**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, review of skin assessments, and facility policy review, the facility failed to prevent, comprehensively assess and timely treat a pressure ulcer and failed to prevent the pressure ulcer from worsening for Resident #298. This affected one resident (#298) of three residents reviewed for skin impairments. The facility census was 51. Actual Harm occurred on 01/05/24 when a new, facility-acquired, skin area was identified on Resident #298's left heel that developed within 30 days of the resident's admission. The area was assessed as a purple-black bruise without swelling and measured 3.5 centimeters (cm) long by 2.5 cm wide. The facility failed to notify the physician or implement any treatment to the left heel until 01/09/24 (five days after the skin injury was identified) resulting in the wound worsening to an unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed) deep tissue injury (purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear) measuring four cm long and three cm wide and covered by necrotic (dead) tissue. Findings Include: Review of the medical record for Resident #298 revealed an admission date on 12/22/23. Medical diagnoses included displaced intertrochanteric fracture of left femur, polymyalgia rheumatica, and Type II Diabetes mellitus without complications. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #298 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #298 had an impairment to her lower extremity and used a walker or wheelchair for mobility. Resident #298 required substantial/maximal assistance from staff to complete bed mobility and partial/moderate assistance with transfers. Resident #298 did not have any unhealed pressure ulcers or injuries. Skin treatments included a pressure reducing device for chair and bed. Review of the physician orders revealed Resident #298 had the following orders in place: Oxycodone 5 milligrams (mg) every six hours as needed (PRN) for pain dated 12/22/23 and a Wound Care (WC) order for left heel to cleanse wound with wound cleanser or normal saline, apply Betadine, and cover with foam (gentle or life) dressing every five days dated 01/09/24 (four days after the wound was identified). Review of progress notes dated from 12/22/23 through 01/18/24 revealed on 01/05/24 at 10:25 P.M., Licensed Practical Nurse (LPN) #61 noted the aide reported Resident #298 was requesting pain medication. LPN #61 spoke with Resident #298 who reported left heel pain rated a seven (out of ten) and stated, it usually only hurts at night. LPN #61 looked at bilateral heels and a dark, boggy, intact area with no drainage, approximately 3.5 cm long by 2.5 cm wide was noted to her left heel. LPN #61 assisted to reposition and elevated her feet on a pillow to help with reducing pressure. Resident #298 was educated on the importance of elevating her feet as much as possible. PRN pain medication was given. On 01/09/24 at 10:53 A.M. (four days later), the physician was notified of a left heel deep tissue injury (DTI) and new order was received to apply Betadine and cover with foam daily. Review of the Medication Administration Record (MAR) dated January 2024 revealed Resident #298 received PRN Oxycodone on 01/05/24 at 9:56 P.M. for pain to her left heel. The pain level was an eight out of ten where ten was the worst possible pain. Review of the Treatment Administration Record (TAR) dated January 2024 revealed Resident #298 received a weekly skin assessment on 01/02/24, 01/09/24, and 01/16/24. None of the assessments noted a 1 for a new impairment. Review of the care plan, dated 12/22/23, revealed Resident #298 had a pressure ulcer to left heel with a start date of 01/12/24. Interventions included assess and record the condition of the skin surrounding the pressure ulcer, observe for and report signs of pain related to the pressure ulcer, treatment per physician order and notify physician if treatment was not effective, and weekly skin assessment, measurement, and observation of the pressure ulcer and record. Review of the Skin Integrity Event - Bruise Event, created on 01/05/24 at 10:34 P.M. and completed at 10:36 P.M. by LPN #61 revealed Resident #298 had facility-acquired bruise on her left heel, approximately 3.5 cm long by 2.5 cm wide. The bruise was purple-black without swelling. Resident #298 reported a pain level of seven out of ten (where ten is the worse possible pain), and described as severe, horrible, intense pain. The immediate intervention was to make sure the resident had an appropriate treatment implemented. The physician and resident representative were notified. This event was invalidated by LPN #61 on 01/09/24 at 10:41 A.M. with a reason of incorrect data. However, the progress note was not invalid. Review of the Skin Integrity Event - Pressure, Stasis, Diabetic Wound Event, created on 01/05/24 at 10:25 P.M. (nine minutes prior to the Bruise Event was opened) but not completed until 01/09/24 at 10:43 A.M. (four days after the event