**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, and interview, the facility failed to provide evidence that enteral tube feedings were administered to prevent weight loss. This affected two residents (#57 and #60) out of three reviewed for tube feeding. The facility also failed to obtain weekly weights as ordered. This affected four residents (#11, #20, #57, and #60) out of six reviewed for nutrition. The facility also failed to provide adequate hydration to prevent dehydration. This affected one resident (#11) out of three reviewed for hydration. The facility census was 63.Actual harm occurred on 06/16/25 when Resident #60, who had severe cognitive impairment and required enteral tube feeding to meet nutritional needs, sustained a 20.6 pound weight loss (in 34 days) as a result of the facility's failure to accurately monitor and record tube feed intakes, obtain weekly weights as ordered, and adjust tube feeding rate timely to prevent further weight loss. On 05/01/25, Resident #60 weighed 207.2 pounds. On 05/07/25 and 05/13/25, Resident #60 weighed 207.0 pounds. On 05/22/25, Resident #60 weighed 197.8 pounds, which was a weight loss of 9.2 pounds (4.4%) in 9 days. On 06/16/25, Resident #60 weighed 186.4 pounds, which was a further weight loss of 11.4 pounds (5.8%) and there was no evidence that the facility had been monitoring Resident #60's weight between 05/22/25 and 06/16/25 or that adjustments had been made to the tube feeding order to prevent further weight loss. The weight loss continued and on 06/19/25 the resident was assessed to sustain an additional weight loss of 7.0 pounds (3.8%) with a recorded weight of 179.4 pounds. Resident #60 sustained a severe weight loss of 13.4% since admission (in 51 days). Findings include: 1. Review of the medical record for Resident #60 revealed an admission date of 04/30/25 with diagnoses including aspiration pneumonia, lung cancer, cerebral infarction, dysphagia, laryngeal cancer, aphasia, and dysarthria. Review of the medical nutritional therapy assessment, dated 05/02/25, revealed Resident #60 received nothing by mouth (NPO) and required a feeding tube to meet nutritional needs. The assessment indicated Resident #60 required 2184 to 2589 calories, 81 to 97 grams of protein, and 2427 to 2832 milliliters (ml) of fluid daily. The nutritional goals included no unplanned significant weight changes, tube feeding formula and flushes as ordered, and weekly weights for four weeks. Review of the nutrition care plan, initiated 05/05/25, revealed Resident #60 was at increased nutritional risk related to gastric tube use, lung and laryngeal cancer, pneumonia, cerebral infarction, dysphagia, hemiplegia, overweight, requiring enteral feedings for nutrition and hydration, and malnutrition. Interventions included but were not limited to: check tube placement prior to medication or tube feeding administration (05/05/25), monitor for complications such as diarrhea, gastric distention, aspiration, and report complications to the physician (05/05/25), monitor labs per orders (05/05/25), monitor need for increased nutritional interventions related to diagnoses, tube feeding, medications, and other listed problems (05/05/25), monitor for signs and symptoms of dehydration such as poor skin turgor, cracked lips, thirst, fever, and abnormal labs (05/05/25), monitor weight per protocol (05/05/25), provide diet as ordered (05/05/25), provide tube feeding as ordered (05/05/25), provide tube feeding and medication flushes as ordered (05/05/25), and report 5% weight loss or gain to the physician and Registered Dietitian (RD) (05/05/25). The nutrition care plan was last reviewed and revised on 05/05/25 at 2:02 P.M. by RD #83.Review of the admission Minimum Data Set (MDS) assessment, dated 05/06/25, revealed Resident #60 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 00. The assessment also indicated Resident #60 received 51% or more of daily calories from tube feeding and 501 milliliters (ml) or more of daily fluid from tube feeding.Review of the physician's orders for Resident #60 identified orders for NPO (ordered 04/30/25), weekly weights for four weeks (ordered 04/30/25, discontinued 06/03/25), bolus enteral feedings of Isosource to infuse 360ml every six hours via enteral tube, flush with 30ml of water after the bolus feed, and record amounts (ordered 04/30/25, discontinued 05/01/25), bolus enteral feedings of Isosource 1.5 to infuse 360ml every six hours via enteral tube for a total of 1440ml of formula providing 2160 calories, flush with 30ml of water after the bolus feed, and record amounts (ordered 05/01/25, discontinued 05/02/25), bolus enteral feedings of Isosource 1.5 to infuse 400ml every six hours via enteral tube for a total of 1600ml of formula providing 2400 calories, flush with 30ml of water after the bolus feed, and record amounts (ordered 05/02/25, discontinued 06/19/25), and bolus enteral feedings of Isosource 1.5 to infuse 500ml every six hours via enteral tube for a total of 2000ml of formula providing 3000 calories, flush with 30ml of water after the bolus feed, and record amounts (ordered 06/19/25). Physician's orders for routine tube feeding flushes were separate from the enteral formula orders and were as follows: free water flushing 250ml once daily via peg tube (ordered 04/30/25, discontinued 05/01/25), free water flushing 250ml every six hours via peg tube (ordered 05/01/25, discontinued 05/02/25), free water flushing 300ml every six hours via peg tube (ordered 05/02/25, discontinued 06/19/25), and free water flushing 250ml every six hours via peg tube (ordered 06/19/25). Review of the weights documented in the vitals portion of the electronic health record and on the Medication Administration Record/Treatment Administration Record (MAR/TAR) for Resident #60 