**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 68 residents, with five sampled, including three 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 observation, interview, and record review, the facility failed to ensure Resident (R)1, who was totally dependent on staff for cares, had been repositioned timely and his brief changed timely after bowel and/or bladder incontinent episodes. Furthermore, the facility failed to monitor R1's skin weekly, conduct weekly wound assessments, and provide wound treatments as ordered. R1 developed an unstageable pressure ulcer (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) on 05/20/24. The facility did not identify the wound until 06/03/24 and failed to assess the wound until 06/05/24. R1's wound progressed to a stage four pressure ulcer (a deep pressure wound that reaches the muscles, ligaments, or even bone). R1 developed additional skin issues to his left outer ankle, left ear, upper right abdomen, and second and third digit of his right hand. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), Down's Syndrome (chromosomal abnormality characterized by varying degrees of mental retardation and multiple defects), and muscle weakness. The Significant Change Minimum Data Set (MDS) dated [DATE], assessed R1 with a short-term and long-term memory loss and impaired decision making. He did not reject care and was dependent on staff for bed mobility, transfers, and toileting, and required a wheelchair for mobility. R1 was always incontinent of bowel and bladder and at risk for developing pressure ulcers/injuries. He had two Stage 2 pressure areas (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) that were not present on admission and/or reentry. R1 required a pressure reducing device for his chair and bed and was not on a turning/repositioning program. He received nutrition or hydration interventions to manage skin problems, application of nonsurgical dressings and ointments/medications other than to his feet. R1 received hospice services. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/12/24, revealed R1 had a memory problem making his decisions regarding tasks of daily life severely impaired. The Urinary Incontinence and Indwelling Catheter CAA dated 01/12/24, revealed R1 was incontinent of bowel and bladder, wore incontinent products, and was dependent on staff for all aspects of toileting needs. The Pressure Ulcer/Injury CAA dated 01/12/24, revealed R1 was at risk for skin breakdown and had two stage two pressure ulcers to his left hip. R1 was dependent on staff for all aspects of bed mobility and had a pressure relieving mattress on his bed and a pressure relieving cushion to his chair. R1 required pressure relieving boots while in bed. The Licensed Nurse (LN) was to do a weekly/PRN (as needed) skin assessment and certified staff were to observe skin daily with cares. The staff were to report any new skin areas to the primary care provider for review. R1 recently changed hospice providers and was back on hospice services. The Quarterly MDS dated 07/11/24, for R1 revealed no change to his memory recall or decision making. R1 did not reject care and continued to be dependent on staff for bed mobility, transfers, toileting, and required a wheelchair for mobility, and had no range of motion impairments, and was frequently incontinent of bladder and always incontinent of bowel. R1 continued to be at risk for developing pressure ulcers/injuries and had one stage two pressure area which was not present on admission/reentry, and one unstageable pressure ulcer (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) which was not present on admission/reentry. R1 required a pressure reducing device for his chair and bed and was not on a turning/repositioning program. He received nutrition or hydration interventions to manage skin problems, required pressure ulcer/injury care, and application of nonsurgical dressings and ointments/medications other than to feet. R1 continued to receive hospice care. The Care Plan dated 07/25/24 for R1 revealed the following: On 11/21/23 the plan revealed R1 had a potential for impaired skin integrity and was at risk for pressure ulcers. The staff were to utilize pressure reduction equipment, turn and reposition R1, used a cushion in his wheelchair/recliner, specialty mattress to the bed and utilized a ROHO cushion (pressure relief cushion that is made of soft, flexible air cells). Staff were to monitor and document location, size and treatment of skin injury and report any abnormalities, failure to heal, signs and symptoms of infection, maceration (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine or feces), to the physician as indicated. The plan further revealed R1 was incontinent of bowel and a risk for impaired skin, rashes and irritation to the peri-area. The staff were to check R1 every two hours and assist with toileting as needed and provide peri-care immediately after incontinent episodes. R1 was totally dependent on staff for bed mobility, required a mechanical lift and two staff to assist with all transfers. R1 required staff to check and change his brief and provide peri-care with every incontinent episode as he allowed. An update on 06/17/24, revealed R1 had a pressure ulcer, stage two, to his right rear iliac crest (the curved area at the top of the hip bone) and left outer ankle related to his diagnosis of terminal illness. The goal was for his pressure ulcer to heal without complications through the end of the next review date. The Registered Dietician was to consult with any ongoing skin concerns and the staff were to encourage good nutrition/hydration to promote healing and follow the dietary interventions as recommended/ordered. The staff were to perform weekly skin/treatment documentation in accordance to the wound nurse assessment and plan of care recommended, and R1 was to be seen by the wound clinic as ordered. An update on 06/19/24, revealed R1 had an acute wound infection and staff were to administer antibiotics as ordered, treatments as ordered, and encourage dietary/fluid intake. The Orders tab included an order dated 04/30/24, instructing staff to assess R1's skin assessed weekly and obtain a set of vital signs for R1, on the day shift on Monday. The staff were to chart the assessment under the weekly skin evaluation. The hospice Skilled Nursing Visit Note dated 05/17/24 at 09:15 AM, revealed Consultant II documented there was a urine odor and R1's brief, gown, bed pad, and linens were all saturated with urine. R1 had a concerning area to his buttocks and a foam dressing applied to protect the skin and prevent breakdown. The visit note included Consultant Staff II communicated with Administrative Nurse D and CNA's regarding the condition of R1. The Assessments tab for R1 lacked a Weekly Nursing Skin Assessment on 05/20/24, the scheduled date the staff were to complete it. The hospice Skilled Nursing Visit Note dated 05/20/24 at 11:10 AM by Consultant Staff II, revealed R1 had an unstageable pressure ulcer to his upper medial buttocks. The wound bed was 50 percent (%) black, 15% yellow, and 35% red in color and measured 4.5 centimeters (cm) length, by 2.0 cm width, by 0.2 cm deep with a moderate amount of serosanguinous (semi-thick blood-tinged drainage) drainage. The note revealed the wound was new and appeared to be unstageable, the physician consulted and advised a treatment, and Consultant Staff II provided the care per orders. Consultant Staff