**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure a comprehensive nutritional assessment was completed and further failed to identify, comprehensively assess and monitor for signs/symptoms of dehydration for 1 of 3 residents (R1) reviewed for change in condition. The facility's failures resulted in harm when R1 required a 3 day hospitalization for profound hypernatremia and hypovolemia. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1's cognition was intact and had diagnoses of congestive heart failure, hypernatremia (a condition where there is too much sodium in the blood that can be caused by diarrhea and not drinking enough fluids) and hyperosmolality (a condition where the blood has a high concentration of salt, glucose and other substances which draws water out of the body's organs). R1 was always continent of bowel and bladder with no special diet. R1 received diuretics. R1's order summary dated 10/8/24, identified R1 had an order to receive torsemide 20 milligrams (mg) twice a day for heart failure. Additional orders to receive docusate sodium (emollient laxative that draws water and fat into your stool, making it softer and easier for stool to pass) give 100 mg twice a day for constipation. R1's Nutritional Therapy assessment dated [DATE] identified R1 was obese with no recent weight change, received a regular diet, used an adaptive divided plate with Dycem, mugs with lids and straws and built-up utensils. R1's food and fluid were adequate to meet estimated needs. Nutritional needs estimation did not identify how many calories, protein, or the amount of fluids R1 would need daily. R1's nutritional assessment did not identify R1 was on diuretics. R1's Bowel and Bladder Observation dated 10/11/24, identified R1 typically had a fluid intake of 501 to 1000 milliliters (ml)/daily. R1's discharge-return anticipated MDS assessment dated [DATE], identified R1 was frequently incontinent of bowel, received a mechanically altered diet and diuretics. Review of R1's record did not include a comprehensive assessment that identified R1's risk for dehydration, nor did the care plan address goals and interventions to prevent or mitigate R1's risk for dehydration related to (but not limited to) level of assistance, diuretic usage, change in diet to thickened liquids, and requiring assistance with eating. R1's care plan identified a problem dated 10/15/24, nutritional status potential for significant wight change and malnutrition. Intervention dated 11/11/24 to provide a pureed diet with nectar thickened liquids, provide feeding assistance when in an upright position in the wheelchair, not in the bed or recliner and complete oral cares after meals due to observed residue in mouth. An additional problem dated 10/30/24, R1 was limited in the ability to toilet self-related to immobility, weakness, and deconditioning, was frequently incontinent of bowel and bladder with a long-term goal to have a Bowel Movement (BM) every 3 days. Interventions included to monitor and record BM every shift and administer docusate sodium, Citrucel (bulk-forming laxative), and Miralax (osmotic laxative) per provider orders and to monitor the effectiveness of the medication. An additional intervention was to encourage fluids and reminder to drink fluids in between meals. R1's Vital report for fluid intake identified total fluid intakes each day for October and November 2024 however, in review of R1's record between 10/8/24 through 10/28/24, revealed the record did not include assessments/evaluations to ensure appropriate fluid balance and/or evident R1 was monitored for signs/symptoms of dehydration. Documented intakes included: 10/8/24: 200 ml 10/9/24: 960 ml 10/10/24: 840 ml 10/11/24: 990 ml 10/12/24: 650 ml 10/13/24: 420 ml R1's hospital discharge summary identified R1 was hospitalized from [DATE] at 5:25 p.m. to 10/16/24,and returned to the facility at 2:45 p.m. R1 was hospitalized for severe hypotension (when blood pressure drops dangerously low), acute respiratory failure with hypoxia (when your lungs suddenly fail to adequately oxygenate the blood leading to a dangerously low level of oxygen in the blood) due to a choking/aspiration event and was discharged with new diet orders for nectar thickened liquids and soft and bite sized diet. 10/16/24: 120 ml 10/17/24: 240 ml 10/18/24: 460 ml 10/19/24: 540 ml 10/20/24: 672 ml 10/21/24: 440 ml 10/22/24: 640 ml 10/23/23: 0 ml R1's hospital discharge summary identified R1 was hospitalized from [DATE] at 10:00 a.m. to 10/29/24 and returned to the facility at 1:00 p.m. R1 was hospitalized for profound hypernatremia and stupor secondary to poor oral intake and hypovolemia (a condition where the body loses too much fluid, such as blood or water which can lead to organ malfunction or failure), R1's torsemide was discontinued due to hypovolemia and may be restarted at a later date if needed. R1 will need to be offered water by staff every 4 to 6 hours, R1 may not ask for water so it needs to be offered. R1's Nutrition Reassessment dated [DATE] identified R1 received