revealed the following recorded weights: 207.2 pounds on 05/01/25, 207.0 pounds on 05/07/25, 207.0 pounds on 05/13/25, 197.8 pounds on 05/22/25, 186.4 pounds on 06/16/25, and 179.4 pounds on 06/19/25. There were no recorded weights between 05/22/25 and 06/16/25. Review of the MAR/TAR documentation for Resident #60 for May 2025 through June 2025 revealed the following: - On 05/14/25, 800ml of Isosource 1.5 was administered, which provided a daily total of 1200 calories (a deficit of 984 calories from the calculated nutritional needs). - On 05/15/25, 800ml of Isosource 1.5 was administered, which provided a daily total of 1200 calories (a deficit of 984 calories from the calculated nutritional needs). - On 05/16/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/17/25, 900ml of Isosource 1.5 was administered, which provided a daily total of 1350 calories (a deficit of 834 calories from the calculated nutritional needs). It was documented that Resident #60 refused the 12:00 P.M. tube feeding formula administration. - On 05/18/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/19/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/20/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/22/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/23/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/25/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/26/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/27/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/29/25, 700ml of Isosource 1.5 was administered, which provided a daily total of 1050 calories (a deficit of 1184 calories from the calculated nutritional needs). - On 05/30/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/31/25, 850ml of Isosource 1.5 was administered, which provided a daily total of 1275 calories (a deficit of 909 calories from the calculated nutritional needs). - On 06/01/25, 600ml of Isosource 1.5 was administered, which provided a daily total of 900 calories (a deficit of 1284 calories from the calculated nutritional needs). - On 06/02/25, 600ml of Isosource 1.5 was administered, which provided a daily total of 900 calories (a deficit of 1284 calories from the calculated nutritional needs). - On 06/03/25, 1100ml of Isosource 1.5 was administered, which provided a daily total of 1650 calories (a deficit of 534 calories from the calculated nutritional needs). - On 06/11/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 06/12/25, 800ml of Isosource 1.5 was administered, which provided a daily total of 1200 calories (a deficit of 984 calories from the calculated nutritional needs). - On 06/14/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 06/15/25, 930ml of Isosource 1.5 was administered, which provided a daily total of 1395 calories (a deficit of 789 calories from the calculated nutritional needs). - On 06/16/25, 1030ml of Isosource 1.5 was administered, which provided a daily total of 1545 calories (a deficit of 639 calories from the calculated nutritional needs). - On 06/20/25, 1000ml of Isosource 1.5 was administered, which provided a daily total of 1500 calories (a deficit of 684 calories from the calculated nutritional needs). - On 06/21/25, 1250ml of Isosource 1.5 was administered, which provided a daily total of 1875 calories (a deficit of 309 calories from the calculated nutritional needs). - On 06/23/25, 1000ml of Isosource 1.5 was administered, which provided a daily total of 1500 calories (a deficit of 684 calories from the calculated nutritional needs).Review of the dietary progress note dated 05/26/25 at 3:02 P.M. indicated Resident #60 had sustained a 4.5% weight loss since admission on Isosource 1.5 at 400ml every six hours with 300ml water flushes to provide 2400 calories, 109 grams (g) protein, and 2422ml free fluid. The note indicated the current tube feeding order was meeting Resident #60's nutritional needs and weight maintenance was desirable. The note indicated no changes were made to the tube feeding order and weekly weights would be continued for close monitoring.Review of the weights documented in the vitals portion of the electronic health record and on the MAR/TAR for Resident #60 revealed weekly weights were not obtained as ordered on 05/27/25 and 06/03/25. There was no progress note indicating the physician or RD were notified of the weight loss on 06/16/25.The nurses note dated 06/17/25 at 3:11 P.M. indicated Resident #60 was visited by a physician's assistant (unnamed) that day and new orders were added for Trazadone to address increased restlessness and agitation. There was no mention of weight loss.Review of the dietary progress note dated 06/19/25 at 4:37 P.M. indicated Resident #60 had sustained a significant weight loss of 15% in one month. The note indicated Resident #60 had increased nutritional needs due to a cancer diagnosis and activity levels. The tube feeding order was increased to Isosource 1.5 to infuse 500ml every six hours with 250ml water flushes to provide 3000 calories, 136g protein, and 2528ml free fluid.On 06/30/25 at 9:36 A.M., an interview with RD #83 stated when weight loss occurred, she would make any nutritional recommendations on the following Monday and the expectation was those recommendations would be addressed by Thursday each week (three days later). She also stated re-weights would be obtained to verify the weight loss. On 06/30/25 at 11:27 A.M., an interview with RD #83 stated she had not done the calculations to determine exact amounts, but a significant weight loss would require a large calorie deficit.On 06/30/25 at 3:57 P.M., an interview with Medical Director (MD) #87 stated the facility probably notified Physician's Assistant #88 of weight changes because the facility usually only notified MD #87 of bigger things. MD #87 said he would just follow