Ulcer Treatment and Prevention Policy dated 10/2013 documented that the nurse will determine whether the ulcer is pressure related or non-pressure related and determine the stage. A description of the pressure ulcer including location, stage, dimensions, depth, the description of the wound base (granulation, necrotic tissue, eschar, slough, epithelial), drainage (amount, color, and odor), wound edges, odor, pain, and progress. Treatment of any new pressure ulcer will begin immediately upon discovery, document in the nurses' notes, and notify the physician and residents representative. The facility failed to document and place interventions to prevent worsening and address pressure injuries for R24, who developed a preventable, stage 3 pressure injury. - Resident (R) 14 's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and muscle weakness. The 11/12/24 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident had a total mood severity score of 00, which indicated no depression and R14 had no behaviors. R14 required total assistance with activities of daily living (ADLs), which included bed mobility, toileting, dressing, transferring, personal hygiene, and bathing. R14 required set-up for eating. He was occasionally incontinent of urine and frequently incontinent of bowel. The MDS identified R14 as at risk for pressure ulcers. No pressure related skin issues were identified on the assessment. R14 had a moisture-associated skin damage (MASD - caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration) and he had a pressure reducing device for his chair and bed. The 11/18/24 Pressure Ulcer/Injury Care Area Assessment (CAA) stated R14 was occasionally incontinent of bowel and bladder. He had a MASD upon admission and treatment was ongoing. He was not able to use briefs related to his skin breaks down with possibly an allergy to briefs. He used a disposable absorbent pad should he have an incontinent episode. Review of the resident's Care Plan on 12/09/24 revealed the following interventions: 10/31/24 - Staff were to reposition R14 frequently, R14 may choose not to reposition as times. Staff to cue and encourage R14 to reposition frequently to decrease pressure to any one area. Staff to provide education on the importance of this as needed. Staff to avoid shearing (the separation of skin layers caused by friction or trauma) skin during positioning and transferring. Staff to conduct a systematic skin inspection weekly. Staff to provide an alternate flow air mattress on the bed. Staff to avoid bony prominences from direct contact with one another, with pillows, foam wedges, and/or sheepskin. Staff instructed to keep the resident's skin clean and dry, as possible. Staff instructed to keep linens clean, dry, and wrinkle free, as much as possible. Staff instructed to keep head of the bed at the lowest degree of elevation as possible. Staff instructed to reduce friction injuries by using lubricants, protective films, dressings, and/or padding as needed. Staff instructed to report any signs of skin breakdown like sore, tender, red, or broken skin areas. Review of the Physician Orders documented the following: Weekly skin assessment once a day on Friday, date ordered 11/03/2024. Triamcinolone acetonide 0.1 % ointment (is used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions) apply topically twice a day, to affected areas between flares when rash is fully resolved to prevent outbreaks, date ordered 11/07/24. Review of weights in the EHR from 10/30/24 until 12/02/24 documented the following weights for R14: 10/30/24 at 02:53 PM weighed 285 pounds (lbs.). 11/04/24 at 02:12 PM weighed 289.9 lbs. 12/02/24 at 01:19 PM weighed 334.8 lbs. Review of the Full Clinical Observation dated 10/30/24 at 05:22 PM, documented R14 had redness of the peri area noted. The 11/02/24 at 12:00 PM Progress Note revealed R14 requested to take a whirlpool bath and was unable to have that completed due his size. R14 had a skin rash with multiple open sores noted on the right buttock. The 11/03/24 at 05:20 PM Progress Note revealed R14 chose to stay in bed throughout the day. R14 was reluctant to reposition at first. After education R14 allowed staff to assist with repositioning. The 11/04/24 at 12:00 PM Progress Note revealed R14 had a large area of shearing noted to the right buttock, which measured approximately ten centimeters by five centimeters. A + D ointment (skin protectant ointment) applied mixed with Collagen (a protein that is used in wound care to help the body heal by stimulating new tissue growth) and covered with a large foam dressing. Review of the Weekly Skin Assessment dated 11/08/24 at 11:34 AM, documented R14 had redness to the bilateral buttocks. No open areas were noted, and staff applied lotion. The 11/11/24 at 06:27 AM Progress Note revealed a Certified Nurse Aide reported R14 refused to be repositioned even though R14 was aware of the presence of multiple open areas and erythema (redness or inflammation of the skin) on his buttocks. Review of the Weekly Skin Assessment dated 11/15/24 at 04:31 PM, documented R14 had erythema noted to buttocks, open area to right buttock, and staff applied an ointment. Review of the Weekly Skin Assessment dated 11/29/24 at 11:37 AM (14 days since the prior skin assessment), documented the resident had redness to the buttocks, the right buttock had a dime sized open