mechanical soft diet with thickened liquids. R1's current intake at meals was 50 to 74%. Food and fluid intake adequate to meet R1's needs was not identified and the assessment did not include an evaluation of R1's daily fluid consumption. R1's bowel and bladder record reviewed between 11/2/24 through 11/13/24 identified R1 had 17 large loose stools. R1's Vital report for fluid intake identified total fluid intakes each day for October and November 2024 however, in review of R1's record between 10/29/24 through 11/13/24, revealed the record did not include assessments/evaluations to ensure appropriate fluid volume balance and/or evident R1 was monitored for signs/symptoms of dehydration. Additionally, the record did not include documentation R1 was offered fluids every 4-6 hours per the hospital Discharge summary dated [DATE]. Documented intakes included: 10/29/24: 0 ml 10/30/24: 1,150 ml 10/31/24: 300 ml 11/1/24: 240 ml 11/2/24: 950 ml 11/3/24: 0 ml 11/4/24: 0 ml 11/5/24: 320 ml 11/6/24: 520 ml 11/7/24: 605 ml 11/8/24: 0 ml 11/9/24: 350 ml 11/10/24: 320 ml 11/11/24: 0 ml 11/12/24: 580 ml 11/13/24: 560 ml R1's Speech therapy (ST) Evaluation and Plan of treatment dated 11/11/24 identified R1 had a diagnosis of dysphagia (difficulty swallowing) required assist with eating and recommendations were to receive nectar thickened liquids with pureed consistencies. During a phone interview on 11/26/24 at 2:02 p.m., family member (FM)-A identified she was R1's guardian. FM-A indicated R1 had previously lived in a group home and had gotten COVID and had four hospitalizations since 9/25/24. FM-A stated the first and second time R1 had problems with her breathing, the third time she had high sodium levels and stated she didn't think R1 was getting enough to drink. FM-A stated after one of R1's hospitalizations she had to be on thickened liquids and didn't think the staff were offering the fluids like they should have been and R1 needed help with drinking fluids. During an interview on 11/26/24 at 4:26 p.m., nursing assistant (NA)-A identified R1 had a pureed diet and thickened liquids and needed assist with eating. NA-A stated she was not aware that fluids needed to be encouraged with R1 until the day she passed away on 11/13/24. NA-A stated the kitchen staff would pick up R1's lunch trays and document the fluids given. NA-A further stated R1 typically did not drink her fluids well. During an interview on 11/27/24 at 9:30 a.m., NA-B indicated R1 was on pureed foods and thickened liquids and stated R1 typically didn't eat much preferred desserts but would drink. NA-B stated initially R1 did not like thickened liquids but once we explained why she had to have thickened she would drink, she liked the thickened juice. During an interview on 11/27/24 at 1:51 p.m. licensed practical nurse (LPN)-B indicated low fluid intake along with loose stools can lead to dehydration and an electrolyte imbalance. LPN-B stated R1 was not drinking enough and was having several loose stools which can lead to dehydration. LPN-B stated she was unsure they had a system in place to monitor fluid intake unless a resident was on a fluid restriction. LPN-B indicated R1 was not being monitored for dehydration. During an interview on 11/27/24 at 12:54 p.m., LPN-A stated R1's care plan did not identify R1 was at risk for dehydration and did not identify the amount of fluids R1 would need daily to prevent dehydration. LPN-A indicated from 11/3/24 to 11/10/24, R1 received less than 600 ml of fluids daily and and 15 large loose stools would place R1 at risk for dehydration. During an interview on 11/27/24 at 1:44 p.m., dietary aide (DA)-A stated the nursing staff are responsible to document flood and fluid intake for their residents. On unit 2 the kitchen staff are responsible to document the food and fluid intake in the resident medical record. The residents who ate in their rooms, dietary would pick up the resident trays and document how much they ate based on what was left on their tray. During an interview on 11/27/24 at 1:15 p.m., dietary manager (DM)-A stated R1's admission nutritional assessment was not comprehensive and did not include R1 was administered diuretic medications, also did not identify the amount of calories and fluids R1 would need daily. DM-A stated she would start getting worried if a resident was not drinking 400 ml per meal. DM-A explained from 11/3/24 to 11/13/24, R1's fluid intake was less than 600 ml daily along with over 15 loose stools during that time, she would worry about dehydration. DM-A was unsure if R1's intakes were being monitored or who would be responsible for that. During a phone interview on 12/2/24 at 12:10 p.m., registered dietician (RD)-A stated a nutritional assessment was completed on all residents upon admit, with significant changes and annually. RD-A stated she did not comprehensively assess R1 for the amount of fluid intake she would need daily and did not develop a care plan for R1's risk for dehydration. RD-A stated typically the average resident would need 1500 ml per day to stay hydrated