the RD's recommendations for any changes because the RD was the expert with weight loss and calculating calories.On 06/30/25 at 4:45 P.M., an interview with the Director of Nursing (DON) verified the documentation on the MAR/TAR indicated Resident #60 did not receive the amount of tube feeding formula that was ordered on numerous days in May 2025 and June 2025.On 07/01/25 at 11:50 A.M., an interview with Regional RD #86 confirmed the documentation indicated the full amount of tube feeding formula was not administered for Resident #60. Regional RD #86 claimed it was just a documentation error, however, she was unable to provide any evidence that the tube feeding formula was administered as ordered. On 07/01/25 at 3:28 P.M., an interview with Regional RD #86 stated RD #83 reviewed the weight change that occurred on 05/22/25, recommended weekly weights to monitor weight trend, and Regional RD #86 confirmed those weekly weights were not obtained after 05/22/25. RD #86 confirmed no changes were made to the tube feeding formula order between 05/02/25 and 06/19/25. Regional RD #86 further stated the way their electronic health records were set up was confusing for the nurses, claiming that was why there were inconsistencies between the physician's orders and the documentation of tube feeding formula administration.On 07/01/25 at 3:53 P.M., an interview with the DON verified the weekly weights were documented as not obtained on the MAR/TAR on 05/27/25 and 06/03/25. The DON was unable to provide a reason why those weights were not obtained.An attempt to interview Physician's Assistant #88 on 07/02/25 was unsuccessful.Review of the facility's policy titled Dietary Enteral Nutrition Care, dated 06/02/20, revealed upon initiation of enteral feeding, the RD would conduct an assessment that included a calculation of the individual's energy, protein, and fluid requirements, as well as any potential medication interactions. If there was an existing enteral nutrition order, a comparison would be made between the individual's requirements and the physician ordered enteral formula and free fluid flush. The RD or designee would monitor weight, skin conditions, labs, physical symptoms, and tolerance to feeding. The nursing staff would communicate any concerns to the physician and RD regarding changes in condition such as weight loss, diarrhea, nausea, vomiting, bloating, gas, and high residual levels. Review of the facility's policy titled Resident Weight Policy, dated 12/12/23, revealed weights would be obtained routinely in order to monitor nutritional health over time. Each resident's weight would be determined upon admission to the facility, weekly for four weeks after admission, and monthly or more often if risk was identified, or as ordered. Nursing was responsible for obtaining weights. After the first four weeks, the resident review committee would determine the need for continued weekly weights. Weights would be recorded in the electronic health record. 2. Review of the medical record for Resident #57 (R #57) revealed an admission date of 01/09/25 with diagnoses of metabolic encephalopathy, moderate protein-calorie malnutrition, dysphagia, and type two diabetes mellitus.Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed R #57 was cognitively impaired, rarely or never able to make needs known, and rarely or never understood communication. The assessment indicated that she was dependent upon two staff members to move in bed, take a shower or bath, and dependent on one staff member for dressing. Review of the physician's orders revealed no pharmacological intervention for anxiety, agitation or restlessness, and no as needed medication for bowel regime. Further review of the physician's orders for June 2025 for R #57 identified orders for Diabetisource AC at 60 milliliters (ml) per hour for 22 hours to provide 1320ml formula and 1584 calories daily (ordered 03/17/25, discontinued 06/30/25), and Diabetisource AC at 65 ml per hour for 22 hours to provide 1,430ml formula and 1,716 calories daily (order dated 06/30/25).Review of medical nutritional therapy assessment, authored by Registered Dietitian (RD) #83 and dated 04/03/25, revealed R #57 received nothing by mouth (NPO) and required a feeding tube to meet nutritional needs. The assessment indicated the ordered enteral feeding would provide 1,584 calories, 79 milligrams (mg) of protein, 1,077 milliliters (ml) of free fluids plus flushes to total 1,977 ml daily. The estimated nutritional needs portion of the assessment was blank and there were no nutritional needs specified. The nutritional goals included tolerance to enteral feedings, no signs or symptoms of dehydration, and no significant weight changes. Review of lab results dated 05/08/25 revealed a basic metabolic panel (BMP) and a complete blood count (CBC) was obtained with results essentially within expected range for diagnosis and no new orders were obtained. Review of the lab results dated 06/05/25 revealed a BMP, CBC and hemoglobin A1C were obtained, and all results were within expected range and no new orders were written. There was no evidence that a Pre-Albumin level was obtained.Review of weights for R #57 revealed a weight loss of 4.8% within 30days. The documented weights were as follows: 152.0 pounds on 05/06/25, 154.2 pounds on 06/09/25, and 146.8 pounds on 06/26/25.Review of the Medication Administration Record (MAR) for R #57 for June 2025 revealed the following: On 06/09/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/11/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/12/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/14/25, 750ml of Diabetisource AC was administered, which provided a daily total of 900 calories (a deficit of 684 calories from what was ordered).On 06/15/25, 810ml of