lesion, and staff applied lotion after his shower. Review of the Weekly Skin Assessment dated 12/06/24 at 11:22 AM, documented no redness, staff applied Opti foam (a brand of foam wound dressings used to treat a variety of wounds, including pressure injuries, skin tears, and abrasions) to the right buttock, and applied lotion. Review of the Point of Care task charting from 10/30/24 through 12/09/24 lacked documentation of R14 refusing repositioning. During an observation on 12/09/24 at 08:26 AM, R14's air loss mattress was flat under R14 on his bed. The air mattress was plugged in, the green light was on, and the dial setting was set at four. R14 reported the air mattress had been flat since 12/08/24. During an observation on 12/10/24 at 07:50 AM, R14's air mattress was soft, the setting was set at four, and the green light was on. R14 reported he did not say anything to the staff about his mattress and he commented I would think they could see it was so soft and it was really not working from the waist down. During an observation on 12/10/24 at 08:46 AM, Certified Nurse Aide (CNA) S applied Triamcinolone acetonide 0.1 % ointment (used to treat skin conditions) and Zinc oxide cream (moisture barrier cream) mixed in her gloved hand to R14's buttocks which was very red in color, with several circular and irregular shaped superficial open areas noted on right buttocks, with base of wounds red in color and a small amount of sanguineous (bloody drainage) drainage noted from open areas. CNA S reported that R14's buttocks looked worse than the week before. Licensed Nurse (LN) T was present in R14's room at the time of observation and reported the household nurse was to a complete a weekly skin assessment, which included measurements and further stated the skin assessment had not been completed by her and she stated she did not have time to measure the open areas. Additionally, LN T reported the facility did not have a wound nurse. LN T applied an ABD pad (large pad to absorb drainage) to the resident's right buttock area after care was provided. During an interview on 12/10/24 at 09:00 AM, Certified Medication Aide (CMA) V reported that R14's air mattress was soft and did not know what the setting of four was on the air pump. She also did not know why R14's air pump setting had a X marked in black marker between numbers five and seven. CNA S reported R14 received a new air mattress in the last week and did not know what the setting numbers on the air pump indicated. CMA V reported that Restorative Aide W was the staff member that decided if an air mattress was used and would be the staff member to ask about the number settings. CNA S reported Maintenance Staff N was aware on 12/09/24 the air mattress was not working per LN T. During an interview on 12/10/24 at 09:33 AM, CNA Restorative Aide W reported the air mattress was implemented on admission, and Maintenance Staff N knew on 12/09/24 that R14's air mattress had a problem. CNA W reported she did not go look at R14's air mattress on 12/09/24. CNA W reported the facility did have back up air mattresses and pumps in storage, but it usually would take a day to have the mattress taken care of as nursing staff do not replace equipment. CNA W reported she would check with a maintenance staff member today. CNA W reported the setting on the dial for air mattress pump was generally set between five and seven for comfort and was not based on weight. During an interview on 12/10/24 at 11:25 AM, LN T reported R14's air mattress on his bed did not have a date when it was applied and reported that R14's air mattress would get firmer when R14 was not in bed. She also reported maintenance was updated on 12/09/24 that the air mattress was soft. LN T further reported maintenance was updated verbally, or a note was placed on their door or desk in the maintenance office, when there was a maintenance concern. During an interview on 12/10/24 at 11:35 AM, Maintenance Staff N reported air mattresses purchased for the facility had a weight limit of 250 pounds and reported that R14 weighed more than the weight limit. Maintenance Staff N reported that he changed out the air mattress last week and did know yesterday that R14's air mattress was not functioning properly. During an interview on 12/11/24 at 09:41AM, Administrative Nurse C reported the facility had no wound nurse, the household nurse would assess skin concerns weekly, and the physician would prescribe treatment for the wounds. Administrative Nurse C reported that if a wound treatment was not effective, the facility would obtain an order for the resident to be assessed at the wound center. Administrative Nurse C could not provide a time frame on how long a resident would have to wait be assessed at the wound center and stated that would be determined by the physician. Administrative Nurse C reported when a resident was noted to have a new open area the household nurse would update Administrative Nurse B and the physician. She also reported that the facility had standing orders for wound treatments. During an interview on 12/11/24 at 02:31 PM, LN U reported he did not measure the redness on R14's buttocks when he admitted to the facility, and he had only measured the right buttock open area one time on 11/04/24. LN U reported there was no wound nurse and could not recall if the provider was updated. LN U reported he used the