and verified that R1 was receiving less than 600 ml daily for 10 days prior to R1's death along with over 15 large loose stools. RD verified R1 was admitted with torsemide and taking this medication would put R1 at risk for dehydration and then was hospitalized from [DATE] to 10/29/24 for severe hypernatremia and was receiving thickened liquids due to difficulty swallowing, these factors put her at higher risk for dehydration. RD-A stated R1's body was losing fluids faster than she could take in and stated R1 should have been monitored for dehydration. During an interview on 11/27/24 at 2:03 p.m., interim director of nursing (IDON) indicated the facility did not currently have a system in place to monitor residents for fluid intake unless a resident was on a fluid restriction. IDON indicated R1's fluid intake was less than 600 ml daily for about 10 days along with over 15 large loose stools which had a high potential to lead to dehydration, the provider should have been notified right away. During a phone interview on 12/2/24 at 2:18 p.m., physician assistant (PA)-A stated any resident who had loose stools, bowel medications should be held, if loose stools continue for two days the provider should be notified to address this. PA-A further stated in conjunction with R1's lack of fluids and chronic loose stools could lead to dehydration which can cause hypernatremia, which is a condition where the level of sodium in the blood is too high. PA-A stated R1 would be at high risk for dehydration with low fluid intake, loose stools and recent history of hypernatremia, facility should be closely monitoring residents like this a reporting it to the provider. Facility policy Dehydration Nutrition Interventions dated 9/2024, included Individuals at risk for dehydration will be identified and provided with sufficient fluid intake to maintain proper hydration and health. Implementation: Each individual will receive sufficient amounts of fluid based on individual need and personal preference to prevent dehydration and maintain health. 1. Risk factors for and/or clinical signs of dehydration will be identified through routine nursing assessments. 2. Adequate fluids should be offered based on a comprehensive nutrition assessment of factors affecting fluid needs and fluid intakes. 3. Fluids should be provided based on each individual's beverage preferences and physician's orders for fluid consistency. 4. If fluids intake is not adequate to meet needs, an IV or enteral feeding tube may be recommended. Facility policy Encouraging and Restricting Fluids dated 7/2024 included: The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. The policy directed staff on the protocol to encourage fluids and documentation requirements. The documentation requirements directed staff to record any evidence of dehydration such as weight loss, confusion, drowsiness, dry skin Further directing staff to notify the supervisor if the resident refuses. Facility policy Comprehensive Medical Nutrition Therapy assessment dated 11/2024 included The RDN will complete a comprehensive medical nutrition therapy assessment for each individual that is referred or identified. The purpose of nutrition assessment is to obtain, verify, and interpret data needed to identify nutrition-related problems, their causes, and significance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to completely inform 1 of 1 residents (R18) of their medical condition. This resulted in actual psychosocial harm for R18, when R18 had been erroneously informed he had a terminal diagnosis, and 2-3 weeks to live, without a medical diagnosis of a terminal condition. Findings include: R18's admission Minimum Data Set (MDS) dated [DATE], identified R18 was cognitively intact, did not exhibit behavioral symptoms or depression, was considered medically complex with problems including anemia, concerns related clotting disorder, end-stage-kidney disease requiring hemodialysis, and diabetes mellitus among other diagnosis. R18 did not have a pressure ulcer at that time, and the MDS did not indicate R18 had a terminal condition. R18's medical provider's note dated 3/18/22, written by a physician's assistant (PA)-A, included, R18 had been admitted to the facility following hospitalization due to concerns of a stroke and was found to have several blood clots in veins but not a stroke. R18 had a history of end stage renal disease (ESRD) and had been receiving dialysis. R18 had been active since admission to the facility, going to dialysis, but also on outings with family and friends, and R18 was hoping to discharge back to his home soon. PA-A recommended R18 decrease his outings and spend more time in therapy in order to meet his goal of returning home. The note did not indicate R18 had a wound at that time, nor did it indicate R18 was in a terminal condition. R18's medical provider's note dated 4/6/22, written by a medical doctor (MD)-A, identified R18 was on dialysis for ESRD and receiving physical therapy for strengthening. R18 had diabetic nephropathy associated with type 