Diabetisource AC was administered, which provided a daily total of 972 calories (a deficit of 612 calories from what was ordered).On 06/16/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/17/25, 810ml of Diabetisource AC was administered, which provided a daily total of 972 calories (a deficit of 612 calories from what was ordered).On 06/18/25, 810ml of Diabetisource AC was administered, which provided a daily total of 972 calories (a deficit of 612 calories from what was ordered).On 06/19/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/21/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/22/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/23/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/24/25, 870ml of Diabetisource AC was administered, which provided a daily total of 1044 calories (a deficit of 540 calories from what was ordered).On 06/25/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/26/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/27/25, 870ml of Diabetisource AC was administered, which provided a daily total of 1044 calories (a deficit of 540 calories from what was ordered).On 06/28/25, 1260ml of Diabetisource AC was administered, which provided a daily total of 1512 calories (a deficit of 72 calories from what was ordered).On 06/29/25, 660ml of Diabetisource AC was administered, which provided a daily total of 792 calories (a deficit of 792 calories from what was ordered).Review of bowel tracking records for R #57 from 06/20/25 through 06/29/25 revealed no evidence of a bowel movement (BM) on 06/21/25, 06/22/25, 06/23/25, 06/25/25, 06/26/25, 06/27/25, 06/28/25, 06/29/25. There was no evidence of any as needed bowel interventions provided during this interval, just the routine daily dose of Miralax.Review of progress notes since admission revealed no documented evidence of anxiety or restlessness. Review of a progress note dated 06/26/25, authored by RD #83, revealed R #57 had a 4.8% weight loss since 06/09/25 (17 days). The note indicated R #57 was often restless, anxious and, per nursing staff, often rolled onto her tubing causing the infusion of formula to occlude. There were no other notes between 01/09/25 and 06/26/25 to indicate R #57 rolled onto her tubing causing the tube feed formula to stop infusing. Review of the progress note dated 07/01/25 at 8:43 P.M. indicated R #57 was transferred to an acute care hospital due to unrelieved brown emesis.An observation on 06/23/25 at 10:30 A.M. revealed that R #57 was in bed lying on her left side, the enteral feeding pump was alarming, and the formula was not infusing. A bag of Diabetisource AC was hanging on a pole and was attached to the infusion pump. The formula bag was labeled with a date of 06/23/25 without a time. Continued observation of R #57's room revealed no staff were present on the unit and no staff entered R #57's room until 12:52 P.M., approximately two hours and 22 minutes after the tube feed was first observed alarming.An observation on 06/23/25 at 12:52 PM revealed MDS nurse #11 walked into R #57 room. The enteral feeding pump ceased beeping. MDS nurse #11 verified that the pump was not infusing formula, that she restarted it and could not say how long the pump was beeping.A continuous observation on 06/24/25 from 8:00 A.M. until 1:13 P.M. revealed R #57 lying on her left side, not laying on enteral tubing. No staff members were observed entering R #57's room at any point during this observation.An observation on 06/25/25 07:41 A.M. revealed R #57 lying on her back with legs bent at the knees, not laying on enteral tubing. Further observations at 10:00 A.M., 12:30 P.M. and 4:03 P.M. revealed R #57 was in the same position.An interview on 06/24/25 at 02:43 P.M. with Certified Nursing Assistant (CNA) #58 revealed that R #57 was checked and changed about every 3 hours. CNA #58 was unable to state when she was last in the room. CNA #58 shared that they had twelve residents to care for all of which were located on the same hallway.An interview on 06/30/25 at 10:23 A.M. with the Director of Nursing (DON) revealed that when R #57's enteral feeding pump beeped then the nurses went down to the resident's room, readjusted the pump and/or tubing, and restarted the pump. The DON stated the pump would be occluded for a minimal time, not a significant amount of time. The DON indicated that she did not know how long a pump would have to be off to cause significant weight loss. The DON verified the documentation on the MAR of less than the ordered amount of enteral feeding. Regarding the lack of bowel movements, the DON stated that the MDS nurse brought a report to morning meeting and identified all residents that had no BM in three days or greater. That information was given to the nurses on the floor for follow-up. Once the information was given to the nurse, the alerts were cleared from the electronic health record system and no further information was tracked. An interview on 06/30/25 at 11:27 A.M. with RD #83 confirmed the documentation in the MAR was less than the ordered amount of tube feeding formula. RD #83 indicated that she would have to do calculations but that a significant weight loss in 30 days would require a large calorie deficit.An interview on 06/30/25 at 03:06 P.M. with Licensed Practical Nurse (LPN) #55 revealed that occasionally the tubing on R #57's feeding pump got kinked. The pump beeped but was not as loud as an IV pole and that R #57's room was two-thirds of the way down the hall away from the nurse's station, so it could not be heard at the nurse's station. LPN #55 Further shared that the second floor had two nurses assigned to split the all the residents on the second floor. Each nurse assigned to a hall also had to split another hall for medication administration and could not hear anything