II communicated with the facility nurse (did not specify name) and R1's durable power of attorney regarding his condition. The Progress Notes dated 05/21/24 at 03:27 PM, for R1 revealed a nutrition/dietary note by Dietary Staff BB. The note revealed per Administrative Nurse D, R1's skin had healed and currently intact, no order changes. The facility failed to notify Dietary Staff BB of R1's pressure area. The Weekly Nursing Skin Assessment dated 05/27/24, documented R1 had no alterations in skin integrity. (This was seven days after the hospice identified an unstageable wound to R1's upper medial buttocks.) The hospice Skilled Nursing Visit Note dated 05/27/24, revealed R1 lacked a dressing to his wound and Consultant Staff II provided wound care as ordered and communicated with the facility staff nurse (name not specified) regarding his condition. The hospice Skilled Nursing Visit Note dated 05/30/24, revealed Consultant Staff II provided wound care as ordered to R1 and coordinated care with LN G. LN G discussed her frustration with Consultant Staff II about staff not communicating if R1's dressing had become dislodged and left open to air. Consultant Staff II provided education to facility staff to frequently reposition and provide peri-care. Consultant Staff II confirmed with LN G that the facility nurse would replace R1's dressing if it should be dislodged or the facility would call hospice to take care of it. The Weekly Nursing Skin Assessment dated 06/03/24, revealed R1 had an unstageable pressure area to right iliac crest (rear) and Administrative Nurse D and hospice were notified. The assessment lacked measurements and characteristics of the pressure area. The hospice Aide Visit Note dated 06/03/24, revealed the aide notified Consultant Staff II that R1's entire brief, outfit, linens, and mattress were soaked with urine when the aide arrived at 10:11 AM. The hospice Skilled Nursing Visit Note dated 06/03/24, revealed the upper medial buttocks wound was 10% red, 80% yellow, and 10% black, measured 3.5 cm by 2.5 cm by 0.1 cm, and the wound had declined in appearance since the last visit. Consultant Nurse II continued to educate staff (lacked names) to frequently reposition R1 and provide peri-care to prevent further skin breakdown and improve skin integrity. The Treatment Administration Record (TAR) dated June 2024 included a treatment order for R1's lower medial back region on 06/04/24. The facility failed to have a treatment order in place for R1's pressure area until 15 days after onset of the area on 05/20/24. The Weekly Pressure Wound Assessment dated 06/05/24 (two days after the facility identified the pressure area, however hospice had identified on 05/20/24), revealed R1 had an unstageable pressure ulcer to his right iliac crest (rear) which measured 4.0 cm by 2.0 cm by 0.1 cm, had a moderate amount of serosanguineous and purulent drainage with slight odor. The wound was covered with 100% slough (dead tissue, usually cream or yellow in color), the surrounding skin macerated (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, or feces), the wound had deteriorated, and lacked an onset date. The facility failed to document wound characteristics until two days after they had identified the area. The hospice Skilled Nursing Visit Note dated 06/06/24, revealed R1's wound had 85% eschar and 15% slough, with a large amount on sanguineous (bloody) drainage with mild odor. R1 was lying on his back upon arrival at 10:40 AM, saturated with urine, and his wound to the lower medial back significantly declined. The staff had been educated extensively by Consultant Staff II on importance of changing and repositioning R1 every two hours being careful to offload the wound, but unsure of how well this is being carried out. Consultant Staff II consulted with the physician and sent a picture of the wound progression, who then changed the treatment orders to the wound. The hospice Chaplain Visit Note dated 06/07/24 revealed Consultant Staff JJ spoke with members of the hospice team [specified names] about the issue of neglect from the facility. The hospice Medical Social Worker Note dated 06/07/24, revealed R1's durable power of attorney (DPOA) posted several signs in R1's room reminding staff to reposition him, change any wet briefs, and offer him drinks when they were in his room. R1's DPOA noticed a new open area to his outer left ankle, photographed the area, and forwarded it to a hospice nurse for review and follow up. The Weekly Nursing Skin Assessment dated 06/10/24, revealed R1 had a pressure area to his right iliac crest measuring 5.5 cm by 3.5 cm. The assessment lacked documentation of any skin issues to R1's left outer ankle, which R1's DPOA had discovered three days prior. The Progress Note dated 06/11/24 at 02:06 PM, by Administrative Nurse D revealed there was a meeting held on 06/11/24 regarding care concerns. Hospice voiced concerns with him being changed on a regular basis and laying on his back too often. R1 had a current wound on the rear ischium (part of the hip bone or over the hip bone area). The facility assured hospice that R1 was on a current every two-hour repositioning schedule and on an air mattress. New hourly checks to be completed for R1 to prevent him from becoming soiled or saturated in his brief and the staff would ensure facility staff repositioned R1 hourly. The Weekly Pressure Wound Assessment dated 06/12/24, revealed R1 had a right iliac crest (rear) unstageable pressure ulcer, lacked onset date, and measured 5.5 cm by 3.5 cm by 0.1 cm, continued to be covered with 100% slough, had moderate amount of purulent (producing or containing pus) and serosanguineous drainage with slight odor, with surrounding skin macerated. This was an increase in size from the prior assessment on 06/05/24. The assessment lacked documentation about R1's left outer ankle, discovered by R1's DPOA five days prior. The Progress Note dated 06/14/24 at 03:26 PM, revealed R1 had a new open area found on his left outer ankle, which was an old pressure area that re-opened. The staff cleaned the area, applied triple antibiotic ointment, and covered with a border gauze dressing. A new wound care order was in place for daily wound care. The facility failed to identify the area until seven days after R1's DPOA discovered the area. The Weekly Pressure Wound Assessment dated 06/14/24 revealed the same measurements and wound assessment as 06/05/24 of the right iliac crest (rear) unstageable pressure ulcer. The assessment revealed a new stage two pressure ulcer to R1's outer left ankle, a previous area which reopened, and measured 0.3 cm by 0.3 cm by 0.1 cm. The hospice Skilled Nursing Visit Note dated 06/16/24 revealed Consultant Staff GG arrived at facility at 11:04 AM, the facility requested a visit due to an increased odor coming from R1's wound. The facility nurse (lacked name) accompanied Consultant Staff GG to R1's room. The old dressing had a moderate amount of serosanguineous fluid, and the wound had an increased amount of necrotic (pertaining to the death of tissue in response to disease or injury) tissue compared to two days ago. Consultant Nurse GG contacted the physician and received new orders for wound treatment, change dressing daily, and start Cipro (antibiotic), 500 milligrams (mg), by mouth, twice daily, for two weeks. The hospice Skilled Nursing Visit Note dated 06/17/24 with arrival time of 04:30 PM, revealed Consultant Staff II attempted to coordinate care