2 diabetes mellitus (kidney damage from diabetes). R18 had been admitted to the facility for generalized weakness, but was improving and the plan was to discharge home. There was no mention of skin problems, or anything to indicate R18 was in a terminal condition. R18's medical providers noted dated 4/12/22, written by PA-A, identified R18 had developed a skin lesion on the right inner gluteal cleft of his buttocks, and some superficial skin breakdown of the gluteal cleft. PA-A wrote the lesion was not open, but was indurated (hard swelling) and approximately 2 cm in length by 0.5 cm in width. A very small opening was noted, but PA-A was unsure if this was related. At that time there was no warmth or redness and no drainage and PA-A indicated this area might be a cyst, and warm packs were ordered to be applied three times per day. PA-A indicated R18 should be seen at the clinic for evaluation if his condition worsened. A Telephone Encounter note dated 4/18/22 indicated PA-A had received communication from the facility that R18's wound had some spreading redness and an open area. PA-A provided an order to start Doxycycline monohydrate (antibiotic) 100 mg two times per day and sulfamethoxazole/trimethoprim (antibiotic) 800-160 mg once daily in the evenings. A diagnosis of cellulitis of the buttocks was provided. R18's medical provider's note dated 4/19/21, written by PA-A indicated R18 was complaining of pain in the gluteal lesion, and PA-A remarked there was the possibility that R18 had developed an abscess. The note indicated PA-A discussed the case with MD-A and the decision was made to incise the wound and drain the cite which was then accomplished. Treatment orders were provided. On 4/19/22, 2:20 p.m. a registered nurse (RN)-A sent an email to a contracted wound care nurse, RN-E, with a picture of R18's wound, asking for an opinion on the wound and the treatment decisions. RN-E replied at 4:09 p.m. he was in agreement with the treatment plan. On 4/21/22, at 10:09 a.m. RN-A sent another email to RN-E (with a copy to PA-A and MD-A) with an updated picture of R18's wound, but with no other information about the wound. RN-A wrote, he is declining so I thought maybe a Kennedy ulcer? [A Kennedy terminal ulcer is a skin wound that appears in some people during their final weeks of life, it is a failure of skin as an organ as the organs shut down] A reply from RN-E came at 10:21 a.m. and said, I guess it's a terminal ulcer. No further emails were provided and no indication that PA-A or MD-A had acknowledged receipt or replied to the email correspondence. R18's progress note dated 4/21/22, at 3:39 p.m. included, R [right] buttock has deteriorated within the last week. Now measures approximately 5 cm long by 3 cm wide There is a hole due to I&D [incision and drainage] on Tuesday, the hole opening measures 0.5 cm and is 3 cm deep at this time. Consultation to wound care nurse completed and the wound appears to be a [NAME] Ulceration. It is a butterfly shape and has yellow stringy slough at this time. [R18 name] was told about this change and what a [NAME] Ulceration is. He understands and all question answered. Called [family member- FM-A] and all questions were answered. [R18] was very upset and saddened by this news. R18's progress note dated 4/22/22, at 4:59 a.m. included, Resident alert and oriented, able to make needs known and uses call light appropriately. Tearful at start of shift after finding out about Kennedy ulcer. Family here at 1900 [7:00 p.m.] and visited until 2300 [11:00 p.m.] Resident slept poorly throughout the night. Voiced that he is worried about dying. R18's progress note dated 4/22/22, at 10:20 a.m. included, Family here at facility at 0900 [9:00 a.m.] for a meeting regarding [R18's] wound. Per Wound Nurse yesterday [R18's] wound appears to be a terminal ulcer. Discussed with family, what the ulcer is, what the next steps are, what to continue etc. [R18] was understanding, family was understanding. All questions answered. [R18] chooses to continue with dialysis at this time until he physically cannot go to dialysis anymore. He is going to stay here and continue course as is at this time. A communication note dated 4/22/22, from R18's dialysis call center, indicated a call was received from RN-A: [R18] had a care conference today to inform patient and family of terminal wound on buttocks. Patient wishes to continue dialysis as long as he can. Use of cushioned blue chair at dialysis to promote comfort. Will forward to care team for pt [patient] update. A communication note dated 4/22/22, from R18's dialysis case manager RN-F, included the following: Told by POD [front line dialysis staff] that [R18] wanted to talk with someone to get more information about his new diagnosis. As chart review found little other than a new gluteal ulcer/abscess, call placed to [facility] to ask for more information. Per [licensed practical nurse (LPN)-A], [R18] was diagnosed yesterday with a Kennedy ulcer, and there had been a family conference today to talk about the poor prognosis (likely 2-3 