that occurred on the other hall. Further shared that Resident #57 used to move about and pull the whole pump and pole over when they were first admitted but doesn't do that anymore.An interview on 06/30/25 at 3:57 P.M. with Medical Director (MD) #87 stated the facility probably notified Physician's Assistant #88 of weight changes because the facility usually only notified MD #87 of bigger things. MD #87 said he would just follow the RD's recommendations for any changes because the RD was the expert with weight loss and calculating calories. MD #87 indicated that he expected lab chemistry to be monitored and to include pre-Albumin levels.Review of the facility's policy titled Dietary Enteral Nutrition Care, dated 06/02/20, revealed upon initiation of enteral feeding, the RD would conduct an assessment that included a calculation of the individual's energy, protein, and fluid requirements, as well as any potential medication interactions. If there was an existing enteral nutrition order, a comparison would be made between the individual's requirements and the physician ordered enteral formula and free fluid flush. The RD or designee would monitor weight, skin conditions, labs, physical symptoms, and tolerance to feeding. The nursing staff would communicate any concerns to the physician and RD regarding changes in condition such as weight loss, diarrhea, nausea, vomiting, bloating, gas, and high residual levels. Review of the facility's policy titled Resident Weight Policy, dated 12/12/23, revealed weights would be obtained routinely in order to monitor nutritional health over time. Each resident's weight would be determined upon admission to the facility, weekly for four weeks after admission, and monthly or more often if risk was identified, or as ordered. Nursing was responsible for obtaining weights. After the first four weeks, the resident review committee would determine the need for continued weekly weights. Weights would be recorded in the electronic health record.Review of the facility's policy titled Bowel Tracking Protocol, dated 03/12/24, revealed bowel movements were documented by nurse aides in the electronic medical record. If the resident had not had a bowel movement for 3 full days (72 hours), and in the absence of other resident-specific orders, the nurse would determine if laxatives were indicated based on the resident's bowel habits and patterns. Step 1: Milk of Magnesia 30 ml at bedtime the evening after 72 hours without a bowel movement (BM) ; Step 2: If no BM by 10:00 A.M. the following day, give bisacodyl suppository 10 mg PR; Step 3: If no BM by the next morning, contact provider for further orders.3. Review of the medical record for Resident #11 revealed an admission date of 04/17/25. Diagnoses included but were not limited to epilepsy, unspecified fracture of right and left pubis, fracture of right tibia, poly osteoarthritis, and repeated falls. Review of the 06/16/25 Minimum Data Set (MDS) for Resident #11 revealed a Brief Interview of Mental Status (BIMS) of 15 which indicated intact cognition. Resident #11 was noted to be independent for self-care, eating and dependent for toileting, bathing, dressing and wheeling 150 feet. Resident #11 was not noted to be on a therapeutic diet and was noted to have significant weight loss and was not on a physician prescribed weight loss program. Review of the 04/17/25 physician order for Resident #11 revealed an order to obtain weight upon admission and then weekly for four weeks once a day on Tuesdays.Review of the facility weight recording form from 04/14/25 revealed a weight for Resident #11 but was not dated as being another date other than 04/14/25 since resident was not at the facility on 04/14/25. Review of the admission progress note for Resident #11 revealed no listed admission weight. Review of the 04/21/25 care plan for Resident #11 revealed increased nutrition and hydration risk related to epilepsy, fracture of pubis, muscle weakness, obesity, diuretic use and potential for fluid related weight fluctuations. Interventions listed were to encourage compliance with diet guidelines, encourage resident to dine in the dining room, monitor dietary intake, monitor lab values per orders, monitor need for increased nutritional intervention related to diagnosis, medication and listed problems, monitor weight per protocol, offer alternate food is less than 50 % of meals, and encourage adequate fluid intake.Review of the facility weight recording form from 04/21/25, 04/28/25, for Resident #11 revealed no weight recorded. Review of the nursing progress note date 04/20/25 timed at 1:59 P.M. for Resident #11 revealed a burning sensation when voiding, and order for a urinalysis (UA) and a urine culture and sensitivity (C &S) test were obtained. Review of the nursing progress note dated 04/21/25 at 3:24 P.M. for Resident #11 revealed an order for Macrobid 100 milligrams (mg) by mouth twice daily for seven days for symptoms of a urinary tract infection.Review of the 04/22/25 lab results for Resident #11 revealed they were completed and a request with an order to repeat the labs on 04/29/25.Review of the facility weight recording form from 05/01/25 (monthly weights) for Resident #11 was 150.8 # and a reweight was requested but not completed. No weight was recorded in the medical record.Review of the facility weight recording form from 05/12/25 and 05/20/25 for Resident #11 revealed no weight recorded. Review of the medical record for Resident #11 revealed a weight on 04/21/25 of 173.2# and 06/16/25 of 164.4 pounds (#) and no additional weights recorded. Weight loss from 4/21/25 to 06/16/25 was 8.8# which was a 5 percent loss.Review of the labs recorded on 04/29/25 for Resident #11 revealed the physician requested no new orders. Review of the 05/12/25 nursing