with LN J, who said she did not have time to talk, when trying to inquire if R1's wound care had been done as R1 was eating supper. LN J then stated it had been done. LN J admitted that she knew her, and the staff, must do better with changing and checking R1 routinely. Consultant Staff II discussed R1's care with Administrative Nurse D, who believed R1 was doing well. Consultant Nurse II showed Administrative Nurse D image of wound from the previous day, discussed status of it, and having the provider that comes to the facility debride (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) the wound if the physician would give the order for it. Consultant Staff II consulted with the physician and R1's DPOA who agreed with the plan, and orders received. The hospice Skilled Nursing Visit Note dated 06/18/24 revealed Consultant Staff II assessed R1's upper medial buttock wound which was covered with 90% eschar (dead tissue) and 10% slough (dead tissue, usually cream or yellow in color). The wound measured 6.5 cm by 5.0 cm. The wound center Progress Note dated 06/19/24 revealed R1 had a pressure ulcer to the right inferior buttock, wound debrided with post debridement measurements of 3.57 cm by 2.95 cm by 0.3 cm, and the post debridement wound stage was a stage three pressure injury (full thickness pressure injury extending through the skin into the tissue below). The hospice Skilled Nursing Visit Note dated 06/19/24 revealed Consultant Staff II arrived as the practitioner just finished debridement of R1's wound, obtained image of wound, and sent to provider for orders since eschar removed. Orders received and Consultant Staff II relayed visit information to LN G, then visited with Administrative Nurse D. Consultant Staff II had visited with R1's DPOA about staff concerns and agreed the implemented checklist should be revised to be done every two hours and plan solidified with Administrative Nurse D for revision to reflect documentation of care to every two hours. The facility failed to provide checklists prior to 06/19/24. The Hourly/Frequent Checks log for 06/19/24 revealed R1 was on his right side at 08:00 AM until turned to left side at 11:00 AM (three hours), where he remained on his left side until he was turned to his back at 02:00 PM (three hours). R1 was on his left side for three hours from 10:00 PM to 01:00 AM when turned to his right side, where he remained until 04:00 AM (three hours) when staff turned him to his left side. The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/20/24 revealed R1's wound care was now three times weekly, and no daily visits warranted. R1 was wet and Consultant Staff II provided peri-care, changed brief, and provided wound care. The Weekly Pressure Wound Assessment dated 06/21/24 revealed the same measurements and wound assessment as 6/12/24 and 06/14/24 for R1's unstageable pressure ulcer to right iliac crest (rear). The facility failed to document current wound characteristics. The Hourly Frequent Checks for R1 dated 06/21/24 revealed R1 was on his right side at 11:00 AM and on his left side at 02:00 PM (three hours). R1 was on his right side at 01:00 AM and the log lacked documentation until 04:00 AM (three hours) to indicate he was on his left side. The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/22/24, revealed Consultant Staff II did an as needed (PRN) visit due to R1's dressing on his wound being saturated. The dressing changed yesterday afternoon for R1 had become completely saturated with wound drainage. Consultant Staff II contacted the physician and orders changed to daily until the wound improved. Consultant Staff II provided wound care per orders and communicated the new change to the DPOA and the facility. The Hourly Frequent Checks for R1 dated 06/22/24 revealed he was on his left side at 11:00 AM and every hour after that until 04:00 PM (five hours) when he was on his right side. R1 was on his right side at 09:00 PM and on his left side at 12:00 AM (three hours later). The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/23/24 revealed Consultant Staff GG arrived at the facility at 06:29 PM and returned to R1's room with an aide from the facility. R1 laid on his back with his brief saturated with urine. The Hourly Frequent Checks for R1 dated 06/23/24, revealed the staff documented he was on his left side at 08:00 PM, 09:00 PM, 10:00 PM, 11:00 PM lacked documentation, and at 12:00 AM. The log lacked R1 moved to right side until 01:00 AM (five hours later). The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/24/24, revealed R1's upper medial buttock pressure ulcer, now labeled as a stage four (a deep pressure wound that reaches the muscles, ligaments, or even bone), included an assessment of the wound to have a large amount of yellow-green drainage with a foul odor and measured 5.5 cm by 4.0 cm by 0.5 cm. Consultant Staff II arrived at the facility at 02:30 PM and noted R1's protective underwear saturated with urine. Consultant Staff II noted wound malodorous after doing peri-care, brief change, and wound care, and contacted the physician regarding this with new orders received for wound care. The Hourly Frequent Checks for R1 dated 06/24/24 revealed R1 was on his left side at 08:00 AM, 09:00 AM, and 10:00 AM (three hours), and on right side at 11:00 AM, 12:00 PM, and 01:00 PM (three hours). R1 was on his left side at 04:00 PM, 05:00 PM, and 06:00 PM (three hours) and on his right side at 07:00 PM, 08:00 PM, and 09:00 PM (three hours), and on his back at 10:00 PM, 11:00 PM, and 12:00 AM (three hours). At 01:00 AM, 02:00 AM, and 03:00 AM (three hours) R1 was on his left side. The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/25/24 revealed Consultant Staff II arrived at facility at 04:30 PM and facility LN K came into the room to look at R1's wound because she had not seen it. The note revealed the upper medial buttocks wound had tunneling (a portion of a wound that extends deeper into the tissue than the surface creating a channel or tunnel) at 11 o'clock position at 0.6 cm, and at six o'clock position that measured 0.4 cm. The tunneling had not been present on the prior assessments. The hospice Skilled Nursing Visit Note dated 06/26/24, revealed Consultant Staff II arrived at 01:50 PM, facility staff finished feeding him lunch, she then conducted her assessment and provided wound care. The note revealed odor continued to be faint but improved. LN G reported the dressing had come off the evening shift and they had only applied a wet-to-dry dressing, which was still intact upon arrival, and had some strikethrough from drainage. Further skin assessment showed a new area to the inner aspect of the left elbow that measured 0.6 cm by 0.4 cm by 0.1 cm, and a new area to his left ear wound measured 0.9 cm by 0.5 cm by 0.1 cm with blood drainage, which appeared to be associated with some pressure from the oxygen tubing in combination with him resting on the left side of his face. The physician advised treatments to the areas. Consultant Staff II labeled both areas as stage two pressure areas. Consultant Staff II communicated with staff nurse (lacked name) regarding R1's condition. The Hourly Frequent Checks dated 06/26/24, revealed R1 was on his right side at 06:00 AM, 07:00 AM, 08:00 AM, 09:00 AM (four hours) until he was on his left side at 10:00 AM. He remained on his left side at 11:00 AM, 12:00 PM, 01:00 PM (three hours) until he was on his right side at 02:00 PM. R1 was on his right side 