**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Numbers MI00153484 and MI00153865. Based on interview and record review the facility failed to promptly assess a change in condition for one resident (Resident #501) of two residents reviewed for pain, resulting in a delay in pain treatment and discovery of bilateral femur fractures. Findings include: Resident #501: On 6/20/2025 at 9:45 AM, Resident #501 was observed sleeping in bed and did not appear to be in any distress. Two CNA (Certified Nursing Assistants) in the room shared the resident is a two person assist and fully dependent on care. On 6/20/2025 at 10:42 AM, Maintenance Director O shared the Shower Aide informed her as they were lowering Resident #501 in the bed (via mechanical lift) it tilted forward. She explained the pivot point was too tight which caused the Hoyer to tilt, but they were able to safely lower the resident to the bed. On 6/20/2025 at 11:05 AM, CNA P stated she last showered Resident #501 on 5/27/2025 and was assisted by CNA H. As they were placing the resident back in bed (via mechanical lift) the legs on the machine closed and the lock was not properly functioning. The Hoyer hit CNA P in the shoulder and CNA H in the leg but the resident was unharmed. On 6/20/2025 at 11:50 AM, Family Member K shared during her visit on 6/1/25 she noticed he was rocking back and forth more intensely which indicated he was in pain. She pulled back his covered and observed his left leg was externally rotated and the right leg was extended straight out on the bed. She notified the nurse that she wanted him transferred to the emergency room for imaging and further treatment. His nurse completed her assessment, and he displayed pain and winced upon his foot being touched. Family Member K continued a CNA noticed his increase in pain and informed her that is why they did not get him up on 6/1/2025. She added the facility has been unable to provide an explanation as to how the bilateral fractures occurred. On 6/20/2025 at approximately 12:15 PM, a review was conducted of Resident #501's medical record and it indicated he admitted to the facility on [DATE] with diagnoses that included, Anxiety, Heart Failure, Dementia, Hypertension, Schizoaffective Disorder and upon admission back to the facility on 6/5/2025 fracture of right and left femur neck. Resident #501 is fully dependent upon staff to meet all his daily needs. Further review yielded the following: Progress Notes: 5/30/2025 at 05:36: Called sister with results per sister's request. Sister stated that resident has had ongoing lethargy x 2 days, and she is concerned since he had a mild fever yesterday and was pocketing food . 6/6/2025 at 12:48: Resident readmitted to facility r/t bilateral femoral fractures . There were no progress notes or assessments regarding Resident #501 increased pain and externally rotated leg and subsequent transfer to the Emergency Room. Care Plan: .Non-ambulatory .total assist with bathing, monitor for impaired skin integrity .assist of two, heard of bed should be elevated for comfort .Provide physical assistance to accept nutrition by mouth .identify sources of discomfort .(Resident #501) is unable to relay pain symptoms: use FLACC pain scale . Skin Assessment: 5/27/25: Residents skin remains warm, dry and intact. Mucous membranes are moist and pink. Skin turgor age appropriate. No open areas or bruising noted . Pain Assessments: 5/27/25 at 20:31: 0 5/27/2025 at 22:29: 0 6/1/2025 at 15:27: 0 ( this was the day his leg was discovered to be externally rotated by his sister). May 2025 MAR (Medication Administration Record): Resident #501 received Acetaminophen on 5/29/25 at 1737 and 5/30/25 at 1806 for pain. Resident #501 was not administered any other pain medications outside of these two times in May 2025. Hospital Discharge Records: Imaging: Acute complete slightly impacted angulated fracture at the right femoral head/neck junction .suspected acute complete fracture of the left femoral head/neck junction .acute significantly displaced fracture of both femurs at the head/neck junction . Orthopedic Surgery Consult Note: Patient is [AGE] year old male presenting with bilateral hip pain. Sister at bedside helping to provide collateral. Reports the past few days she has noticed patient being more uncomfortable .both extremities are externally rotated, left one appears slightly more shortened compared to the right one .Appears to have some discomfort with passive motion of his hips . RLE (right lower extremity): externally rotated . LLE (left lower extremity): Externally rotated . Hospital Course: This is [AGE] year old male with bilateral femoral neck fractures status post unknown mechanisms. Patient is nonambulatory at baseline and does not assist with transfers. Medicine was consulted for medical management. Thorough discussion and shared decision making with the patients family occurred and ultimate decision for nonoperative management was reached . Facility Investigation Conclusion: .during investigations with staff and residents, abuse, neglect or misappropriation was not identified. Based on interviews and record reviews it can be concluded that these injuries present at subacute and may be a result of previous injury and/or pathological in nature . On 6/20/2025 at 12:25 PM, Nurse E reported there was nothing communicated in report regarding increased pain for Resident #501. CNA S alerted her in the evening that she needed to assess Resident #501 but before she was not able to make it to the his room, his sister came to get her. Nurse E shared Resident #501's left leg had slipped off the pillow and resembled the shape of a frog leg. His sister asked why his leg was externally rotated when, from her observation it did not appear to be externally rotated. Nurse E slid her hand under his heel, and he winced and said ohhh ohhh. From there, their on-call practitioners were contacted and orders were provided to send him out. Nurse E was asked why there was no documentation regarding her assessment of resident. She reported she did not complete a progress note or the transfer documentation as she was extremely busy. She stated she knows that it was required of her and the DON (Director of Nursing) asked her a few times to complete the necessary documentation and she failed to do so. On 6/20/2025 at 1:10 PM, an interview was conducted with East Unit Clinical Care Coordinator C regarding Resident #501. She reported she was alerted that Monday that he went out to the hospital and was not aware his leg was externally rotated. Resident #501 is a mechanical lift and fully dependent on staff to meet their needs. She expressed he has always rocked back and forth but they had various levels on intensity. If his rocking was harder paced that would indicate a need for further assessment. On 6/20/2025 at 1:30 PM, CNA H stated Resident #501 does not move his legs and it takes two staff to care for him due to his stature. She stated she does not recall any reports from the 3rd shift regarding an increase in pain. She added he did rock back and forth and his sister indicated that was a sign of pain/discomfort. But the rocking was not consistent. CNA H expressed when providing incontinence care he would typically grimace when cleaning his genital area but she was not sure if that was due to him being sensitive or uncomfortable with a woman providing care. On 6/20/2025 at 1:55 PM. Nurse R reported Resident #501 rocked back and forth but it was not continuous throughout the day. She stated she noticed it more upon his return from the hospital as he would rock and makes and noise. On 6/20/2025 at 2:30 PM, CNA S was interviewed regarding Resident #501. The CNA stated on Saturday (5/31/25) when she arrived to work she noticed he was in increased pain. She noticed it as if they were getting him into his chair and tuning and repositioning him. CNA S shared he was grunting more and seemed uncomfortable. Additionally, she observed the left leg was bent into the right and that is atypical as he does not move his legs. She stated she had never seen him like that and informed the nurse about his increased pain and his leg, but was unsure if an assessment was conducted. CNA S reported it was discussed during their shift reports and passed along to 1st and 3rd shift. She said on Sunday evening the 1st shift aide did not get him out of bed due to his increase in pain. She added she heard that after this shower on 5/27/2025 is when the change in condition initially occurred and added that he was sensitive in his genital area during incontinence care. On 6/20/2025 at 4:05 PM, an interview was conducted with CNA G regarding Resident #501. Upon her arrival to work on