pro[TRUNCATED]

Based on observation, record review, facility policy review and interview the facility failed to ensure timely assessments were completed, wound care was completed as ordered and adequate interventions were implemented to prevent the development of pressure ulcers for Resident #33 and Resident #51. The facility census was 58. Actual Harm occurred on 04/03/23 when Resident #33, who required extensive to total dependence from staff for activities of daily living (ADL) including bed mobility, toileting and transfers, was found to have an unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to his right trochanter (hip). On 04/18/23 Resident #33 was identified with another unstageable pressure ulcer to his left trochanter. There was no evidence adequate interventions and monitoring was in place to prevent the development of these wounds or to ensure the wounds were identified prior to being unstageable. Actual Harm also occurred on 05/17/23, when Resident #51 who required extensive assistance from staff for ADL care including bed mobility, transfers, and toileting, was found to have an unstageable pressure ulcer to his right buttock/ upper posterior thigh. There was no evidence adequate interventions and monitoring was in place to prevent the development of this wound or to ensure the wound was identified prior to being unstageable. This affected two residents (#33 and #51) of three residents reviewed for pressure ulcers. Findings included: 1. Review of medical record for Resident #33 revealed an admission date of 08/30/22 with diagnoses including acute kidney failure, hypertension, cerebral infarction, and dementia. Review of care plan dated initiated on 01/24/23 (last revised on 06/07/23) revealed Resident #33 had actual impaired skin integrity related to the coccyx, right hip, and left hip areas. Interventions included to administer medication and treatments as ordered, to assess and document status of the wounds, to complete skin checks per protocol, to monitor nutritional status,to turn and reposition as indicated, and to use pressure relieving devices as indicated to bed and wheelchair. Review of Braden Scale Pressure Ulcer Risk Assessment completed on 02/24/23 by Registered Nurse (RN) #616, revealed Resident #33 was at moderate risk for developing pressure ulcers due to the following risk factors: occasionally moist, chairfast, very limited with mobility, inadequate nutrition, and a problem with friction and shear. Review of care plan, revised 03/30/23, revealed Resident #33 had an activities of daily living (ADL) self-care deficit related to impaired cognition and mobility. Interventions included assist with ADL's including dressing, grooming, toileting, and feeding, assist with one staff with bed mobility, assist with two staff with toileting, and transfer with two staff assist with a mechanical lift. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/30/23 revealed Resident #33 was rarely and/or never understood. He required extensive assist of two staff with bed mobility and was totally dependent of two staff with transfers. He required extensive assist of one staff with toileting and was unable to ambulate. He was at risk for pressure ulcers but had no pressure ulcers at the time of the assessment. Review of nursing notes dated from 03/01/23 to 04/03/23, for Resident #33, revealed there were no skin impairments/ pressure ulcers identified to his right trochanter area prior to 04/03/23 when the Wound Nurse Practitioner (NP) #615 found an unstageable pressure ulcer during wound rounds. Review of Wound Evaluation progress note dated 04/03/23 and completed by Wound NP #615 revealed Resident #33 had a new pressure wound to his right trochanter that was found as unstageable. The wound measured 1.8 cm in length, 1.2 cm in width and unable to determine depth due to slough. The note revealed the wound contained 100 percent slough. Review of Weekly Wound Assessment V1-V5 dated 04/04/23 and completed by Former Registered Nurse (RN) #617 revealed Resident #33 had an unstageable in house acquired pressure ulcer to his right trochanter hip. The pressure ulcer measured a length of 1.8 cm, width of 1.2 cm and unable to determine depth due to the slough. The wound was described with a small amount of serous (this watery fluid) drainage and the wound bed contained yellow slough. Review of nursing notes dated, 04/04/23 to 04/18/23, revealed no evidence Resident #33 had any skin impairments/ pressure areas to his left trochanter prior to 04/18/23 when former RN #617 documented she had found the unstageable pressure ulcer. Review of Weekly Wound Assessment V1-V5 dated 04/18/23 and completed by former RN #617 revealed Resident #33 had an unstageable in house acquired pressure ulcer to his left trochanter hip that measured 7.3 cm in length, 5.5 cm in width and had a depth of .1 cm. The wound was described as having small amount of serosanguineous (containing fluid and clear fluid) drainage and the wound bed was yellow. Review of Wound Evaluation progress note dated 04/26/23 and completed by Wound NP #615 revealed Resident #33 had a left trochanter pressure ulcer that was unstageable. The note revealed the wound measured 4 cm in length, .8 cm in width and unable to determine depth due to slough. The note revealed there was a small open area in the above measurement that was .5 cm in length, .5 cm in width and 100 percent slough with surrounding dark purple tissue. Review of Treatment Administration Record (TAR) dated May 2023 revealed Resident #33's treatment order to his right trochanter was to cleanse his wound with wound cleanser, apply Xeroform, and cover with border foam three times a week and as needed. There was no documentation the treatment order was completed on 05/16/23 or 05/23/23. The treatment record also