11:00 PM through 01:00 PM (three hours) and on his left side at 02:00 AM, 03:00 AM, and 04:00 AM (three hours) until 05:00 AM when he was on his right side. The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/27/24 revealed Consultant Staff II the dressing to R1's inner aspect of his left elbow dislodged. The facility failed to identify R1's dressing was not intact. The Weekly Pressure Wound Assessment dated 06/28/24 for R1 revealed unstageable pressure area to right iliac crest with the same measurements and wound characteristics as the assessment on 06/12/24, 06/14/24, and 06/21/24. The left ankle had the same measurements as the assessment on 06/14/24 and 06/21/24. The facility failed to document R1's current wound characteristics. The TAR dated June 2024 for R1 revealed documentation of 9 indicating other, see progress note for the wound care to right buttock on 06/28/24. The Progress Notes lacked an entry for 06/28/24 to indicate why the staff did not provide wound care to the right buttock. The Hourly Frequent Checks dated 06/28/24 for R1 revealed he was on his right side at 06:00 AM, 07:00 AM, 08:00 AM, and 09:00 AM (four hours) on his left side at 01:00 PM until 04:00 PM when on his right side (three hours). The log revealed R1 was on his right side at 11:00 PM, 12:00 AM, and 01:00 AM (three hours), and on his left side at 02:00 AM, 03:00 AM, and 04:00 AM (three hours). On 06/29/24 the log revealed R1 was on his left side at 11:00 PM, 12:00 AM, and 01:00 AM (three hours), and on his right side at 02:00 AM, 03:00 AM, and 04:00 AM (three hours). The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/30/24, revealed Consultant Staff MM arrived at the facility at 01:40 PM and R1 was lying flat on his back, his brief very saturated in urine. The Hourly Frequent Checks dated 06/30/24 for R1 revealed he was on his left or right side for three hours at a time on five different occasions. The facility failed to reposition R1 every two hours. The Weekly Nursing Skin Assessment dated 07/01/24 for R1 revealed he had a pressure area to his right iliac crest and left outer ankle. The assessment lacked any areas to his left ear or the inner aspect of his left elbow. The hospice Skilled Nursing Visit Note dated 07/01/24 revealed R1's wound to his left ear had scabbed over, and Consultant Staff II had concern that the wound to his lower back was tunneling. The upper medial buttock wound measured 6.0 cm by 3.0 cm by 0.5 cm, with tunneling 1.5 cm at nine o'clock and ten o'clock and 3.5 cm tunneling to 11 o'clock and twelve o'clock. The wound had large amount of serosanguineous and yellow-green drainage with mild odor. The inner elbow stage two pressure area measured 0.8 cm by 0.5 cm by 0.1 cm and improved. The Hourly Frequent Checks dated 07/01/24 revealed R1 was up for supper at 05:00 PM, 06:00 PM, and 07:00 PM (three hours). R1 was on his right side at 01:00 AM, 02:00 AM, 03:00 AM (three hours). The facility failed to reposition R1 every two hours. The facility lacked Hourly Frequent Checks for R1 on 07/02/24. The TAR dated July 2024 lacked documentation the staff provided wound care to R1's right buttock on 07/02/24 per physician order. The Hourly Frequent Checks dated 07/03/24, which was on the blank backside of another log, revealed R1 was on his left side for three hours on three occasions, and on his right side for three hours on one occasion. The facility failed to reposition R1 every two hours. The Weekly Pressure Wound Assessment dated 07/04/24, for R1 revealed no changes in the measurements for the right iliac crest and the left ankle. The wound characteristics for the right iliac crest had not changed since 06/05/24. The wound assessment lacked the wound to the inner aspect of the left elbow. The facility failed to document current wound characteristics. The hospice Skilled Nursing Visit Note dated 07/07/24, revealed Consultant Staff MM arrived at 04:30 PM and R1 was lying in bed on his back, incontinent of bowel and bladder and his brief saturated with urine. The TAR dated July 2024 revealed R1 had a weekly skin assessment performed on 07/08/24. However, the Assessment tab lacked a Weekly Nursing Skin Assessment for 07/08/24. The facility failed to perform a weekly skin assessment per physician order. The Weekly Pressure Wound Assessment dated 07/11/24 revealed no changes in the measurements for the right iliac crest and the left ankle. The wound characteristics for the right iliac crest had not changed since 06/05/24. The facility failed to document current characteristics of R1's wounds. The hospice Medical Social Worker Visit Note dated 07/12/24, revealed Consultant Staff KK arrived at 10:50 AM, revealed R1's DPOA also present during visit. R1 found in a soiled brief, and his bedding and pads soiled with wound drainage. The hospice Skilled Nursing Visit Note dated 07/12/24, revealed Consultant Staff MM arrived at 03:40 PM and staff reported R1's dressing was coming off and saturated before lunch today, so they changed it. The note included orders received to insert a 16 French urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) to dependent drainage to assist with wound healing. Consultant Staff MM inserted the urinary catheter. The hospice Skilled Nursing Visit Note dated 07/14/24, revealed Consultant Staff HH arrived at 09:55 AM for R1's visit. Consultant Staff HH provided wound care. The old dressing had drainage that saturated the dressing with a copious (large) amount of purulent drainage with foul odor. Consultant Staff HH updated the facility staff nurse, LN L, on R1's wound care. The Weekly Pressure Wound Assessment dated 07/18/24, revealed R1 had one wound present to his sacral area that was unstageable and measured 6.0 cm by 3.0 cm by 0.5 cm with prior measurements of 5.5 cm by 3.5 cm. The wound had serosanguineous and purulent drainage of a large amount and with slight odor. The wound bed was covered with 25% slough and had 76 to 100 % granulation tissue (new tissue formed during wound healing) with the surrounding skin macerated. The wound had tunneling/undermining of 1.5 cm at nine and ten o'clock, and 3.5 cm and 11 and 12 o'clock, the wound had deteriorated. The assessment lacked any other wounds. The hospice Skilled Nursing Visit Note dated 07/23/24, revealed R1's stage four pressure ulcer to his upper medial buttock measured 8.0 cm by 5.8 cm by 0.5 cm with 3.0 cm undermining at 12 o'clock and 3.5 cm at seven and nine o'clock, with a large amount of serosanguineous drainage. The Weekly Pressure Wound Assessment dated 07/25/24, for R1 revealed the same measurements to the unstageable sacrum pressure ulcer as the week prior with no changes to the wound characteristic assessment. The assessment revealed wound deteriorated and lacked any other pressure wounds. The facility failed to document current wound characteristics. The hospice Skilled Nursing Visit Note dated 07/27/24, revealed Consultant Staff HH arrived at 08:55 AM and checked in with LN NN, who voiced no concerns. The note revealed new skin issues identified of a stage one pressure ulcer (pressure wound which appears reddened, does not blanche, and may be painful but is not open) to his second finger of his right hand with an onset date of 07/25/24 and a pressure ulcer, lacked stage, to his third finger of his right hand with an onset date of 07/25/24. On 07/29/24 at 11:10 AM, observation revealed R1 laid in bed on an air mattress tilted to his right side with the head of the bed