was initially created) by LPN #61 revealed Resident #298 had a facility-acquired left heel wound measuring approximately 3.5 cm long by 2.5 cm wide. The wound was not staged and did not include a comprehensive assessment of the wound bed or the surrounding skin of the area. New interventions included to utilize transfer/draw sheets/trapeze to decrease friction and avoid positioning resident directly on skin breakdown. Treatment orders was marked yes. Physician and resident representative were noted to be notified on 01/09/24 at 10:44 A.M. Review of the Wound Management Detail Report dated 01/12/24 at 10:00 A.M. and completed by LPN #50 revealed Resident #298 had a facility acquired pressure ulcer to her left heel that measured four cm long by three cm wide. The wound was staged as an unstageable, deep tissue injury with necrotic tissue. The wound was 100% covered by eschar tissue (dead tissue that sheds or falls off from the skin, typically tan, brown, or black, and may be crusty. When a wound has eschar on top of it, the wound cannot be classified because it makes it difficult to see the wound underneath). The surrounding skin had redness and was blanchable (can make it go away by pressing on it). Interview on 01/17/24 at 5:10 P.M. with Resident #298 revealed the resident's left heel was still sore. Resident #298 stated she thought she caused the wound while trying to turn over in bed one night. The resident stated the wound was not seeping and she thought it was closed. Resident #298 stated the physician looked at the wound yesterday, 01/16/24. Resident #298 stated the wound was being covered with a dressing. A request to interview LPN #61 was made however according to the Administrator, the nurse was attending a funeral and unavailable to be interviewed. An interview with Medical Director (MD) #47 was attempted via telephone however no return contact was received. Interview on 01/18/24 at 9:08 A.M. with LPN #96 revealed she was not wound certified but based off of her nursing experience and education, if a wound had necrotic tissue, it would typically be staged at least as an unstageable pressure ulcer, not a deep tissue injury, because the professional would not be able to see the wound bed to determine an appropriate stage. Observation and interview on 01/18/24 at 9:12 A.M. of Resident #298 in her room with LPN #96 revealed the resident was laying in bed at the time of the observation with a blanket covering her. Resident #298 agreed to allow this surveyor and LPN #96 to look at her feet. LPN #96 raised the blanket and confirmed the resident's heels were not elevated off the mattress. Both heels were laying directly on the mattress. Resident #298's left heel was observed with a clean dressing in place dated 01/14/24. LPN #96 offered to place a pillow under the resident's heels. Resident #298 stated, there is supposed to be one under my heels but the aide had been busy and must have forgotten. Resident #298 was observed with facial grimacing when LPN #96 raised her left heel off the mattress and placed it on the pillow. Resident #298 confirmed her left heel hurts a little bit. Interview on 01/18/24 at 10:13 A.M. with Assistant [NAME] President (AVP) #101 confirmed a wound treatment for Resident #298's left heel wound that was identified on 01/05/24 was not initiated until 01/09/24 (four days later). AVP #101 confirmed a treatment should have been implemented immediately upon identification of a new skin area. AVP #101 stated the information included in the Bruise Event by LPN #61 was accurate as far as the description of the area. LPN #61 was not wound certified so she was unable to officially stage the area. Interview on 01/18/24 at 10:35 A.M. with LPN #50 revealed she had completed the wound assessment on 01/12/24 (seven days after the wound was first identified) for Resident #298 and had staged the wound as an unstageable, deep tissue injury. LPN #50 confirmed Resident #298's left heel wound had not been officially staged prior to 01/12/24. LPN #50 stated she did not know why the area was documented as a deep tissue injury on 01/09/24 because the area had not been officially staged yet. LPN #50 confirmed she was not wound certified but had some experience with wounds from a previous job. LPN #50 stated LPN #61 requested she look at the resident's left heel wound. LPN #50 stated the area was small and may heal fairly quickly if Resident #298's heels were off-loaded. Interviews on 01/18/24 at 10:43 A.M. and 11:37 A.M. with Assistant Director of Health Services (ADHS) #84 confirmed she was the facility's designated wound nurse and she completed wound rounds weekly. ADHS #84 stated Resident #289's left heel wound was identified while she was off from work due to COVID-19 on 01/05/24 but she was just informed of the wound yesterday, 01/17/24 (12 days after the wound was identified). ADHS #84 stated she returned to work on 01/11/24 and she did not know why she was not notified of the new wound area upon her return or why another