revealed Resident #33's treatment order to his left hip that was to cleanse his left hip with wound cleanser, apply Xeroform, cover with border foam every Tuesday, Thursday and Saturday. There was no documentation the treatment was completed on 05/16/23, 05/23/23, or 05/25/23. Review of physician's orders from June 2023 revealed Resident #33 had an order dated 04/04/23 to cleanse right trochanter wound with wound cleanser, apply Xeroform, and cover with border foam three times a week and as needed; and an order dated 05/03/23 cleanse left hip with wound cleanser apply Xeroform, cover with border foam every Tuesday, Thursday and Saturday on night shift and side to side turned every two hours. Review of TAR for June 2023 revealed Resident #33's treatment to his left hip was not documented as completed on 06/01/23. Review of Wound Evaluation progress note dated 06/21/23 completed by Wound NP #615 revealed Resident #33 continued to have unstageable pressure ulcers to his right and left trochanter. The right trochanter measured a length of 1.5 cm in length and a width of 1 cm with 100 percent slough. The left trochanter pressure ulcer measured 5 cm in length and 8 cm in width with also 100 percent slough. Interview on 06/28/23 at 9:14 A.M. and at 2:22 P.M. with Licensed Practical Nurse (LPN)/Wound Nurse #614 revealed she had only been the wound nurse approximately for three weeks. She verified, after review of the documentation, that Resident #33's right trochanter was found as an unstageable pressure ulcer on 04/03/23, per the Wound NP #615 notes from the wound rounds, as that was the first the wound was documented. She also verified Resident #33's left trochanter pressure ulcer was also found as unstageable on 04/18/23. She verified Resident #33 required extensive to total dependence of staff for his bed mobility, toileting, and transfers. She verified the wounds should have been detected prior to being found unstageable. She verified the identified treatments were not documented as completed on the TAR for May 2023 and June 2023 as noted above. She verified if the treatments were not documented on the TAR, then most likely they were not done. She revealed she completed all the wounds treatments every Wednesday on the wound rounds. When she first started, she noted several times when treatments were not completed as ordered. She stated that when went to complete the treatment, the same treatment was in place that she had completed days prior. She verified the floor nurses were not doing the treatments as ordered. Observation on 06/28/23 at 11:41 A.M. of wound care completed by LPN/ Wound Nurse #614 and Wound NP #615 revealed Resident #33's right trochanter had an unstageable pressure ulcer that measured 1.5 cm in length, one cm in width and contained 100 percent slough with a small amount of serosanguineous drainage. The observation revealed Resident #33's left trochanter was an unstageable pressure ulcer that measured three cm in length, four cm in width and contained in the wound bed 100 percent slough. The treatment was completed according the the current order. Interview on 06/28/23 at 11:41 A.M. with Wound NP #615 verified, upon review of her notes, that Resident #33's pressure ulcer to his right trochanter was found on wound rounds as unstageable on 04/03/23. She revealed Resident #33's left trochanter pressure ulcer, that she evaluated on 04/26/23, was previously identified, according to the documentation on 04/18/23, as unstageable. The facility was unable to provide evidence adequate interventions had been implemented and were in place prior to the developed and failed to ensure skin monitoring was being completed to prevent the development of these wounds and to ensure the wounds were identified prior to being unstageable 2. Review of medical record for Resident #51 revealed an admission date of 06/29/21 with diagnoses including peripheral vascular disease, failure to thrive, lymphedema, chronic kidney disease, heart failure and diabetes. Review of care plan dated 06/29/21 revealed Resident #51 had a self-care deficit. Interventions included Resident #51 required staff assistance with dressing, grooming, and toileting, bed mobility of one staff assist, toileting of two staff assist, and transfers with two staff assist. Review of care plan dated 06/29/21 (with a revision date of 08/02/22) revealed Resident #51 had a potential for skin breakdown related to impaired mobility and incontinence. The interventions included to turn and repositioned as indicated, apply pressure relieving devices as indicating including ROHO cushion and air mattress, and to complete skin assessments per protocol. Review of annual MDS 3.0 assessment, dated 03/09/23 revealed Resident #51 had intact cognition. He required extensive assist of one person with bed mobility, transfers, dressing, toileting, and personal hygiene. He was unable to ambulate. Review of Wound Evaluation progress note dated 03/29/23 and completed by Wound Nurse Practitioner (NP) #615 revealed Resident #51 had moisture associated skin damage (MASD) to his left buttock. There were no documented concerns regarding his right buttock/ posterior thigh area. Review of physician's orders from 01/01/23 to 06/28/23 revealed an order dated 05/17/23, that was discontinued on 06/14/23, to cleanse wound to right buttocks with wound cleanser, apply Xeroform, cover with bordered foam and change daily. There was another order dated 06/14/23 to apply triad to right buttocks/ upper thigh area, cover with border foam and change daily and as needed, turn and reposition every two hours, and apply pressure reducing cushion to wheelchair. There were no other wound care treatment orders prior to 05/17/23 for his right buttock/ upper posterior thigh region. Review of Wound Evaluation progress