elevated approximately 45 degrees, lacked clothing to upper body and lower body covered with a sheet, hands appeared contracted (abnormal permanent fixation of a joint or muscle), and a urinary cat[TRUNCATED]

The facility census totaled 70 residents, with 18 in the sample, including one resident reviewed for accident hazards. Based on observation, interview, and record review the facility failed to ensure staff provided adequate supervision and followed the resident's fall prevention interventions to prevent further falls for Resident (R) 18, including one fall which resulted in a fractured (broken bone) right femur (thigh bone) and surgical repair. Findings included: - R18's diagnoses from the Electronic Health Record (EHR) documented anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), and schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The 07/19/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R18 required extensive assistance of one staff for bed mobility, dressing, and personal hygiene, and extensive assistance of two staff for transfers. R18 had no falls since the prior assessment. The 02/23/23 Quarterly MDS documented a BIMS of 15, indicating intact cognition. R18 required extensive assistance of two staff for all activities of daily living. The MDS further noted R18 had no falls since the prior assessment. R18 required surgery to repair a fracture to the pelvis, hip, leg, or ankle. The 01/25/23 Care Plan documented R18 was at risk for falls. The Care Plan directed staff to follow facility fall protocol. The Care Plan directed staff to use a body pillow for positioning and mattress perimeters for R18 as of 09/19/22. The Care Plan lacked an intervention for the fall on 12/25/22. Review of the Fall Investigation dated 12/25/22, documented at 01:41 PM, R18 turned on his call light and the responding CNA entered the room, then left the room to gather linens to change R18's bed. While the CNA was out of the room, R18 rolled off the bed, which resulted in a fracture to his right femur. The investigation noted the bed was not at an appropriate height. The investigation lacked witness statements, identification of causal factors, and resident interviews. Review of Progress Note dated 12/25/22, documented a CNA reported to the nurse he had been in the room changing R18's linens, he stepped out of the room to get linens, and R18 rolled out of the bed while he was outside of the room. R18 had a laceration to the right side of his head and a skin tear to his right hand. R18 complained of pain to his right hip. The staff obtained his vital signs and the nurse cleaned the wounds and did not move R18 until emergency service (EMS) staff arrived to assess R18. EMS staff and a Licensed Nurse lifted R18 from the floor to a stretcher. R18 complained of pain to his right leg. R18 transferred via ambulance to the hospital for further evaluation. Review of Progress Note dated 12/27/22, documented R18 returned from the hospital around 03:00 PM, via gurney, transported by an outside transportation services. R18 had a suprapubic (a urinary catheter that is inserted through a small incision in the lower abdomen) catheter in place. R18 had confusion and his speech was not clearly understood. R18 had an incision to his right hip due to a surgical procedure. R18 had a dressing covering the incision with an order to leave the dressing in place until his follow up appointment, and the staff were to apply ice intermittently to his right hip for discomfort, as needed. The staff were to use a mechanical lift for transfers of R18, with the assistance of two staff. Review of the Fall Scene Investigation Questionnaire dated 12/25/22, documented the CNA had answered the questions of toileting time and noted a urinary catheter in place, R18 was incontinent at the time of fall, had no footwear in place, noted the last time R18 had eaten was at lunch, noted R18 was changed at 01:45 PM, and seen at lunch, at noon. Furthermore, the CNA documented R18's call light was on, R18 told him nothing, and the fall happened because R18 rolled to the floor. On 04/26/23 at 03:25 PM, observed R18 lying in his bed, in the regular height position, with no mattress perimeters or body pillow in place. He rested with his eyes closed and awoke at the calling of his name. On 04/26/23 at 03:25 PM, R18 reported on the morning of 12/25/22, he had just woke up and rolled over, right onto the floor. R18 stated he did not think anyone was trying to hurt him. On 05/01/23 at 08:36 AM, Certified Nurse Aide (CNA) D reported in the event of an incident or altercation, staff should report to the nurse immediately and stated several fall interventions that the facility used. She did not know of any fall interventions needed for R18. On 04/27/23 at 04:40 AM, Licensed Nurse (LN) N reported with a fall, she assessed the resident, provide any first aid needed, call for EMS if needed, make a thorough progress note, and notify management, provider, and family. LN N reported the nurse was responsible for putting an intervention in place to prevent further falls. On 04/27/23 at 10:30 AM, Administrative Staff A revealed she expected staff to notify her immediately of incidents. She confirmed the nurse should make a complete progress note to include the entirety of the incident and any interventions put into place. Administrative Staff A confirmed no witness statements, identification of causal factors, or resident interviews were completed for R18's 12/25/22 fall which resulted in a fracture. The facilities 12/23/21 Fall Prevention Program policy documented falls could result in injury and the very least, emotional trauma. The facility role was to assure they identified the residents at risk for falls and assure the facility had individualized preventive approaches in place to assist with the prevention of future falls. The facility failed to provide adequate supervision and assistive devices to prevent accidents, when R18 fell out of bed on 12/25/22, which resulted in a right femur fracture and required surgical repair. - Environmental tour of the facility, on 05/01/23 from 02:00 to 04:00 PM, with maintenance staff Z, revealed the following resident accessible areas contained the following areas/items with accident hazards to the residents of the facility. The 100 Hallway had two bulbs in each of four of the hallway ceiling lights, lacked any type of protective coverings to protect in case of broken glass any resident that may be walking under them if they broke. Maintenance staff Z verified the light bulbs lacked the protective coverings they should have. The large courtyard between hallways 100 and 300, contained a large cement pad in the middle. The cement was approximately 12 by 12 feet, and all edges were raised above the ground level, approximately 4 to 6 inches. These areas could cause any resident in the courtyard to trip and fall onto the cement pad. On the 200 Hallway a residents shower/toilet room on this hallway contained a shower with walls coming out to the front. The front corners of the shower contained tiles which were broken and cracked off in several areas along them. This presented a accident hazard for lower leg injury to any resident using this shower and coming in and out of the shower area. The same shower/toilet area contained metal grab bars for stability to get on and off of the toilet. One side grab bar was loose when grabbed, which could potentially cause a resident that might grab it to lose balance and