nurse completed the wound assessment on 01/12/24. ADHS #84 stated she assessed Resident #289's left heel wound for the first time on 01/17/24 but had not entered the assessment into the resident's record yet. ADHS #84 confirmed the wound was unstageable because it was covered with necrotic tissue and she could not see the wound bed. ADHS #84 also stated it appeared to be a deep tissue injury, not a bruise. ADHS #84 confirmed the area should have been comprehensive assessed and staged by a wound certified nurse prior to 01/12/24 (seven days later). ADHS #84 stated the facility did not have a wound physician who made rounds on the resident and if a resident needed more extensive wound care the facility would need to refer them to a local wound clinic. Review of the facility policy, Guidelines for General Wound and Skin Care, date 05/10/17, revealed the policy stated, the following general wound and skin care guidelines should be followed for all residents with potential and/or actual impairment in skin integrity. Use pillows or wedges for positioning to avoid skin on skin contact. Evaluate the need for heel floats/boots. Document type of wound, location, stage (if applicable), length, width, depth in centimeters, base, drainage, periwound tissue, and treatment of the wound weekly using the wound/skin treatment flow sheet. Notify the wound care nurse/nurse supervisor for all new stage II-IV pressure ulcers or if you have any questions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, and facility policy review, the facility failed to timely address or implement effective nutritional interventions for Resident #298 who experienced a significant weight loss. This affected one resident (#298) of three residents reviewed for nutrition. The facility census was 51. Actual Harm occurred on 01/05/24 when Resident #298's weight revealed a significant weight loss of 5% in less than 30 days. The Registered Dietitian (RD) was not notified and did not address the significant weight loss until 01/10/24 (five days later) to make nutritional recommendations. The facility did not implement the nutritional recommendations from the RD that were made on 01/10/24 until 01/12/24 (seven days after the significant weight loss was identified). The nutritional interventions were not properly monitored by the facility staff for effectiveness. Resident #298 was weighed again on 01/15/24 (ten days following the initial identification of a significant weight loss) which showed an additional 4% weight loss. Resident #298's total weight loss was 9% in less than 30 days. Findings Include: Review of the medical record for Resident #298 revealed an admission date on 12/22/23. Medical diagnoses included displaced intertrochanteric fracture of left femur, polymyalgia rheumatica, and Type II Diabetes mellitus without complications. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #298 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #298 had an impairment to her lower extremity and used a walker or wheelchair for mobility. Resident #298 required substantial/maximal assistance from staff to complete bed mobility and partial/moderate assistance with transfers. Resident #298 weighed 123 pounds (lbs) with no noted weight loss or gain in the last month or six months. Resident #298 was on a therapeutic diet. Resident #298 did not have any unhealed pressure ulcers or injuries. Review of weights dated from 12/22/23 to 01/15/24 revealed Resident #298 weighed 123 lbs on 12/22/23 at 10:15 P.M., 116 lbs on 01/05/24 at 3:53 P.M. (a seven lb weight loss), and 111 lbs on 01/15/24 at 9:57 A.M. (an additional five lb weight loss and a total weight loss of 12 lbs in less than 30 days). Review of meal intakes dated from 12/22/23 through 01/18/24 revealed Resident #298's intakes varied from 1-25% to 76-100%. From 12/22/23 to 01/05/23 (15 days), the resident's intake was documented as 50% or less 13 times. Review of the care plan dated 12/22/23 revealed Resident #298's Profile Care Guide included a regular diet, regular texture, thin liquids, and fortified foods. The care plan noted Resident #298 did not like cottage cheese. Review of the progress notes dated from 12/22/23 through 12/27/23 revealed on 12/22/23 at 5:37 P.M., Resident #298 was admitted to the facility. Vital signs were within normal limits. The resident had three surgical incisions to her lower left extremity from hip fracture surgery. Resident #298's abdomen was noted to be distended (bloating or swelling in the belly area) was noted. On 12/23/23 at 10:54 A.M., Resident #298 was noted to have non-pitting (does not indent when pressure is applied) swelling to her left lower leg as well as abdominal distension. On 12/24/23 at 11:54 P.M., 12/25/23 at 11:26 A.M., and 12/27/23 at 11:48 P.M., Resident #298 was noted without any swelling to either leg and abdominal distension was noted. Review of the admission Nutrition assessment dated [DATE] at 8:13 A.M., revealed Resident #298's current body weight on 12/22/23 was 123 lbs. with