that Tuesday evening (5/27/2025) she was informed in report that he had a shower in the latter part of 1st shift and slept the majority of 2nd shift. As CNA D and N were providing care to Resident #501's roommate he (Resident #501) woke up and they stated his eyes were rolling to the back of his head, he gritted his teeth, was grimacing and making noises like a horse. This was not his baseline and the aides alerted the nurse who after reviewing his chart stated his behavior was due to his diagnosis but to the aides this was far beyond his regular behaviors. CNA G stated she recognized he was in pain, as he was pressing his hands into his groin area and did not want to move them. On 6/20/2025 at 4:25 PM, CNA N shared she was providing care to the roommate of Resident #501. While they were doing care Resident #501 began to breathe harshly and she initially thought he was snoring. It sounded abnormal so they checked on him, they attempted to gain his attention, but he was not responding (he would look at the staff typically). Upon closer observation his eyes were rolled into the back of his head and when they tried to touch him he had a visceral reaction. He clenched his body, and he was breathing like they had never heard him do before. The noises he made were not normal either and it appeared he is was in agony. When they touched him, he began to cry and yelped out. CNA N alerted the nurse to his change and she completed a chart review and vitals. Upon her assessment she stated he has these movement due to his diagnosis, the CNA reported what they observed was not his baseline nor his typical movements. On 6/20/2025 at 4:50 PM, an interview was conducted with CNA D regarding Resident #501. She reported on the night of 5/27/2025 they were providing care to another resident and heard Resident #501 make an odd noise. When they pulled the curtain back, they saw Resident #501's eyes were rolling in the back of his head which lasted a few minutes. They were calling his name but he did not turn his head toward them like he normally would. He was pressing his body into the bed in a jerking movement. CNA D reported this was atypical of him. They did alert the nurse to this, but she attributed it to his current diagnosis set. On 6/23/2025 at 11:05 AM, Therapy Director J reported Resident #501 was fully dependent upon staff for his daily care. When he admitted to the facility he was fully dependent with max assist and that did not change during his stay at the facility. She added they did range of motion with his arms which they did see improvements with but they were completing the range of motion not him. Therapy did not work with his legs but looking at the notes there would not have been any gains made. On 6/23/2025 at 12:30 PM, Nurse I reported she did pick up 3rd shift a few weeks ago and recalled the aides reporting Resident #501 seemed to be in more pain than usual. She stated he was rocking back/forth and puffing his lips out and blowing. Nurse I shared she had never worked with him before and after chart review found his diagnoses that attributed to his rocking and blowing. Nurse I was asked if she administered pain medications and she stated she did not, as after he was repositioned, he appeared more comfortable. Nurse I stated she did not complete a progress note but added it on the 24-hour nurse report form. It can be noted from the investigation that it was discovered Resident #501 has an increase in pain and change in condition on the night of 5/27/25. Multiple staff indicated he was visibly uncomfortable and in increased pain days prior to his sister observing his leg being externally rotated. This information was relayed to nursing staff but there was no subsequent nursing progress notes or assessments which led to his delay in treatment and recognizing the change in condition. On 6/23/2025 at 5:20 PM, the Administrator and DON (Director of Nursing) shared Resident #501 was transported to the hospital for pain on 6/1/2025. They were not aware of his fractures until 6/4/25 and that is when the investigation began. They concluded from their investigation Resident #501 did not have a change in condition that would have alerted the staff to complete additional assessments. He was transferred to the hospital at the behest of his responsible party. The DON and Administrator were informed Resident #501 did have a change in condition the night of 5/27/2025 and continued until his sister recognized his externally rotated leg five days later. They reported they were unaware he had a change in condition as staff did not report it to them during their investigation. It can be noted an aide did mention in her statement she noticed his leg was turned oddly but there was no further follow-up regarding this statement. 6/24/2025 at 12:20 PM, Medical Director BB was asked if he received notification from the facility regarding increased pain and behaviors outside of the norm for Resident #501 on the night of 5/27/2025 or morning of 5/28/202, he stated he did not. Medical Director BB was informed the resident began to display increased pain that continued throughout the week and abnormal behaviors. He reported he was not made aware of this. Review was conducted of the facility policy entitled, Change in Resident Condition Physician /Family Notification, revised March 2021. The policy stated, .To ensure provision of the necessary care and services to meet the highest practicable physical, mental and psychosocial well being of each resident . The resident has a significant change in physical, mental, or psychosocial status i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications . On 6/24/2025 at 9:37 AM, the Administrator reported the facility does not have a policy for pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number MI00149458. Based on observation, interview and record review, the facility failed to operationalize policies and procedures for skin/wound assessments and prevent the development of pressure ulcers for three residents (Resident #1, Resident #2, and Resident #3) of three residents reviewed for wound and skin care, resulting in Resident #1's development of facility- acquired Stage III pressure ulcer to the coccyx area, five suspected deep tissue injuries on the right and left feet and pain; Resident #2's development of facility-acquired right buttock pressure wound stage II and right ischium pressure wound stage IV, and the potential for wounds to go undetected and untreated, pain and wound infection. Findings include: A review of the facility document titled Wound Measurement, revealed, .Suspected Deep Tissue Injury-Purple or maroon localized area of discolored intact skin or bold-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue . and .Stage III-Full thickness tissue loss, Subcutaneous fat may be visible but bone, tendon or muscle and not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling . Resident #1: A review of Resident #1's medical record revealed an admission into the facility on 7/10/24 and readmission on [DATE] with diagnoses that included Alzheimer's disease, weakness, obesity, pressure ulcer of sacral region stage 3 with onset date 11/24/24, pressure-induced deep tissue damage of right heel with onset date 11/21/24, and pressure-induced deep tissue damage of left heel with onset date 11/21/24. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident had severely impaired cognitive skills for daily decision making and was dependent on staff for oral hygiene, toileting hygiene, bathing, personal hygiene, transfers and needed partial/moderate assistance to roll left and right. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no unhealed pressure ulcers/injuries. A review of the MDS dated [DATE] revealed the Resident had one unhealed pressure ulcer/injury that was documented at a Stage 3 pressure ulcer and five current unhealed pressure ulcers/injuries at Unstageable-Deep tissue injury and zero of the number of these unstageable pressure injuries that were present upon admission/entry or reentry. A review of Resident #1's Wound Measurement documentation in the medical record revealed the following: -Date 11/21/24, Observations: Site: Right outer foot, Type: Pressure, Length 1.5 cm (centimeters), Width 1 cm, Stage: Suspected Deep Tissue Injury. Assessment notes included: (Resident #1's name) has an unstageable wound to her right outer foot. She is severely cognitively impaired due to dementia. She relies on staff for repositioning. Her appetite is fair. She is incontinent of her bladder and bowels. Staff assist her to reposition prn (as needed) -Date 11/26/24, Observations: Site: right heel, Type: Pressure, Length 2.9 cm, Width 3.3 cm, Stage Suspected Deep Tissue Injury; Site: left heel, Type: Pressure, Length 0.7 cm, Width 0.2 cm, Stage Suspected Deep Tissue Injury; Site: Right Small Toe, Type: Pressure, Length 0.7 cm, Width 0.4 cm, Stage Suspected Deep Tissue Injury; Site: Right outer foot, Type: Pressure, Length 1.6 cm, Width 1.1 cm, Stage Suspected Deep Tissue Injury; Site: Left outer foot, Type: Pressure, Length 3.0 cm, Width 1.2 cm, Stage Suspected Deep Tissue Injury. Assessment notes included: (Resident's name) was assessed this morning while resting in bed. She has finished her breakfast (provided by staff) throughout the course of the assessment. During palpation over the areas of impairment (Resident's name) demonstrates brief symptoms of pain via facial grimacing, sharp intake of break (breath) and minor pulling away of the extremity. The right heel presents with a large, fluid filled blister and darkened tissue beneath. The discoloration on the outer edge presents as dark maroon in color and is flush with the skin. Similar presentation superior near the pinky toe. The left foot presents with a large area on the outside of the foot that is maroon around the edges and light in the center. This area is soft, boggy and retaining a small amount of fluid. The left heel also presents with a non-blanchable reddened area, boggy in nature. Since observing the discolorations (Resident name) has been provided with bilateral lower extremity prafo boots. She is using a pressure relieving mattress; however, a bariatric bed and air mattress have both been requested. She had recently been referred to skilled therapies for evaluation of her wheelchair positioning and a new wheelchair is in process of being obtained at the facility. -Date 12/6/24, Observations: Site: right heel, Type: Pressure, Length 2.9 cm, Width 3.3 cm, Stage Suspected Deep Tissue Injury; Site: left heel, Type: Pressure, Length 0.7 cm, Width 0.2 cm, Stage Suspected Deep Tissue Injury; Site: Right Small Toe, Type: Pressure, Length 0.7 cm, Width 0.4 cm, Stage Suspected Deep Tissue Injury; Site: Right outer foot, Type: Pressure, Length 1.6 cm, Width 1.1 cm, Stage Suspected Deep Tissue Injury; Site: Left outer foot, Type: Pressure, Length 3.0 cm, Width 1.2 cm, Stage Suspected Deep Tissue Injury. Assessment notes included: (Resident's name) was assessed this morning while resting in bed. During palpitation over the areas of impairment. The right heel presents with a large, fluid filled blister and darkened tissue beneath. The discoloration on the outer edge presents as dark maroon in color and is flush with the skin. Similar presentation superior near the pinky toe. The left foot presents with a large area on the outside of the foot that is maroon around the edges and light in the center. This area is soft, boggy and retaining a small amount of fluid. The left heel also presents with a non-blanchable reddened area, boggy in nature. Since observing the discolorations (Resident's name) has been provided with bilateral lower extremity prafo boots. She is using a pressure relieving mattress, however, a bariatric bed and air mattress have both been requested. She had recently been referred to skilled therapies for evaluation of her wheelchair positioning and a new wheelchair is in process of being obtained at the facility. The bariatric bed and air mattress had not been initiated when mentioned they were requested on 11/26/24. -Date 12/12/24, Observations: Site: right heel, Type: Pressure, Length 3 cm, Width 2.5 cm, Stage Suspected Deep Tissue Injury; Site: Right Small Toe, Type: Pressure, Length 1.5 cm, Width 0.4 cm, Stage Suspected Deep Tissue Injury; Site: Right outer foot, Type: Pressure, Length 1.6 cm, Width 1.1 cm, Stage Suspected Deep Tissue Injury; Site: Left outer foot, Type: Pressure, Length 3.0 cm, Width 1 cm, Stage Suspected Deep Tissue Injury. Assessment notes included: (Resident's name) has an unstageable wounds to her right outer foot, right foot near her small toe and Left foot. She is severely cognitively impaired due to dementia. She relies on staff for repositioning . -Date 12/19/24, Observations: Site: Coccyx, Type: Pressure, Length 4 cm, Width 3cm, Depth 0.1 cm Stage: III; Site: right heel, Type: Pressure, Length 2.9 cm, Width 3.3 cm, Stage Suspected Deep Tissue Injury; Site: left heel, Type: Pressure, Length 3 cm, Width 2 cm, Stage Suspected Deep Tissue Injury; Site: Right Small Toe, Type: Pressure, Length 0.7 cm, Width 0.4 cm, Stage Suspected Deep Tissue Injury; Site: Right outer foot, Type: Pressure, Length 1.6 cm, Width 1.1 cm, Stage Suspected Deep Tissue Injury; Site: Left outer foot, Type: Pressure, Length 3.0 cm, Width 1.2 cm, Stage Suspected Deep Tissue Injury. Assessment notes included: (Resident's name) has multiple pressure wounds to her body. She relies on staff to reposition her. Her appetite is poor and she relies on staff to feed her. She is incontinent of her bladder and bowels . Treatments are completed as ordered. She is on an alternating air mattress. -Date 12/26/24, Observations: Site: Coccyx, Type: Pressure, Length 4.5 cm, Width 3cm, Depth 0.1 cm Stage: III; Site: right heel, Type: Pressure, Length 2.9 cm, Width 3.3 cm, Stage Suspected Deep Tissue Injury; Site: left heel, Type: Pressure, Length 30.5 cm, Width 20.5 cm, Stage Suspected Deep Tissue Injury; Site: Right Small Toe, Type: Pressure, Length 0.75 cm, Width 0.43 cm, Stage Suspected Deep Tissue Injury; Site: Right outer foot, Type: Pressure, Length 1.65 cm, Width 1.1 cm, Stage Suspected Deep Tissue Injury; Site: Left outer foot, Type: Pressure, Length 3.0 cm, Width 1.2 cm, Stage Suspected Deep Tissue Injury. Assessment notes included: (Resident's name) has multiple pressure wounds to her body. She relies on staff to reposition her. Her appetite is poor and she relies on staff to feed her. She is incontinent of her bladder and bowels . Treatments are completed as ordered. She is on an alternating air mattress. -Date 1/16/24, Observations: Site: Coccyx, Type: Pressure, Length 5 cm, Width 4cm, Depth 3 cm Stage: III; Site: Right outer foot, Type: Pressure, Length 1.5 cm, Width 1 cm, Stage: Suspected Deep Tissue Injury; Site: Left outer foot, Type: Pressure, Length 1 cm, Width 1 cm, Stage Suspected Deep Tissue Injury. Assessment notes included: (Resident's name) was readmitted with 3 pressure areas. She relies on staff to reposition her. She is now receiving tube feeding. She is incontinent of her bladder and bowels. She is at risk for further break down due to the diagnosis of Alzheimer's, depression, CKD (chronic kidney disease), HTN (hypertension) and hypothyroidism. Staff reposition her prn. Staff assist her to complete meals and fluids. Staff provide incontinence care upon rising, before and after meals, at HS (nighttime) and prn. Treatments are completed as ordered. She is on an alternating air mattress. Prafo boots are applied at HS and PRN. There was a description of the coccyx wound but not of the other wounds. A review of the progress notes revealed a lack of assessment of the other wounds. A review of Resident #1's medical record revealed a lack of documentation of the resident being repositioned and a lack of documentation regarding the application of the Parfo boots. A review of Resident #1's Short Term Care Plan Wound and Skin, revealed a care plan on 11/20 for the problem Potential for infection as evidence by: Redness and Tenderness was indicated, handwritten 1.5cmx (by) 0.8 cm deep tissue injury to outer R (right) foot. The Approaches included, Medication as Ordered, Ensure culture ., Document presence of S/S (signs and symptoms) of infection ., Assess nutritional needs ., Ensure availability of fluids, Notification of authorized representative PRN, Assess pain level within EMAR, TX (treatment) as ordered, Document compliance with TX and response to TX prn, Consult Health Care Practitioner PRN, Weekly/prn measurement of the area, Positioning guidelines/other indicated approaches for this resident: (no items documented). No further guidelines or approaches were identified on this care plan for positioning or other indicated approaches. The Short Term Care Plan had documentation for vital signs, drainage, odor, surrounding warmth, surrounding edema and compliant with positioning guidelines. A review of Resident #1's Short Term Care Plan Wound and Skin, revealed a care plan on 11/24 for the problem Potential for infection as evidence by: Symptoms: Stage I pressure injury coccyx with similar approaches as listed above with approach #10. Add indicated additional approaches to protect the residents skin to the permanent plan of care: (no other approaches were listed.) Further documentation was requested of the Short Term Care Plans (STCP) after