fall. Maintenance staff Z verified the broken tiles and the loose grab bar could cause accidents to the residents. The 400 Hallway contained the facility special care unit with a resident census of 9. An unlocked residents' shower/toilet room contained multiple resident care items and personal belonging stored in the room's shower areas. The contents stored included pictures, suitcases, clothes, a wheelchair, two large plastic barrels, window blinds against the wall, décor items, and an oxygen tank caddy. This room was so full of items that it created a accident hazard for any of the 9 residents if they wandered into the room and tripped on the items. The special care unit's activity/snack room area contained a sink with cabinets along one side wall of the room. A large storage cabinet just inside this room doorway, stood open. The cabinet held a spray bottle of Spic and Span Disinfectant, to keep out of the reach of children hazard label. The same open cabinet contained a plastic open topped container, that held multiple different types/colors of fingernail polish. These should be kept out of the reach of children also. These hazardous chemicals were accessible to all 9 residents on the special care unit with impaired cognition. The 500 Hallway's southeast exit door entered into a courtyard. On this day the facility had a group of workers cleaning up this courtyard of old metal and tree limbs/trash. On 4/27/23 observation revealed the courtyard contained multiple old mechanical lifts and other old metal equipment, but today at this time they were removed. The courtyard did contain a cement pad, approximately 3 by 3 feet, which was raised along all the edges approximately 2 to 4 inches. Any resident in the courtyard could easily trip on this accident hazard. The facility failed to provide necessary housekeeping and maintenance services to maintain a safe environment for the residents of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 60 residents with 15 residents in the sample and three residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to prevent the development of a stage 4 (sore that extends below the subcutaneous fat into deep tissues like bone) pressure ulcer (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) for dependent Resident (R)52, who admitted to the facility with intact skin. The facility further failed to monitor and assess the facility acquired pressure ulcer on R52's coccyx (small triangular bone at the base of the spine). Findings included: - R52's Physician Progress Note dated 09/15/21 revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion) and metabolic encephalopathy (a brain disease caused by chemical imbalance in the blood due to an illness or organs that are not working as well as they should). The Discharge- return anticipated Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score could not be completed. R52 had short-term memory problems and did not have any pressure ulcer/injury. The Significant Change MDS dated 07/28/21 revealed a BIMS score of four, which indicated severely impaired cognition. R52 required extensive assistance from staff for bed mobility and toilet use, and limited assistance from staff with eating. R52 was frequently incontinent of bladder and bowel. R52 weighed 108 lbs. (pounds), was 61 inches tall, and experienced weight loss, but was not on a physician prescribed weight-loss program. R52 had one unstageable pressure wound and utilized a pressure reducing device for her chair and bed. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 07/28/21 revealed R52 triggered for urinary incontinence due to decrease mobility and was at risk for skin breakdown due to being occasionally incontinent of bowel and bladder. The Pressure Ulcer/Injury CAA dated 07/28/21 revealed R52 triggered for pressure ulcer/injury due to periods of incontinence of bowel and bladder, increased weakness, and needed extensive assistance with repositioning. The Care Plan dated 08/03/21 revealed R52 had an alteration in skin related to an open area on her coccyx that was a chronic, unstageable pressure injury. Interventions included for staff to encourage good nutrition and hydration in order to promote healthier skin. Staff would turn and reposition every two hours and as needed (PRN). The licensed nurse would perform a weekly skin assessment. Staff would cleanse the area, pat dry, apply skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes) to peri wound (tissue surrounding a wound), apply SilvaKollagen Gel (a silver antimicrobial collagen gel with hydrolyzed collagen which supports autolytic debridement) to wound bed, apply collagen, cover with dry dressing, and change the dressing three times a week. The 06/01/21 admission Summary Progress Note revealed R52's skin was intact. The 06/13/21 Health Status Note revealed R52 had a small open area at the top of her coccyx, which measured 1-centimeter (cm) x 3-millimeter (mm) x 1mm. The 06/17/21 Weekly Skin Evaluation revealed the resident had a dime sized, stage 2 wound to the sacrum. The Weekly Skin Evaluation further had a notice in red letters stating: NOTE: If an open area, proceed to appropriate skin condition report. (A skin condition report was not completed.) An order dated 06/18/21 to apply skin prep to open area on coccyx each shift and as needed (PRN) after incontinence, every shift for skin integrity, and every eight hours as needed. Discontinued on 06/23/21. An order dated 06/23/21 for weekly skin assessments. An order dated 06/24/21 to cleanse right buttock wound with wound cleanser, apply skin prep to wound edge, apply cut to size alginate (a multipurpose type of wound dressing), cover with foam dressing, change Monday through Thursday till healed. Discontinued 06/25/21. An order dated 06/26/21 to cleanse right buttock wound with wound cleanser, apply skin prep to wound edges, apply dime size Santyl (a sterile enzymatic debriding ointment) to wound bed, apply cut to size Xeroform (a fine mesh gauze occlusive dressing impregnated with petrolatum) to wound bed, cover with border dressing, change daily. Discontinued on 08/01/21. The 07/21/21 Social Services Note revealed R52 signed on to hospice care to care for R52's wounds. An order dated 07/22/21 for House Supplement Shake (nutritional supplement drink) 4 ounces (oz). Review of the Hospice Visit Note Report on the following dates revealed: 07/27/21- Sacral wound measured 2.7cm x 2.5cm. 08/02/21- Sacral wound measured 2.7cm x 2.5cm. 08/09/21- Applied sacral wound treatment. 