note dated 05/17/23 and completed by Wound NP #615 revealed Resident #51 had a new unstageable pressure ulcer to his right buttock/ posterior upper thigh that measured a length of five centimeter (cm), width of 2.5 cm and a depth that was unable to be determined due to slough. The note revealed the wound had serosanguinous drainage and contained 100 percent slough. Review of Weekly Wound Assessment V1-V5 dated 05/17/23 and completed by former RN #617, revealed Resident #51 had an unstageable in house acquired pressure ulcer to his right buttock that measured a length of 5 cm, width 2.5 cm and the depth was unable to be determined as there was slough. The assessment revealed the date the wound was identified was 12/07/22 but subsequent interview with Licensed Practical Nurse (LPN)/ Wound Nurse #614 verified this was inaccurate as the date should have been 05/17/23. The assessment revealed the wound had a small amount of serosanguinous drainage and the wound bed was yellow and red. Review of quarterly MDS 3.0 assessment, dated 06/09/23 revealed Resident #51 had intact cognition and required limited assist of one person with bed mobility and extensive assist of one person with transfers, toileting, and personal hygiene. He was unable to ambulate. Review of Wound Evaluation progress note dated 06/14/23 and completed by Wound NP #615 revealed on assessment Resident #51's unstageable pressure ulcer to his right buttock/ upper thigh was healed with 100 percent epithelial tissue. Review of Wound Evaluation progress note dated 06/21/23 and completed by Wound NP #615 revealed Resident #51's wound to his right buttock/ upper thigh had reopened and was classified as a Stage III (full thickness skin loss in which adipose tissue (fat) is visible in the ulcer) measuring a length of 16 cm, width of eight cm, and a depth of 0.1 cm. The note revealed he had scattered open areas and 40 percent of the scattered areas had epithelia tissue with purple discoloration. Review of Weekly Wound Assessment V1-V5 dated 6/21/23 and completed by Licensed Practical Nurse (LPN)/ Wound Nurse #614 revealed Resident #51 had an in-house acquired Stage III pressure ulcer to his right buttock/ upper posterior thigh that measured a length of 16 cm, width of eight cm, and was 0.1 cm in depth. The assessment noted the wound had moderate amount of serosanguinous drainage and the wound bed was red. Review of Review of Wound Evaluation progress note dated 06/28/23 and completed by Wound NP #615 revealed Resident #51 continued to have a Stage III pressure ulcer to his right buttock/ posterior upper thigh area that measured 11 cm in length, two cm in width and 0.1 cm in depth. The note revealed he had 100 percent granulated tissue to the scattered open areas with moderate serosanguinous drainage. Interview on 06/28/23 at 1:11 P.M. with Wound NP #615 verified Resident #51, on 05/17/23 during wound rounds was found to have an unstageable pressure ulcer to his right buttock/ posterior thigh region. She revealed she did not have in her notes that he had any skin issues to his right buttock just his left from 01/01/23 to 05/17/23. She revealed the unstageable pressure ulcer resolved on 06/14/23 but reopened and was found at a Stage III on 06/21/23. Interview on 06/28/23 at 2:22 P.M. with LPN/ Wound Nurse #614 revealed she had only been the wound nurse approximately for three weeks. She revealed upon review of the Weekly Wound Assessment V1-V5 dated 05/17/23 Resident #51's pressure ulcer to his right buttock/ posterior thigh area was found as an unstageable. She verified that the date on the assessment was dated as 12/07/22 as the date when identified but she revealed this had to be inaccurate as on review Resident #51 had not received any treatments for his right buttock/ posterior thigh region from 01/01/23 to 05/17/23 and/or that she had any documentation he had any issues. She also revealed he had a pressure ulcer to his left buttock that was identified on 12/07/22 and felt the previous nurse had mixed up the dates on the assessments. She verified that Resident #51 needed staff assistance with his activities of daily living including with toileting as he was incontinent. She verified since he required assistance most likely his pressure ulcers should have been detected at a prior stage than unstageable/ Stage III. She verified the unstageable pressure ulcer healed on 06/14/23 but then was found at a Stage III on 06/21/23. Observation on 06/29/23 at 10:28 A.M. of wound care for Resident #51 completed by LPN #607 revealed Resident #51 had a Stage III to his right buttock that was red. She applied the treatment as ordered. There was no evidence adequate interventions were in place prior to the development of the unstageable pressure ulcer. In addition, there was no evidence of ongoing monitoring to prevent the development of this wound or to ensure the wound was identified prior to being unstageable. During the onsite investigation, the facility identified 19 residents, Resident #2, #3, #4, #5, #7, #11, #14, #17, #27, #33, #34, #36, #37, #47, #48, #49, #51, #57, and #58 with pressure ulcers. Review of facility policy labeled, Skin and Wound Care Best Practices dated 06/10/22 revealed the purpose of the policy was to provide evidence based preventative skin care and wound treatment to prevent unavoidable skin complications. The policy revealed prevention included provide pressure reduction and redistribution for those at risk including reposition at a frequency determined by risk assessment. The policy revealed educating the nursing aide staff on the importance of basic care such as bathing, repositioning, toileting, skin care and nutrition. This deficiency represents non-compliance investigated under Master Complaint Number OH00143562 and Complaint Number OH00143520.