the Resident returned from the hospital but was not received prior to the exit of the survey. A review of Resident #1's care plan revealed a Focus (Resident's name) is at risk for altered functional mobility and ADL's . Intervention for Skin, after the onset of pressure ulcers, included: Skin Impairment Location: both feet, sacrum revision on 11/27/24 Heels elevated in bed as tolerated; Inspect heels with care and report to charge nurse as indicated **Parfo boots to be worn ATC (around the clock) as tolerated, with a revision date on 11/27/24. The care plan and STCP-for potential for infection, lacked the identification of the multiple facility acquired pressure ulcers, and STCP for each individual wound with a lack of person centered approaches/interventions for the prevention and healing of the wounds and updated as wounds developed. A review of Resident #1's weekly nursing skin assessments revealed a skin assessment done on 8/28/24 and then on 9/11/24, 14 days apart; 11/27 skin assessment completed then not completed until 12/9 which was 12 days since the last skin assessment completed, then completed on 12/18 which was 9 days since the previous skin assessment completed; skin assessment completed on 12/18 from which the Resident was discharged to the hospital on 12/30 which was nine days between the completed skin assessments and transfer to the hospital. On 1/17/25 at 11:25 AM, an observation was made of Resident #1 lying in bed. The Resident did not engage in conversation but nodded yes for surveyor to watch dressing change completed with Clinical Care Coordinator, Nurse E and Nurse K. The old dressing was removed from the coccyx wound, area opened, reddened. The old dressing had packing that was covered by a foam dressing. When asked about the packing, Nurse K indicated that the order was not for a packing but both Nurses indicated it was a good idea and Nurse E indicated she would have the treatment order changed. The area was cleansed and Santyl applied to the wound bed and covered with a border foam dressing. An observation was made of the air mattress on the bed with settings of normal pressure, #3 comfort level and float. On 1/21/25 at 10:34 AM, an observation was made with Clinical Care Coordinator (CCC), Nurse E of Resident #1's feet and heels. An observation was made of Resident #1's feet and legs with dry flaking/peeling skin on bilateral feet and lower legs. The right heel where the blister had been, had pink skin and was not open, the outer foot areas had a brownish area in the middle of the wound bed and were not open. An observation was made with Nurse E of the air mattress machine. The settings were on 3-harness/comfort level and the air circulation was on float. When asked why the air mattress was on float, the CCC reported that she was not aware of the difference between float and alternating, but indicated she thought it was the air flow through the mattress. The Nurse indicated that they put all the air mattresses on alternating, and it should not be on float. The Nurse switched it to alternating. Resident #2: A review of Resident #2's medical record revealed an admission into the facility on 2/3/21 and readmission on [DATE] with diagnoses that included diabetes, Alzheimer's disease, weakness, Fournier gangrene and pressure ulcer of right buttock with onset date 11/21/24. A review of Resident #2's MDS dated [DATE] revealed the resident had one Stage 2 pressure ulcer that was not present upon admission/re-entry, had a Brief Interview of Mental Status score of 11/15 that indicated moderately impaired cognition, was dependent on staff for transfers and needed partial/moderate assistance with mobility to roll left and right. A review of the MDS dated [DATE] for Significant change revealed the Resident had two Stage 2 pressure ulcers that were not present upon admission/re-entry and had one Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) that was not present upon admission/re-entry. A review of Resident #2's Short Term Care Plan Wound and Skin, revealed a care plan on 11/21 for the problem Potential for infection as evidence by: Purulent Drainage was indicated, handwritten unstageable wound to right buttock. The Approaches included, Medication as Ordered, Ensure culture ., Document presence of S/S (signs and symptoms) of infection ., Assess nutritional needs ., Ensure availability of fluids, Notification of authorized representative PRN, Assess pain level within EMAR, TX (treatment) as ordered, Document compliance with TX and response to TX prn, Consult Health Care Practitioner PRN, Weekly/prn measurement of the area, Positioning guidelines/other indicated approaches for this resident: (no items documented). No further guidelines or approaches were identified on this care plan for positioning or other indicated approaches. The Short Term Care Plan had documentation for vital signs, drainage, odor, surrounding warmth, surrounding edema and compliant with positioning guidelines. A review of Resident #2's Wound Measurement documentation in the medical record revealed the following: -Dated 11/25/24, Observations: Site: Left heel, Type: Pressure, Length, 1.8 cm, Width 0.6, Depth 0.1, Stage: II; Site: Right Ischium, Type: Pressure, Length 3 cm, Width 4.2 cm, Depth 0.1, Stage: II, Right Ischium irregular shaped similar to a star. Assessment notes: There is a wound on resident's right ischium in the skin fold which is believed to be some pressure likely but also moisture excoriation based on the shape of the wound. The wound has several thin areas that stretch away from the center base [due to skin folds] giving it a star like shape. It is superficial at this time. His heel continues to heel slowly and is better when he is compliant with elevating his legs. There are no s/s of infection. The wound bed remains beefy red. -Dated 1/20/25, Observations: Site: Right buttock, Type: Pressure, Length 1 cm, Width 3 cm Depth 0.2 cm, Stage II; Site: Left buttock, Type: denuded blister, Length 1 cm, Width 1cm, Stage II; Site: Right Ischium, Type: Pressure, Length 1 cm, Width 1 cm, Depth 0.1 cm, Stage IV. Assessment notes: [assessment completed today for 1/17/2025] Wound on his right ischium [also labeled as right gluteal fold in the treatment orders] continues to heal slowly 2' (secondary) to poor oral intake especially poor protein intake despite protein supplement . He wound edges are healed to a more round shape [from original star-like shape]. There is scant drainage noted on previous dressing and no drainage noted during cleansing. The wound edges are flush with wound bed which remains pink. The peri wound area is appropriate for ethnicity and remains intact. There is no slough or s/s of infection. He has been more compliant with bed rest however he has been requesting that staff position him with pillows to help float his sacrum coccyx are but not actually lying on his side. Resident encouraged and tolerated lying on his side with pillows behind his back and supporting his leg for a short period of time. His heels remains pink and intact [free from pressure of breakdown]. New pressure area observed over the weekend to the right of his gluteal fold/right buttock/sacrum. The area is unusually shaped linear curve. The wound bed is beefy red with scant sanguineous drainage noted. Left Buttock across the gluteal fold [from right buttock wound] is a denuded blister [skin firm and slightly gray from blister stretching out skin and reabsorbing] Peri wound is pink and intact also. A review of the wound measurement documentation revealed wound measurements and assessments completed on 11/25/24 and then on 12/6/24, 11 days apart. A review of Resident #2's Skin Assessments from 8/26/24 to present revealed the following: 8/26/24 completed. 9/15/24, 20 days past the last skin assessment completed on 8/26/24. 10/13/24 and then after 14 days, skin assessment completed on 10/27/24. 11/3/24 and then after 14 days, skin assessment completed on 11/17/24. 11/21/24 and then after 10 days, skin assessment completed on 12/1/24. 