standing orders for treatment to the area. LN U reported he would not stage the area on the right buttock, he did not know the air mattresses had a weight limit, and the settings on the air pump were set for residents' weight. During an interview on 12/11/24 at 03:31 PM, Administrative Nurse B reported R14's air mattress was a concern. Additionally, she reported that no one knew that the air mattresses had a weight limit or what the numbers on the setting of air pump were for. Administrative Nurse B reported that CNA W would receive direction from Administrative Nurse C or herself to apply an air mattress to resident's bed. She expected the household nurse to complete a thorough skin assessment weekly, which included measurements. Administrative Nurse B reported R14 should have had more consistent documentation for his refusal of care and could not state what the CNA's should be charting in point of care. Administrative Nurse B reported the nurses really could use updated training on wound care and prevention and had been looking at a program from another company. Review of the facility's undated Operating Manual Air Pro Elite Alternating Pressure Pad and Pump documented the following: Pump setting chart patient weight lbs. 85-140 lbs. setting to be set at one to two. 120 - 165 lbs. setting to be set at two to four. 150 - 195 lbs. setting to be set at three to five. 175 - 205 lbs. setting to be set at four to seven. 200 - 250 lbs. setting to be set at five to eight. Review of the undated Air - Pro mattress specifications provided by facility documented the air mattress purchased had a weight limit of 250 lbs. Review of the facility's Pressure Ulcer Treatment and Prevention dated 10/2013 documented the following: All residents will be assessed for risk for developing pressure ulcers and interventions to prevent impaired skin integrity. A resident who develops pressure ulcers shall receive appropriate monitoring and treatments to promote healing. When assessment of the ulcer is completed, staff are to determine the stage of the ulcer, document a description of the ulcer (which should include measurements, drainage, wound edges, pain) and document progress of ulcers. The facility failed to place an appropriate weight-based intervention to prevent pressure injuries for R14, who developed multiple preventable, facility acquired, stage two (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure injuries. Additionally, the facility failed to monitor, measure, and assesses R14's skin consistently. This placed the resident at risk to worsen his current pressure ulcers and/or develop more skin issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 73 residents with 18 sampled. Based on observation, interview, and record review, the facility failed to initiate weight loss interventions for cognitively impaired Resident (R) 72, who had an identified weight loss of 10.75% in four months. This deficient practice had the potential to negatively affect the resident's physical well-being. Findings include: - Review of R72's diagnoses from the Electronic Health Record (EHR) included dementia (progressive mental disorder characterized by failing memory, confusion) and vitamin deficiency (is the condition of a long-term lack of a vitamin). The Annual Minimum Data Set (MDS) dated [DATE], documented R72 had moderately impaired cognition. The resident had a total mood severity score of 00, which indicated no depression. R72 displayed no behaviors and the resident required maximum assistance with activities of daily living (ADLs), to include eating, oral care, toileting, dressing, footwear, and personal hygiene. The MDS indicated R72 had no weight loss. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 08/23/24, documented R72 required two staff assistance with most of her ADLs. R72 required one staff assistance with meals and noted R72's intake would vary; at times she was alert and able to eat some and at times it was difficult to wake R72 up enough to eat. The Nutritional Status CAA dated 08/19/24, documented R72 was at a high risk for weight loss due to being a new admission and the change in lifestyle. The CAA noted it would proceed to care plan for monitoring of nutritional status and for monitoring of weight. The Quarterly MDS dated 11/14/24, documented R72 had moderately impaired cognition. The resident had a total mood severity score of 00, which indicated no depression and no behaviors. R72 was totally dependent for all ADLs and had no weight loss. The Care Plan dated 08/06/24, revealed R72 required staff assistance to go to and from meals. The staff were to assist the resident as needed with eating. R72's morning routine included to get up around 07:00 AM, staff were to assist R72 with ADLs, encourage R72 with oral intake of food and fluids, and offer R72 snacks in between meals and at bedtime, as she was often hungry. The staff were to obtain weekly weights for R72 and notify the provider and family of significant weight changes. Review of the Physician Orders documented R72 with a regular, no added salt diet, with finely chopped meats, dated 08/06/24. Review of weights in the EHR from 08/06/24 until 12/02/24 documented the following weights for R72: 08/06/24 at 03:39 PM weighed 93 pounds (lbs.). 