weeks to live?) As writer unfamiliar with Kennedy ulcer, looked up information and noted that wound bears uncanny resemblance to calciphylaxis wound [a rare, but serious kidney complication where the calcium builds up inside blood vessels of the fat and skin]. Writer asked [PN-A] to please view information about calciphylaxis and to ask her team if they considered this as a diagnosis. Also asked if there had been any biopsies taken, which might prove or disprove either diagnosis. [PN-A] will follow up with [facility] while writer asks Nephrologist to review as well. R18's nephrologist, MD-B, wrote several communication notes dated 4/22/22 which indicated: Would need skin biopsy to see whether this is calciphylaxis or not. Wound clinic consult order placed. After RN-F replied to say it would be two weeks before an appointment could be made, MD-B wrote, I have placed consult for wound clinic. As discussed with you today please see if anyone can see him in the Wound Clinic sooner to comment on whether this ulcer is really Kennedy ulcer or not. He is in nursing home and they are discussing about end of life cares. A communication note dated 4/25/22 from RN-F indicated, Received call back from [RN-A]. They have doctor rounds with [R18] today, and will reassure patient and family that all departments are working together as a team to make accurate diagnosis and will work together to support them. R18's medical provider's note dated 4/26/22, written by PA-A indicated R18 had presumed cellulitis of the right buttock. PA-A remarked on concerns that the appearance of the wound might have represented a terminal ulcer, but PA-A wrote that R18's pain was improving, he was mentally clear, eating well and his wound was much improved. PA-A wrote that Nephrology had stopped medications with calcium due to a concern for calciphlylaxis as the etiology of the wound. A medical provider's note dated 4/28/22, written by a wound specialist, MD-C indicated R18 was being seen for the wound on his right gluteal cleft. MD-C wrote that chart notes document a concern for a Kennedy terminal ulcer and Nephrology was concerned for calcipylaxis. MD-C wrote that R18 came to the appointment with (FM-A), and indicated (FM-A) reported frustration that R18 had been given a diagnosis of a Kennedy terminal ulcer. MD-C wrote that the wound did not appear to have the appearance of calciphylaxis or Kennedy terminal ulcer. MD-C's note indicated the wound, appears to have started as a skin/soft tissue infection around April 12th, s/p (status post) I&D 4/19/22, now with element of pressure ulceration. Diagnosis provided included, Pressure ulcer-Stage IV-first [pressure ulcer affecting bone/tendon] assessment. During an interview on 5/2/22, at 4:38 p.m. R18 stated he had a wound on his buttocks which required he spend most of his time in bed. R18 expressed sadness about this since he enjoyed going out to stock sales and riding in the country. R18 stated he had hoped to go home soon, but would not be able to since his wound required dressing changes several times per day, and a visiting nurse could only come a few times a week. R18 said his wound had, started as a little pimple and rapidly progressed, and was now a stage IV pressure wound. R18 stated he wasn't sure anyone knew what was going on with his wound, but he had been to the wound clinic now and felt things might be improving. R18 had been provided a pressure reducing mattress for his bed, a different chair for dialysis and had been instructed to stay off the wound as much as possible. During a telephone interview on 5/4/22, at 9:11 a.m. RN-F stated the dialysis team had been aware that R18 had a sore on his buttocks. RN-F said she could not recall getting any calls from the facility about the wound, but had an expectation that the facility would call to provide updates. RN-F stated she knew of the wound because R18 had kept her apprised of his condition. RN-F then stated R18 had arrived to dialysis one day (unsure of date) in tears and overwhelmed and said they [facility] told him he was going to die. RN-F stated R18 told her he had a Kennedy ulcer. RN-F stated the renal team was concerned, as the wound looks similar to a wound dialysis patients can get [not a terminal ulcer]. RN-F stated the reason they had, weighed in on it was because it was a, big deal, and a, shock for R18. RN-F said R18 told her the facility had held a care conference to tell him he was terminal and would have to make end of life decisions. RN-F stated the renal team contacted their physician MD-B, who was reported to have said R18 needed a second opinion and ordered a referral to the wound care clinic. During an interview on 5/4/22, at 10:19 a.m. the facility director of social services (SW) stated R18 had initially planned a short term stay at the facility, and wanted to return to his home. SW stated they had discussed what type of referrals he would need to go home, including home modifications, nursing care and meal preparation. However, R18 had had some setbacks with a wound. SW stated RN-A had kept her