12/1/24 and then after 35 days, skin assessment completed on 1/5/25. On 1/21/25 at 1:15 PM, an observation was made with Resident #2 of the dressing change to the buttock and ischial pressure wounds completed by Nurse J. The Resident was lying in bed, answered questions and engaged in conversation. Nurse J had removed the old dressings from the three areas, right buttock, left buttock and ischial wound. The dressing on the right buttock had drainage, the Nurse had used a 4 x 4 to cleanse the wound than folded the 4 x 4 over and cleansed the wound on the left buttock. The Nurse used the same 4 x 4 to cleanse both wounds and had not changed gloves and performed hand hygiene between the cleansing of the two wounds. The old dressing on the left buttock did not have any drainage. The Nurse got another 4 x 4 and started to clean the wound on the right ischial prior to changing gloves and performing hand hygiene. The Nurse stopped and leaving the 4 x 4 at the ischial wound, changed his gloves. It was noted that a small open area was observed by the Nurse of the Residents scrotum. The area was cleansed, and ointment was applied. Resident #3: A review of Resident #3's medical record revealed an admission into the facility on [DATE] and discharged on 1/4/25 with diagnoses that included enterocolitis due to Clostridium difficile, rhabdomyolysis, diabetes, heart failure and kidney failure. A review of Resident #3's Skin Assessments revealed a skin assessment completed on 12/4/24 and then completed next 12 days later on 12/16/24 and then not completed again until 12/30/24, 14 days after. On 1/21/25 at 11:46 AM, an interview of conducted with the Director of Nursing (DON) regarding the lack of skin assessments for Resident #1 and 2 and lack of assessment of the wound for Resident #1. The DON indicated that CCC, Nurse E might have her wound notes from week to week that are not in the electronic medical record. The lack of consistent skin assessments on a weekly basis was reviewed. The DON stated, Yes, I can see that the documentation is a concern. When asked about the air mattress alternating versus float, the DON indicated that it should be alternating and when addressed that the care plan did not have the machine settings, the DON indicated that they put the settings on the pump and can add alternating to the sticker. On 1/21/25 at 2:30 PM, an interview was conducted with CCC, Nurse E regarding Resident #1's development of the facility acquired pressure ulcers. When asked about facility policy on doing weekly skin assessments, a review was conducted of the lack of consistent weekly skin assessments. The Nurse indicated skin assessments were to be completed weekly. The Short Term Care Plan (STCP) for wounds were reviewed. The Nurse indicated that there should be a STCP for each wound. A review of the STCP revealed there was not a care plan for each individual wound. The Nurse indicated that the Nurses look at the wounds daily, and document on the STCP. A review of the STCP revealed that documentation had not occurred daily, and the documentation was not available for all wounds. The documentation would be for that specific wound with one STCP for each wound. Resident #2's wounds were reviewed with CCC, Nurse E. The Nurse reported that the left buttock origination was 1/19/24 and stated, I followed up on it yesterday, a denuded blister. A review of progress notes revealed that the wound had not been documented on 1/19/24 and the Nurse stated, I don't know why she didn't mention it in her note. The ischium was reported as started 11/21/24. A review of the STCP dated 11/21/24 listed Unstageable wound to right buttock, but the wound measurement documentation revealed two wounds at that time to the left heel and right ischium. The Nurse reported that each wound should have their own care plan, and the nurses were to document daily on the wounds. A review of the documentation of symptoms revealed that they were not done daily. The Nurse indicated that they are kept in a binder and once the page is filled, it is uploaded into the medical record. A request for the STCP's for Residents #2 and #1 were requested. The Nurse reported that our expectations are daily for the dressing and short term care plan documentation, and that there should be one for each wound. When asked who sets up the STCP, the Nurse reported the charge nurses or who ever discovers it, they should be adding a STCP in. A review of Resident #2's medical record revealed not all wounds identified with a care plan. The dressing change completed on Resident #2 with Nurse J was reviewed. The concern of professional standards of care for infection prevention was discussed with CCC, Nurse E. Review of the facility policy Skin at Risk Assessment Documentation, Staging & Treatment last revised January 2020 revealed, Policy: It is the policy of this facility to assess resident risk factors for the development of impaired skin integrity .It is the policy of this facility to assess skin on a regular basis to determine whether changes in the patient's skin condition have occurred. Weekly measurements and narrative assessments are conducted on existing pressure injuries .9. Re-assess and measure a pressure ulcer a minimum of weekly .10. Document the appearance of the wound with considerations to the physical characteristics as applicable to the resident: a. Location b. Stage c. Size d. Color e. Peri-wound condition f. Wound edges g. Sinus tracts or tunneling h. Exudate i. Odor .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an ongoing and comprehensive nutritional assessment and timely implementation and evaluation of person-centered interventions to prevent weight loss for one resident (Resident #94) of two residents reviewed, resulting in Resident #94 experiencing a severe weight loss and the likelihood for a decline in overall health status. Findings include: An observation of Resident #94 occurred on 2/12/24 at 11:53 AM in their room. The room was dark, with the light with the overhead lights off and the window shades closed. The Resident was in bed, with one leg half off the bed and their eyes open. The Resident had a gaunt appearance. When spoke to, Resident #94 made eye contact and smiled but did not provide a verbal response. The Resident's lips were noted to be dry with peeling skin. There were no beverages on the dresser next to the bed and/or the overbed table. Record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses which included heart disease and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 1/2/24, specified the Resident was severely cognitively impaired and required setup assistance for eating. The MDS further revealed the Resident did not have a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not receiving a therapeutic or mechanically altered diet. On 2/13/24 at 8:08 AM, Resident #94 was observed sitting in their wheelchair in the hallway of the facility. The Resident did not have a beverage within reach. Resident #94 was thin with a gaunt appearance. On 2/14/24 from 8:49 AM to 9:05 AM, Resident #94 was observed in the hallway of the facility sitting in their wheelchair across from the nurses' station, between the activity/dining room entrance and the medication cart. The Resident was unattended by staff, fidgeting, and did not have a beverage within reach. Review of Resident #94's care plans revealed a care plan entitled, Potential risk factors for nutritional concerns include lactose intolerance to milk to drink, dementia . has had a good appetite and enjoys meals in the dining room most days . has had some recent decline in intake, weight loss, change in swallow--goal for adequate intake, some weight gain as able (Initiated: 10/5/23; Revised: 1/29/24). The care plan included the goal, Adequate hydration will be maintained as evidenced by good skin turgor, moist mucous membranes, and no undesired weight loss and the following interventions: - Evaluate significant weight change with routine weights (Initiated: 10/5/23) - Honor Special Food Preferences: enjoys raisin bran, pizza, salad with ranch, honey on toast, juices, flavored water, cannot tolerate milk to drink (lactose) but can tolerate ice cream, and similar (Initiated and Revised: 10/5/23) - Nutritional Supplements per Dietary Assessment: 206 (fortified) juice with meals (Initiated: 10/5/23; Revised: 1/22/23) - Refer to ADL flow sheet for diet specifications (Initiated: 10/5/23) - Registered Dietician evaluation prn (as needed) (Initiated: 10/5/23) Review of Resident #94's EMR revealed another care plan entitled, Altered functional mobility and ADL's related to impaired cognition secondary to the diagnosis of Dementia . (Initiated and Revised: 10/5/23). This care plan included the interventions: - (Resident #94) needs redirection frequently . has meals in the EDR (dining room) . (Initiated and Revised: 10/16/23) - Diet: Pureed (Initiated: 1/28/24) - Eating: Provide set up assistance. Encourage intake, offer snacks (Initiated: 10/5/23; Revised: 10/12/23) - Liquids: Thin-regular, spout cup (Revised: 2/8/24) A review of Resident #94's weight documentation in the EMR was completed. As of 2/14/24, the Resident experienced a severe weight loss of 15.04% since their admission the facility and a 6.98% weight loss over the past month. Weight documentation in Resident #94's EMR included: - 10/5/23: 