08/19/24 (13 days since prior weight) at 01:09 PM weighed 94.8 lbs. 08/26/24 at 10:10 AM weighed 93.2 lbs. 09/02/24 at 03:43 PM weighed 89.8 lbs. 09/09/24 at 08:57 AM weighed 104 lbs. 09/10/24 at 09:15 AM weighed 103 lbs. 09/16/24 at 01:01 PM weighed 85.6 lbs. 09/23/24 at 10:46 AM weighed 94.6 lbs. 09/30/24 at 02:18 PM weighed 86.8 lbs. 10/14/24 (14 days since prior weight) at 03:39 PM weighed 86.6 lbs. 10/21/24 at 10:09 AM weighed 89.6 lbs. 10/28/24 at 03:30 PM weighed 85.4 lbs. 11/04/24 at 10:23 AM weighed 94.2 lbs. 11/18/24 (14 days since prior weight) at 11:19 AM weighed 92.6 lbs. 12/02/24 (14 days since prior weight) at 12:19 PM weighed 83.1 lbs During a review of weights in EHR on 12/09/24 at 02:07 PM. On 08/06/2024, the resident weighed 93 lbs. On 12/02/2024, the resident weighed 83 pounds which is a -10.75 % Loss. The 08/15/24 at 11:58 AM Dietary Progress Note revealed R72 received a regular diet, no added salt with finely chopped meats. R72 required assistance with meals. R72's weight was 93 pounds. The 11/21/24 at 12:07 PM Dietary Progress Note revealed R72 received a regular diet, no added salt with finely chopped meats. R72 required assistance with meals. R72's weight was 92.6 pounds. R72's weight history had fluctuated since admission on [DATE], with a weight range between 84-94 pounds. The 12/01/24 at 12:17 PM Progress Note revealed staff reported R72 had a decrease in food intake. According to the report, R72 ate only jelly at lunch on 11/30/24. R72 slept all morning and was assisted up at lunchtime, where the resident consumed ice cream and a few bites of apples. During an observation on 12/09/24 at 07:53 AM and 09:07 AM, R72 remained in bed, and was not assisted to the dining room for breakfast. During an observation on 12/09/24 at 10:13 AM, R72 remained in bed, eyes open and she reported she was thirsty. During an observation on 12/09/24 at 01:35 PM, R72 sat in the dining room and Certified Nurse Aide (CNA) S assisted the resident with eating. During an observation on 12/10/24 at 09:06 AM, CNA S entered R72's room to assist her. During an observation on 12/10/24 at 11:05 AM, R72 was in dining room eating her breakfast independently. During an interview on 12/11/24 at 10:29 AM, Registered Dietician Y reported that weight loss for all residents was addressed at the weekly risk meeting. Registered Dietician Y would receive the information from Administrative Nurse C. Registered Dietician Y reported that R72's weight loss was discussed on 12/05/24 and reported he was not sure if the weight loss was a true weight loss, and this was his first day back since that meeting. He reported that the facility had a weight loss protocol and R72 was not started on any dietary interventions after that meeting and she would need to start on supplements due to the 10 percent weight loss noted in four months. During an interview on 12/11/24 at 02:46 PM, Licensed Nurse (LN) U reported staff assisted the residents up when they were awake, and the residents were not made to get up for meals. However, if the resident was not up for breakfast and lunch, they would be assisted up for the supper meal. LN U reported if there was a three-pound weight loss or weight gain noted when resident was weighed, the resident would have to be re-weighed. During an interview on 12/11/24 at 03:31 PM, Administrative Nurse B reported that R72 was discussed at the 12/05/24 risk meeting about the weight loss and reported no progress note was written. Administrative Nurse B was not sure why no new orders were obtained for her weight loss of 10.75%. Administrative Nurse B reported that was a significant weight loss and that was a concern. During an observation on 12/12/24 at 08:20 AM, Certified Medication Aide (CMA) X zeroed the wheelchair scale and weighed R72's empty wheelchair with the chair cushion and foot pedals attached. CMA X noted the weight of 44.6 lbs. During an observation on 12/12/24 at 08:40 AM, CMA X weighed R72 on the wheelchair scale, and noted a weight of 128.8 lbs. CMA X completed the math and reported R72 weighed 84 pounds. CMA X reported that the nurse on the unit was updated with all the weights that were completed. During an interview on 12/12/24 at 10:16 AM, Administrative Nurse C reported that residents' weights were reviewed weekly at the risk meeting. She reported if the CNA observed a change in the weight, the CNA would update the household nurse, and the household nurse would update Administrative Nurse B. Administrative Nurse C confirmed that R72's weight was 84 pounds and the EHR lacked documentation of progress notes and orders for supplements for weight loss that had occurred. Administrative Nurse C reported that R72 was discussed 12/05/24 risk meeting. The facility's policy Weight Policy and Protocol dated 02/2018 documented the following: All elders of the facility will be evaluated for weight stabilization for timely identification of weight loss and treatment. Significant weight loss would be defined as five percent loss in 30 days and 10 percent loss in 180 days. The provider, elder, and or surrogate decision maker would be notified of the significant weight loss and would be referred to the Registered Dietitian immediately for assessment and recommendations. The facility failed to initiate weight loss interventions for cognitively impaired R72, who had an identified weight loss of 10.75% in four months. This deficient practice had the potential to negatively affect the resident's physical well-being.