08/12/21- Treatment to coccyx replaced. An order dated 08/04/21 Cleanse sacral wound with wound cleanser, lightly pat dry, apply skin prep to wound edges, apply SilvaKollagen gel to wound bed, cover with cut to size collagen, cover with dry dressing, hospice to change Monday and Friday, our staff to change dressing on Wednesday, one time a day every Wednesday for sacral wound. Discontinued 08/05/21. The 08/05/21 Health Status Note revealed R52's Durable Power of Attorney (DPOA) only wanted hospice to assist with wound care for a two-week period of time between 07/24/21 - 08/06/21, then the facility would provide care similar to before signing on to hospice. An order dated 08/06/21 Cleanse sacral wound with wound cleanser, lightly pat dry, apply Santyl to wound bed, cover with cut to size collagen, over with dry dressing, change dressing Monday-Wednesday-Friday. Discontinued 08/18/21. An order dated 08/19/21 Cleanse buttock open area with wound cleanser, pat dry, apply Santyl to wound bed, cover with cut to size Xeroform, cover with folded 4x4 (sterile dressing), cover with border gauze, change daily. Discontinued 09/12/21. The 08/20/21 Nutrition/ Dietary Note written by Registered Dietician (RD) J revealed R52 had an open area on her coccyx and recommend adding MedPass (nutritional supplement liquid) 120 milliliters (ml), BID for extra calories. The 08/24/21 Activities Note revealed new orders to consult [local wound center] to evaluate and treat the wound on the resident's coccyx. The 09/03/21 Nutrition/Dietary Note revealed RD J again recommended adding MedPass (nutritional supplement liquid) 120 ml, BID for extra calories. The 09/07/21 Health Status Note revealed an order for Metronidazole (antibiotic) 500 mg BID for 14 days for wound infection. The 09/12/21 Weekly Skin Condition Report revealed the resident had a stage three pressure wound to the sacrum, which measured 4.0cm long (l) by 1.4cm wide (w) x 1.7cm depth (d). An order dated 09/12/21 to consult [local wound center] (specialized wound care provider) to evaluate and treat the resident's coccyx wound. An order dated 09/12/21 Coccyx wound, flush open area with normal saline/wound cleanser, pat dry, apply skin prep peri wound. Then apply Santyl to wound bed (thickness of a nickel), pack loosely with alginate. Cover with boarder gauze. Change BID (for excess drainage) and PRN if soiled, damp or dislodged. An order dated 09/12/21 to flush the open area to the resident's coccyx with normal saline and wound cleanser, pat dry, apply skin prep to the peri wound, apply Santyl to wound bed (thickness of a nickel). Staff were to pack the wound loosely with alginate (a multipurpose type of wound dressing) and cover with boarder gauze. Staff would change the dressing twice daily (BID) (for excess drainage) and PRN if soiled, damp, or dislodged. An order dated 09/14/21directed staff to consult hospice to evaluate and treat R52. The 09/15/21 [local wound center] Progress Note revealed an initial coccyx wound encounter, which measured 3.2cm l x 1.5cm w x 1cm d. The resident had bone exposed with undermining noted at 11:00 (on a clock scale) and ending at 6:00 with a maximum distance of 1.6 cm. The wound was noted with copious (abundant) amounts of serosanguineous (semi-thick reddish drainage) drainage. Weekly Skin Evaluations were completed on 06/28, 07/12, 07/19, 07/26, 08/02, 08/09, 08/16, 08/30, and on 09/20/21. (Staff did not complete a Weekly Skin Condition Report which allowed for more in-depth documentation of wound measurements, description of the wound condition, treatment followed, and intervention(s) used.) Review of the September 2021 Electronic Treatment Administration Record (ETAR) revealed the record lacked evidence staff completed weekly skin assessments on 09/06/21 and 09/27/21. Staff did not complete the physician ordered BID wound treatments on the following dates: 09/14, 15, 16, 17, 18, 21, 22, 26, 27, and 09/28/21. Staff further failed to complete wound care at all on 09/23/21. Observation on 09/30/21 at 09:30 AM revealed staff took R52 in her wheelchair from the dining room to her bedroom and placed her in bed on her left side. R52 went to sleep. At approximately 12:00 PM on 09/30/21 staff brought R52 to the dining room for lunch and she had a pressure relieving cushion in her wheelchair. Observation on 10/05/21 at 02:09 PM, Licensed Nurse (LN) H changed R52's dressing to her coccyx. LN H wore gloves and removed the old bordered dressing. The wound was clean, had no sign of infection, no drainage, and no foul odor. LN H used wound cleanser to clean the wound and patted the area dry with gauze. LN H applied skin prep around the peri-wound area, applied Santyl to the wound bed, and packed the wound with calcium alginate. LN H stated there was no bordered gauze available, so he covered the wound with an ABD (highly absorbent sterile dressing) pad and taped the edges. LN H stated there was another wound care company that came in to measure R52's wounds. Interview on 09/30/21 at 09:20 AM, Certified Nurse Aide (CNA) O stated R52 had a sore on her coccyx and the nurses changed the dressing one to two times daily. CNA O stated staff repositioned R52 every two hours and she had a cushion in her wheelchair. CNA O stated R52 had only a standard mattress on her bed and staff packed pillows under her. Interview on 10/04/21 at 04:01 PM, CNA V stated R52 had a sore on her coccyx that was always dressed. CNA V stated R52 would lay down in her bed when she was not in the dining room. CNA V stated R52 had a cushion in her wheelchair and a regular mattress on her bed. Interview on 10/05/21 at 07:30 AM, LN P stated measurements for open sores should be documented in the Skin Condition Report. LN P stated R52 started on hospice care 07/23/21 and was taken off 08/13/21. LN P stated hospice should have documented R52's wound measurements in the hospice communication notebook. LN P stated she could not find any wound measurements beside the Skin Condition Report dated 09/12/21. LN P stated the [local wound center] had not been in to see R52 or anyone since there had been COVID in the building. LN P stated the nursing staff taking care of R52's wound should have documented wound measurements. LN P stated there was no air mattress used for R52 because she moved around a lot in her bed and there was a possibility of this being a fall hazard. LN P stated all mattress used were anti-pressure mattresses. Interview on 10/05/21 at 01:33 PM, Administrative Staff A stated she expected nursing staff to document wound measurements at least on a weekly basis. Interview on 10/06/21 at 11:03 AM, Administrative Assistant M stated Nurse Practioner N stated [local wound center] was on the case to treat R52's wound. In an interview on 10/07/21 at 02:34 PM, Physician Y stated he expected the facility to keep track of the wound measurements in order to follow the progression of the wound. The Pressure Injury/Skin Breakdown- Clinical Guidelines policy revised October 2010 revealed, The nursing staff will complete an evaluation of the skin weekly. The Pressure Injury Treatment Guidelines policy revised November 2017 revealed, Document on the tools provided by the community .information in accordance with the facility policy and professional standards of practice. The facility failed to prevent the development of a stage four pressure ulcer for dependent, Resident (R)52 who admitted to the facility with intact skin. The facility further failed to monitor and assess the facility acquired pressure ulcer on R52's coccyx/sacral area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 60 residents with 15 residents in the sample and three residents reviewed for nutrition. Based on observation, interview, and record review the facility failed to monitor weights regularly, place effective interventions, and follow-up on registered dietician recommendations for nutritional supplementation, which resulted in Resident (R)52 experiencing severe weight loss of 17.73 percent in 108 days between 05/13/21 through 09/03/21. Findings included: - R52's Physician Progress Note dated 09/15/21 revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion) and metabolic encephalopathy (a brain disease caused by chemical imbalance in the blood due to an illness or organs that are not working as well as they should). The Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. R52 required limited assistance with