166.2 (pounds) lbs. - 11/8/23: 167.4 lbs. - 12/6/23: 163.4 lbs. - 12/11/23: 161.2 lbs. - 12/18/23: 157.6 lbs. - 1/4/24: 147 lbs. - 1/12/24: 151.8 lbs. - 2/14/24: 141.2 lbs. (15.04 % weight loss since 10/5/23 and a 6.98% Loss from 1/12/24) Review of Resident #94's Health Care Provider orders in the Electronic Medical Record (EMR) revealed the Resident's diet order was changed to Regular diet Pureed texture, Thin consistency on 1/28/24. From 10/5/23 to 1/27/24, Resident #94's diet order was, Regular diet Mechanical Soft texture, Thin consistency. The reason listed in the order for the change was suppose to be downgraded to pureed. There were no Healthcare Provider orders for nutritional supplements, weight monitoring, food intake monitoring, and/or diagnostic laboratory testing for nutritional status monitoring. Resident #94's EMR did not include task documentation of daily food and/or hydration intake (Food Intake Record-FAR). Review of Resident #94's Nutritional Services Quarterly Review dated 1/4/24 detailed the following, Current Weight: 157.6 . Weight Changes . None . regular diet, regular texture, thin liquids . appetite good, eating > 50% of meals . Nutritional Review . on a regular texture diet with thin liquids, and tolerates it well . has had some increased behaviors recently and appetite has not been as good . is eating better . Awaiting reweigh to ascertain weight changes but anticipate some loss . Goal for continued adequate oral intake as able remains at risk for weight loss . Assessment was signed on 1/5/24 by Certified Dietary Manager H. Note: Resident #94's EMR detailed they weighed 147 lbs. on 1/4/24. Review of Progress Note documentation revealed the following: - 10/5/23 at 12:58 PM: Interdisciplinary Documentation . admitted to our facility this morning . came from home . alert to person and situation. He has dementia/Alzheimer's and is confused . independent for transfers and dependent upon staff for ADL cares . is incontinent . is on regular diet with thin liquids, sits at assist table in dining room and requires encouragement with eating, mostly to stay on track . - 12/23/23 at 10:27 AM: Interdisciplinary Documentation . (Spouse) called today and expressed concerns of resident sleeping too much . states when here for the Christmas party the other day (Resident #94) kept falling asleep in their chair and seemed to have little to no interest in eating . - 12/23/23 at 2:36 PM: Interdisciplinary Documentation . CNA (Certified Nursing Assistant) report that resident did wake up and have some breakfast this morning, states had 25-50% of breakfast with assistance and for lunch ate about 25% but kept closing eyes . did awaken easily by the call of name but was holding the food in mouth. Lots of encouragement was provided during meal . - 1/22/24 at 8:12 AM: Interdisciplinary Documentation . weight is trending down with decreased oral intake. Staff assisting as needed with intake. Variable intake likely r/t (related to) recent behaviors . Recommend addition of 206 juice with meals for weight maintenance. Notified therapy of recent pocketing, possible swallowing difficulty. - 1/28/24 at 6:07 AM: Interdisciplinary Documentation . Per report, resident was having trouble chewing foods. Diet was downgraded to pureed. Diet slip filled out and gave to kitchen . - 1/29/24 at 12:35 PM: Interdisciplinary Documentation . diet was downgraded to puree texture over the weekend. Change in medications done--note recent weight loss, supplements now in place. Goal for weight maintenance as able or slow gain. Updated plan of care. - 2/7/24 at 7:33 AM: Interdisciplinary Documentation . continues with poor oral intake despite encouragement and assist as well as alternatives offered . refuses to open mouth for staff, often at mealtime, sometimes taking a few bits, sometimes no intake at all. Discussed oral intake with unit coordinator. Supplements in place, but poor intake overall. - 2/8/23 at 12:45 PM: Interdisciplinary Documentation . Nursing staff requested spout cup with meals for support for independent intake. Updated menus. Further review of Resident #94's EMR revealed documentation of behaviors throughout their stay in the facility including increasing behaviors on 10/16/23. An interview was completed with Therapy Manager I on 2/14/24 at 10:38 AM. When queried if Resident #94 was receiving any therapy services, Director I stated, Not on therapy. When asked if the Resident had been evaluated for therapy services, Director I replied, (Resident #94) does not have a med B benefit for therapy and revealed the Resident had never been evaluated and/or picked up by therapy services due to lack of insurance coverage. On 2/14/24 at 12:43 PM, an interview was conducted with Certified Dietary Manager H. When asked who had completed Resident #94's nutritional assessments, Manager H revealed they completed resident nutritional assessments. When queried if the facility had a Registered Dietician, Manager H responded that a Registered Dietician was available but not present in the building. When queried regarding Resident #94, Manager H revealed they were aware of the Resident's significant weight loss and stated, Staff started feeding (Resident #94) within the past month. With further inquiry regarding the weight loss, Manager H stated, (Resident #94) had an increase in behaviors and their intake started going down. Manager H was asked when the Resident started to display increased behaviors with decreased intake and replied they were unsure of the timeframes. When queried food and fluid intake is documented in the EMR, Manager H replied, Nursing started documenting in the notes this past week. A review of progress note documentation was completed with Manager H at this time. Review revealed inconsistent documentation which included breakfast and lunch intake on 2/7/24, 2/8/24, 2/12/24, and 2/13/24. When queried if there was a task for intake documentation, such as a FAR, Manager H reviewed the EMR and revealed a task for intake monitoring/documentation was not active. Manager H stated, I can trigger that (intake task documentation/FAR). When asked why intake monitoring was not already in place for a Resident with significant weight loss, Manager H replied, I can't answer that. Manager H then stated, I just triggered it (EMR task for intake monitoring documentation). When queried how often Resident #94 is supposed to be weighed, Manager H replied, Weekly. When queried why weekly weights were not completed in the EMR, Manager H reviewed the EMR documentation and confirmed weights had not been completed weekly but did not provide further explanation. When asked if Resident #94's weight loss was unintended, Manager H confirmed it was. Manager H was then asked what interventions had been implemented and/or attempted to prevent the Resident #94 undesired weight loss and stated, 206 juice supplement three times a day was added 1/22/24. When queried who administered the supplement, Manager H disclosed dietary services place it on the Resident's food trays. When asked how they monitored if Resident #94 received the 206-juice supplement, if they drank it, and how much they drank, Manager H replied they did not know. Manager H revealed there was no current documentation of intake. When asked if Resident #94 received other beverages on their food tray, Manager H responded, Yes. Manager H was then asked how they would distinguish if the Resident consumed the 206-supplement juice or another beverage when reviewing the intake documentation task which they triggered in the Resident's EMR and revealed they would not know. Manager H then stated, I am adding it to the MAR. When queried if nursing staff will administer the supplement and document on the MAR, Manager H specified the supplement will continue to be served on the Resident's food trays prepared by dietary staff. When queried regarding the facility procedure for administering, monitoring and documenting nutritional supplement intake, Manager H indicated nursing staff will have to follow up with (Resident #94's) aide when documenting if Resident #94 received and drank the supplement. When queried what Resident #94's Usual Body Weight (UBW) was, Manager H revealed they believed it was their admission weight. Manager H was then asked what Resident #94's total caloric needs were, if their need had changed following their weight loss, and location of documentation. Manager H reviewed the Resident's most recent nutritional assessment and stated, Not in the assessment. With further inquiry regarding when they first identified the Resident's weight loss, Manager H stated, On January 4th, I was waiting for a reweight. When asked to explain the process