up to date on what was happening with the wound, that it was a terminal wound and RN-A had set up a meeting with the family. SW said the family was very private so it was determined that it was not necessary for the entire interdisciplinary team to meet with the family, but just to have RN-A since they would need to, talk about sensitive things. SW did not know if a physician had determined R18 to be terminally ill, but stated, there was a wound specialist who looked at the wound, [RN-A] reached out to the wound specialist and he took a look at it. SW stated she had provided RN-A with some pamphlets to give the family on decision making and resources for end of life. During an interview on 5/4/22, at 10:15 a.m. R18 stated he had attended a meeting at the facility where he was told, his condition was terminal. R18 stated, I thought I was going to die. R18 expressed concern about FM-A who was very upset about what they had been told. R18 stated he thought he was going to have to make a decision about whether or not to continue his dialysis treatment, saying, I understood with a wound like that, well, it goes pretty quick and I thought I would have more time! R18 expressed this sudden terminal diagnosis was extremely upsetting to him and FM-A and he had believed he was going to die for a week before he found out the diagnosis was in error by facility staff and not diagnosed by a provider. R18 was observed to shake his head, and look down at his lap with a sad countenance. During an interview on 5/4/22, at 10:49 a.m. RN-A stated, I am not a certified wound nurse, but I am the one who monitors wounds. RN-A stated she had communicated with PA-A regarding the changes in R18's wound, and PA-A had provided treatment that included warm packs, antibiotics and opening the wound up. On 4/20/21, RN-A had been doing wound rounds, and, pretty much overnight, there was thick yellow slough [slough is dead tissue in the wound caused by inflammation]. RN-A stated she had contacted the nurse consultant RN-E and said, He mentioned it could have been a Kennedy ulcer or a terminal ulcer. RN-A said R18 went to dialysis on Friday 4/22/21 and the nurse manager there thought there was an aspect of calcification. RN-A said that nurse, MD-B and PA-A decided R18 should go to the wound clinic for an evaluation. RN-A stated she had never seen a Kennedy ulcer, but that RN-E had. RN-A said, RN-E had only seen R18's wound in a picture after it had gotten worse. RN-A stated a physician had not provided a diagnosis of a Kennedy ulcer or of a terminal condition, but said she had met with R18 and his family on 4/22/21 before he left for dialysis to discuss the possibility of this being a terminal ulcer. RN-A stated she provided them with resources for making decisions, including information about hospice care. RN-A stated, I discussed the potential for this to be a terminal ulcer, and I said I wasn't certified and hoped I was wrong. RN-A reported the family was, shocked and wanted to know why she thought it was a terminal ulcer. She said she told them she had reached out to a wound specialist about it. RN-A stated she had called dialysis to discuss the meeting, but said she had not documented this, and was unsure of who she spoke with. During a telephone interview on 5/4/22, at 11:21 a.m. PA-A stated she had been away from work during the time the 4/21/22, email had been sent from RN-A asking if the ulcer might be a Kennedy terminal ulcer. PA-A became aware the wound appeared to be worse after her return to work, and also becoming aware R18 and family had been told he had a terminal ulcer. PA-A stated a terminal diagnosis for R18 had never been given by her, or any physician, and to her understanding RN-E had simply suggested a terminal ulcer might be a possibility, and he was a nurse, not a medical provider. PA-A stated the communication to a resident of a terminal condition would be, distressing, adding, he did not have a terminal illness! PA-A stated such news would be, shocking and upsetting. PA-A expressed frustration with how things had been handled by the facility and stated, I came back from being gone and had to clean up that mess. When interviewed on 5/04/22, 3:38 p.m. The facility director of nursing (DON) stated , Luckily, he is better than was thought, but I understand, there was an emotional toll. A facility policy titled [NAME] Care Center: Palliative/End-of-Life Care-Clinical Protocol, dated 9/20/21 indicated the purpose was to provide end of life care according to the standards of practice set forth. The policy indicated, the physician will help identify or verify underlying causes of a resident's decline and it is not uncommon for patients to have potentially treatable conditions or have potential for improved function and quality of life that has not been identified or treated adequately. In addition, the policy indicated, the physician will advise the resident/patient, family and facility staff about the prognosis and overall medical plan periodically, including any impact of significant changes of condition.