eating. R52 weighed 108 pounds was 61 inches tall, and experienced weight loss, but was not on a physician prescribed weight-loss program. The Quarterly MDS dated 08/29/21 revealed a BIMS score of four, which indicated severely impaired cognition. R52 required limited assistance with eating. R52 weighed 108 pounds, was 61 inches tall, and experienced weight loss, but was not on a physician prescribed weight-loss program. The Nutritional Status Care Area Assessment dated 07/28/21 revealed R52 recently upgraded to a regular diet with regular texture and thin liquids. R52 had no difficulty noted with eating. The Care Plan dated 06/30/21 revealed R52 had a potential for alteration in nutrition and fluid intake related to dementia. R52 required a mechanical soft diet with thin liquids. Interventions included house shakes (nutritional supplement drink) two times daily initiated on 07/28/21, staff would maintain R52's focus by redirecting her to eat at mealtimes, monitor intake of food and fluids, offer diet as ordered, and take R52 to the dining room for meals. The Care Plan dated 07/06/21 revealed R52 had a potential for nutritional problem related to needing increased assistance with meals due to dementia. Interventions included for staff to invite R52 to activities that promoted additional nutritional intake. Staff were to monitor and document refusals to eat, assist with eating as needed, and the registered dietician would evaluate and make diet change recommendations as needed (PRN). A review of the Physician Orders included the following: Order dated 07/27/21 for regular diet, regular texture, thin consistency. Order dated 07/22/21 for house supplement shake, 4 oz. (ounces). Further review of Physician Orders lacked an order to obtain the resident's weights. The July 2021- September 2021 Electronic Medication Administration Record (EMAR) lacked any documentation of house supplements given to R52 as ordered. Review of the Nutrition- Amount Eaten Task in the EHR from 09/07/21 - 10/05/21 lacked any documentation noting the percentage of meals the resident consumed. (Access to this information was limited to the last 30 days.) A Nutrition/ Dietary Note dated 08/20/21 by Registered Dietician (RD) J revealed R52 weighed 108 pounds and triggered for a weight loss of 13.8 lbs. (pounds) or an 11.3 percent weight loss in 90 days. R52 received a regular diet, regular texture, and had meal intakes of less than 50 percent. R52 had an order for house shakes provided with meals and RD J recommended to add Med Pass (nutritional supplement to add calories, protein, and other nutrients) 120 milliliters (ml) twice a day. Review of the EHR revealed a lack of evidence staff implemented Med Pass 120 ml, BID and was recommended by RD J on 08/20/21. A Nutrition/ Dietary Note dated 09/03/21 by RD J revealed R52 weighed 100.2 pounds and had a weight loss of 16 lbs. or a 14.4 percent weight loss in 90 days. R52 received a regular diet, regular texture, and had meal intakes usually of less than 50 percent. R52 had an order for house shakes provided with meals and RD J recommended to add Med Pass 120 ml, twice a day. Review of the EHR revealed a lack of evidence staff implemented Med Pass 120 ml, BID as recommended by RD J on 09/03/21. Review of the EHR revealed the following weights: 05/13/21 119.0 lbs. 05/19/21 121.8 lbs. No weights available in the Electronic Health Record (EHR) from 05/20/21 through 08/05/21. 08/06/21 108.0 lbs. which indicated a 11.33 percent weight loss in 80 days (a severe weight loss.) No weights available in the EHR from 08/07/21 through 09/02/21. 09/03/21 100.2 lbs. which indicated a 17.73 percent weight loss in 108 days (a severe weight loss.) Observation on 09/30/21 at 8:38 AM revealed R52 had a breakfast of scrambled eggs, a bowl of oatmeal, French toast, sausage, an 8 oz. cup of orange juice, and an 8 oz. cup of milk. Staff assisted R52 with her meal and she consumed approximately 20 percent of her meal, 75 percent of her orange juice, and no milk. No observation that staff offered R52 a supplement during this meal. Observation on 09/30/21 at 12:12 PM revealed staff assisted R52 with her meal and offered her a lunch that consisted of spinach, beans, cornbread, a cookie, an 8 oz. cup of lemonade, and an 8 oz. cup of water. R52 was not very cooperative and consistently wanted to lean forward in her wheelchair. R52 consumed less than 25 percent of her meal, and approximately 50 percent of her lemonade and water. No observation that staff offered R52 a supplement during this meal. In an interview on 09/30/21 at 09:20 AM Certified Nurse Aide (CNA) O stated R52 was totally dependent with feeding. CNA O stated R52 used to feed herself, but in the past month she needed staff help. CNA O stated R52 no longer ate snacks when offered. CNA O stated he thought R52's weight was pretty consistent and did not think she had lost weight recently. CNA O stated R52 was offered Mighty Shakes (nutritional supplement), but trying to get R52 to drink it was a real challenge. CNA O stated R52 could be very stubborn. In an interview on 10/05/21 at 07:30 AM, Licensed Nurse (LN)P stated R52 had not been eating very well. LN P stated if the Registered Dietician recommended Med Pass and weekly weights due to weight loss, staff should have followed up on this recommendation. In an interview on 10/05/21 at 01:33 PM Administrative Staff A stated if the Registered Dietician recommended Med Pass for R52, the facility should follow-up on this recommendation. In an interview on 10/06/21 at 02:50 PM, Registered Dietician J stated she gave her recommendations to the dietary manager to pass on to the Director of Nursing (DON) to follow-up on, but the facility did not have a DON for some time. Registered Dietician J stated she was not sure if the facility could implement an order for weekly weights or if the physician had to write an order for this. Registered Dietician J was not sure if the facility followed up on her recommendations, but stated she expected the facility would follow-up on her recommendations. In an interview on 10/06/21 at 11:03 AM, Administrative Assistant M stated Nurse Practitioner N was unavailable for interview, but would pass on what she said. Administrative Assistant M stated Nurse Practitioner N stated she was going to write an order for Med Pass, resident weights should be on the Medication Administration Record (MAR), and the dietician would have been the one who ordered weights more frequently. According to Administrative Assistant M, Nurse Practitioner N stated R52 had dementia, many co-morbidities, and was failing in health. The Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol policy revised February 2018 stated, Monitor and document the weight and dietary intake of residents in a format which permits readily available comparison over time .weight loss .greater than 10% is severe .The Interdisciplinary Team, should attempt to identify conditions and medications that may be causing anorexia, weight loss .Identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes .Strategies to increase a resident's intake of nutrients and calories may include .nutritional supplementation .The Physician, with input from the staff, will determine the most appropriate intervals for weight assessments. The facility failed to ensure staff regularly monitored weights and implemented recommendations from the Registered Dietician to help reduce weight loss, which resulted in R52's severe weight loss.