for a reweight, Manager H revealed they were waiting until the weight obtained the following week. When queried if they thought the weight was inaccurate, Manager H indicated did. Manager H was then asked why they would wait a week to obtain another weight if they thought the weight was inaccurate and revealed they always wait until the next weekly weight prior to making changes. Resident #94's Nutritional Services Quarterly Review assessment dated [DATE] was reviewed with Manager H at this time. When queried regarding documentation on the assessment specifying the Resident had a good appetite and was eating greater than 50% of their meals when intake was not documented consistently and a FAR was not in place, Manager H replied they thought intake looked good from nursing notes. All of Resident #94's documented weights were reviewed with Manager H at this time. When queried why no weights were obtained between 12/18/23 (157.6 lbs.) to 1/4/24 (147 lbs.) and for the week of 11/12/23 to 11/18/23, Manager H was unable to provide an explanation. Review revealed Resident #94 experienced a 5.85% weight loss from 11/8/23 (167.4 lbs.) to 12/18/23 (157.6 lbs.). Manager H verified the Resident's weight loss began in December 2023. When queried if they had identified, assessed, and documented on the weight loss in December, Manager H reviewed the EMR and confirmed they had not documented a note or assessment. When asked, Manager H revealed they need to improve their documentation. When queried if they implemented any interventions in December 2023, Manager H reviewed the care plan including the care plan history and revealed there were no new interventions. With further inquiry regarding interventions, Manager H revealed the only interventions that had been added to the care plan were the 206-juice supplement with meals on 1/22/24 and a diet downgrade on 1/28/24 to pureed. When queried why Resident #94's diet was downgraded, Manager H revealed nursing staff had verbalized concerns that Resident #94 was pocketing food. When queried if a speech evaluation was completed, Manager H indicated they did not know. When asked if they had attempted fortified foods, Manager H revealed they had not. When asked the rationale, Manager H did not provide a response but indicated they would add fortified foods. When queried if the Resident received a snack, Manager H revealed the Resident is able to have a snack but since it is not ordered, a snack is not specifically prepared for them. When queried how they monitor if the Resident is eating a snack for their nutritional needs, Manager H revealed they do not. When asked if they had attempted finger foods, favorite foods, stimulation, assistance, and/or modifying the times Resident #94 eats, Manager H revealed the only other intervention in place was nursing staff assistance to eat when needed. When queried regarding the quarterly MDS assessment dated [DATE] specifying the Resident had not had a weight loss, when a recent weight had not been completed and the Resident had a 5.85% loss from 11/8/23 to 12/18/23, an explanation was not provided. When queried if they were able to see a concern related to Resident #94's weight loss including lack of timely interventions and comprehensive evaluation/reevaluation, Manager H revealed they did and verbalized understanding. An interview was completed with the Acting Director of Nursing (DON) Registered Nurse (RN) A on 2/14/24 at 3:01 PM. When queried regarding the reason for Resident #94's admission, RN A revealed the Resident's family were no longer able to care for them at home. When queried if Resident #94 was at risk for weight loss upon admission, RN A indicated they were. RN A was informed of observations of Resident #94 without a beverage in reach. When asked, RN A indicated the Resident should have a beverage available and in reach. Resident #94's weights and weight loss were reviewed with RN A at this time. When queried regarding interventions implemented to prevent weight loss, RN A stated, I do know the girls (staff) assist (Resident #94) with meals as needed. RN A was queried regarding facility policy/procedure related to obtaining resident weights and stated, Most of our weights are weekly. When asked why Resident #94's weights were not completed weekly, RN A was unable to provide an explanation. When queried if it is reasonable to make follow up on weights, RN A stated, That is reasonable. RN A was then queried regarding the Resident's diet being downgraded to pureed without having a speech therapy evaluation. RN A indicated a therapy screen should have been completed. After reviewing the EMR, RN A revealed they were unable to locate documentation of a speech therapy screen related to possible pocketing when eating. When queried if Resident #94 receives snacks and how staff monitor if they consumed the snack, RN A stated, If it is ordered, then it would be charted on. RN A reviewed Resident #94's EMR and stated, Not there. When asked, RN A confirmed the lack of documentation of Resident #94's intake. When queried how the Resident's nutritional status is accurately and comprehensively monitored when their intake is not documented, RN A confirmed it could not. When queried regarding the lack of interventions, RN A stated, I agree. An interview was completed with the facility Administrator on 2/15/24 at 8:10 AM. When queried regarding Resident #94's severe weight loss including lack of monitoring, assessment, and implementation of interventions, the Administrator revealed they were aware of the concern and agreed. The Administrator verbalized the concern would be addressed. Review of facility policy/procedure entitled, Weight Management (Effective April 2015, Revised: (Blank) revealed, Purpose: To assist the resident to maintain acceptable parameters of nutritional status such as body weight and protein levels . 5. In the event of a patterned or significant unplanned weight loss . the IDT is responsible for assessing and implementing individualized interventions . 7. Improving intake via wholesome foods is generally preferable to adding nutritional supplementation . Examples of interventions to improve food/fluid intake include: a. Fortification of foods. b. Offering smaller, more frequent meals. c. Providing between-meal snacks or nourishments. d. Increasing the portion sizes of a resident's favorite foods and meals; and providing nutritional supplements. 8. The nutritional plan of care is evaluated a minimum of quarterly and as indicated to determine if current interventions are being following and if they are effective .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #33 On 10/31/22, at 12:33 PM, Resident #33 was lying in their bed. They had a urinary catheter hooked to the bed frame. The urine in the tubing was noted to have an orangish red color. There was a strong urine odor to the room. On 11/01/22, at 12:35 PM, an observation along with Nurse Y of Resident #33's catheter was observed. The catheter tubing had sediment and blood noted. Nurse Y was asked what they saw and Nurse Y stated, cloudy urine with sediment and Nurse Y was asked if they saw blood at all and Nurse Y stated, yes, it looks like bloody sediment. Nurse Y was asked to pull the blanket back for an observation of the catheter insertion site which was through the lower abdominal wall. The site had bloody drainage and no dressing noted. On 11/01/22, at 12:59 PM, Infection Control (IC) Nurse T entered Resident #33's room to assess their urine color and odor. IC Nurse T looked at the catheter bag and stated, they saw hematuria (blood in urine.) IC Nurse T assessed the catheter tubing and was asked what they saw and IC Nurse T stated, bloody sediment. IC Nurse T was asked if they smelled a strong urine odor in the room and IC Nurse T stated, yes, I will get ahold of the doctor. Most likely change the catheter and get a urine. On 11/02/22, at 3:30 PM, a record review of Resident #33's electronic medical record revealed a readmission on [DATE] with diagnosis of Urinary Tract Infection (UTI), MS and Hemiparesis. Resident #33 required extensive assistance with all Activities of Daily Living (ADL) and had severely impaired cognition. A review of the physician orders revealed Change indwelling catheter only as needed per physician orders based on clinical indicators such as infection, obstruction or sediment. Start Date 6/27/2022 . An added physician order to obtain a urine sample was added during survey of . Obtain UA (urinalysis) with culture if indicated one time only .Start Date 11/1/2022 . A review of the progress notes revealed 11/1/2022 14:59 (2:59 PM) . Suprapubic catheter was replaced this afternoon in compliance with facility protocol and quality measures as the previous indwelling catheter was no longer functioning as intended. Orders . for catheter replacement were followed, and the resident tolerated the procedure will. Catheter was placed, urine return was obtained, and catheter was stabilized to the proximal lower extremity. Urine specimen was obtained for culture and sensitivity . On 11/03/22, at 10:26 AM, The Director of Nursing (DON) was asked what the expectation of the nurse of a resident who has a urinary catheter and the DON stated, the expect the nurses assess the catheters. On 11/03/22, at 12:15 PM, a record review of the facility provided UA result for Resident #33 resulted the following: . Culture received . OUT OF RANGE RESULT REVIEW .UA COLOR ORANGE . UA APPEARANCE TURBID . UA BILIRUBIN SMALL . UA BLOOD LARGE . UA PROTEIN 100 . UA NITRITES POSITIVE . UA LEUKOCYTES ESTERASE LARGE . UA WBCS >100 . UA RBCS >100 . UA SQUAMOUS EPTHELIAL CELLS 10-25 . UA BACTERIA 4 + . Based on observation, interview, and record review, the facility failed to 1.) assess and monitor for urinary/catheter changes for Resident #33 and prevent facility acquired urinary tract infections for three (3) Residents (#9, #76, #95) resulting in the likelihood for bladder injury, cross contamination and facility acquired urinary tract infections requiring antibiotic therapies. Findings Include: Record review of facility 'Urinary Tract Infection; Catheter Associated UTI's (CAUTI's) Prevention & Surveillance Guidelines' policy dated 10/2011 revealed it is the policy of the facility to apply evidenced-based guidelines to alterable risk factors in the development of nosocomial Urinary Tract Infections (UTI's) . Resident #9: In an interview and observation on 10/31/22 at 10:27 AM with Resident #9 during the entrance tour of the survey revealed a catheter with large amount of urine, estimated over 1000cc hanging at the bedside with a leaf privacy flap. In an interview with Resident #9 about his catheter revealed about the catheter, the resident stated that it hurts sometimes and gets plugged up. Resident #9 stated that he had a Urinary Tract Infection (UTI) and it hurt and bleeds at times. Record review of Resident #9's Urinalysis lab results dated 10/25/2022 revealed a positive result. Record review of Resident #9's Medication Administration Record (MAR) for the month of October 2022, revealed that Keflex (antibiotic) 500mg oral was started for infection. Observation and interview on 11/02/22 at 07:51 AM of Resident #9 while lying in bed revealed Observed urinary catheter with a bag with privacy flap, bag is full 1300 cc and touching the floor. Resident #9 was able to raise his bed to get the catheter off the floor but left the bed up higher than usual. Resident #9 stated that no one (staff) has given him water yet or emptied his catheter bag. In an interview on 11/02/22 at 08:40 AM with the Director of Nursing (DON) was asked about the emptying of catheter bags? The DON stated that catheter bags should be emptied at the end of each shift. The first shift started at 6:00 AM, the state surveyor questioned the 1300 cc estimated amount in the catheter bag of Resident #9, and that the catheter bad was laying on the floor. The DON stated that the catheter bag should not be touching the floor and cross contamination was brought up from dirty floors to catheter bag, and no there should not be that much urine in the bag this early in the morning. The DON revealed that Resident #9's catheter bag has a filter due to his urine sediment is heavy in the urine and if the bag is full then the filter cannot filter out the sediment. In an interview on 11/02/22 at 01:48 PM with the Infection Control Preventionist (RN/ICP) T stated that Resident #9 did have a Urinary Tract Infection (UTI) with catheter in place. Record review of infection control logs revealed that in March 2022, Resident #9 did get a UTI culture was Proteus Mirabilis and E. Coli and had a catheter in place. Now, in October 2022 he has another UTI with Klebsiella pneumonia and was placed on Keflex. Yes, it was facility acquired. He has had repeat UTIs the catheter is changed when the physician orders it. We collect the urine sample with a sterile syringe, and we follow [NAME] 8th edition. In an interview on 11/02/22 at 4:21 PM with the Director of Nursing (DON) Follow up: The DON stated that she did go down to Resident #9's room, and you were right the catheter bag is 2000 cc bag and it did have 1300cc and was hanging low. His Certified Nurse Assistant (CNA) D was talked to about why it was not emptied. A foley bag It should be emptied 1 time a shift and this one was not. Record review on 11/03/22 at 09:03 AM of Certified Nurse Assistant (CNA) D paper form 'Performance review and Clinical Skills Check' dated 9/1/2022 and signed by the Infection Control Preventionist as checked off as Satisfactory. Resident #76: Record review of Resident #76's Minimum Data Set (MDS) quarterly dated 9/6/2022 revealed a [AGE] year-old female with brief interview of mental status of Zero. Resident #76's medical diagnosis included: hypertension, peripheral vascular disease, non-Alzheimer dementia, depression, psychotic disorder, weakness, difficulty walking, and low back pain were some of the diagnoses. Record review of section G: Functional status revealed toileting and personal hygiene were coded as #4 (total dependence- full staff performance every time #2 One-person physical assist. Section H: Bladder and Bowel: always incontinent of both urine and bowel. Record review on 11/01/22 at 4:32 PM of Resident #76's urinalysis dated 9/16/2022 result was positive. Record review of Resident #76's Medication Administration Record for the month of September 2022, Keflex 500mg oral three times a day was started on 9/18/2022 for urinary tract infection. In an interview on 11/0/22 at 01:35 PM with the Infection Preventionist T revealed that Resident #76's in September 2022 had a urinalysis cultured results of E. Coli and was put on Keflex antibiotic. The Infection Preventionist T revealed that this was a facility acquired Urinary Tract Infection, and that there was no Peri care education was done at that time. Resident #95: Record review of Resident #95's Minimum Data Set (MDS) quarterly dated 8/23/2022 revealed an [AGE] year-old female with brief interview of mental status of Zero. Resident #76's medical diagnosis included: coronary artery disease, hypertension, septicemia, urinary tract infections, non-Alzheimer dementia, anxiety, depression, and psychotic disorder were some of the diagnoses. Record review of section G: Functional status revealed toileting were coded as #3 (Extensive assistance- full staff provided weight bearing support) Support provided: coded #3 Two-person physical assist. Section H: Bladder and Bowel: frequently incontinent of both urine and bowel. Record review of Resident #95's progress notes revealed that in the month of July 2022 Resident #95 had a change of condition with lethargy. Record review of Resident #95's July 2022 Medication Administration Record (MAR) revealed on 7/28/2022 Resident #95 received Rocephin 1 gram Intramuscular. Record review of the Infection Control July antibiotic log revealed that there was record of the antibiotic injection noted. Record review of Resident #95's urinalysis on 7/29/2022 revealed positive for E. Coli and started antibiotic. Record review and interview on 11/02/22 at 01:42 PM with Infection Preventionist T revealed that Resident #95's had a facility acquired urinary tract infection, she was hospitalized , came a back to the facility with Peripheral Inserted Central Catheter (PICC) line and ertapenem intravenous (IV) antibiotic daily. The Infection Preventionist T stated that the organism was e. Coli. The state surveyor asked about the last facility Peri care education was given to staff. Infection Preventionist T stated that the 1st week of October 2022 with skills check week. Interview with Infection Preventionist T revealed that Resident #95 had a Urinary Tract Infection (UTI) in July 2022 with lethargy and hospitalization. The Urinalysis came back on 7/29/22 culture positive for E. Coli. Resident #95 came back from hospital stay in first week of August on Meropenem IV with PICC line. Infection Preventionist T stated that yes it was facility acquired. The Infection Preventionist T looked through large white binder for peri care education. There was none done, but it was covered in the October 2022 skills labs. There was no return demonstration observed of staff. Rocephin antibiotic 1 gram IM was given on 7/28/2022, but I didn't get it on the antibiotic log. The physician did a risk vs benefits note in the progress notes.