a hospital weight of 124 lbs. The resident was noted for a risk of weight/fluid variances post surgery and post intravenous fluids (IVF) at hospital. Monitor weights as available. Increased metabolic demands related to hip fracture and surgery. Edema (swelling) noted per nursing masking actual weight and/or potential weight changes. Malnutrition risk related to edema masking actual weight and/or potential weight changes. Diet: Controlled Carbohydrate (CCHO). The diet was adequate to meet Resident #298's calculated needs. Intakes ranged from 26% to 100%. No dietary recommendations were made. Monitor weights, labs, physical parameters to evaluate diet and intakes meet actual needs with current interventions. Honor food preferences within ordered diet. Review of progress notes dated from 12/28/23 through 01/01/24, 01/03/24 through 01/05/24 through 01/09/24 revealed Resident #298 did not have any edema or abdominal distension noted. Review of the progress notes dated 01/02/24 at 7:35 A.M. and 01/09/24 at 7:10 A.M. by Medical Director (MD) #47 revealed there was no edema noted in the physician's assessments. Review of the progress note dated 01/05/24 at 10:25 P.M. revealed Licensed Practical Nurse (LPN) #61 identified a new dark, boggy intact area with no drainage measuring approximately 3.5 centimeters (cm) long by 2.5 cm wide to Resident #298's left heel. There was no documentation of the identified significant weight loss when Resident #298's weight was 116 lbs on 01/05/24. There was no documentation the Registered Dietitian (RD), physician, or resident representative were notified of the significant weight loss. There was no documentation a re-weight had been completed. Review of the Nutrition - Weight/Wound Note, dated 01/10/24 at 11:13 A.M. revealed Resident #298's current weight was 116 lbs taken on 01/05/24 (five days earlier). A significant weight loss of seven lbs or 5.7% in two weeks was noted. Recommended weekly weights for four weeks. Increased metabolic demands related to skin impairment. Loss may be related to recent acute care events. Consider diet liberalization to maximize nutritional support in advanced age setting. Intakes were 51-100%. Recommend changing diet to Fortified diet, regular texture, thin liquids to offer additional calories and protein. Monitor weights with nutritional interventions as recommended. Review of the Metabolic/Nutrition Event dated 01/10/24 and completed by Registered Dietitian (RD) #102 revealed the dietitian recommended to change diet to fortified diet, regular texture, thin liquids (discontinue controlled carbohydrate diet) and weekly weights for four weeks. The physician and resident representative were notified on 01/12/24 (seven days after a significant weight loss was identified). Review of the care plan for Resident #298 revealed the care plan had been revised on 01/10/24 and indicated the resident had experienced a significant weight loss within 30 days. Interventions included offer encouragement and assistance with eating as needed (PRN), provide diet, supplements, medications, adaptive equipment, and snacks as ordered, and weigh as ordered. Additionally, Resident #298 required increased caloric, protein, and/or nutrient needs related to presence of impaired skin integrity. Interventions included encourage fluids, obtain weight as ordered or as needed, provide diet as ordered, and provide supplements, vitamins, and/or minerals as ordered. Review of an Interdisciplinary Team Note (IDT) dated 01/12/24 at 4:51 P.M. (two days after recommendations were made and seven days after a significant weight loss was initially identified) revealed the dietitian recommends to add fortified foods to diet. MD #47 notified and agreed. Review of the physician's orders revealed Resident #298 had the following diet order: Controlled Carbohydrate, regular texture, fortified food, and thin liquids dated 01/12/23. An order for weekly weights had not been implemented as recommended. Review of the progress note dated 01/16/24 at 6:45 A.M. by MD #47 noted Resident #298's weight on 01/15/24 at 9:57 A.M. was 111 lbs (an additional five lb loss). Review of the Nutrition - Weight Note, dated 01/17/24 at 10:29 A.M., revealed Resident #298's current weight on 01/15/24 was 111 lbs. An additional weight loss of five lbs in ten days was noted and a significant weight loss of 12 lbs in 24 days or 9.5% weight loss was noted with decreased meal intakes. Monitor weights as available. Fortified diet as ordered. Recommend to discontinue CCHO diet in advanced age setting with poor meal intakes. Intakes ranged from 26-75%. May benefit from an appetite stimulant. Consider consulting with the physician for an appetite stimulant such as Remeron. Monitor oral intakes and weight trends with recommended interventions. Review of the Fortified Foods List revealed the options included: yogurt parfait, power shake, cheese and cracker plate, peanut butter crackers, and cottage cheese plate. Observation and interview on 01/17/24 at 1:00 P.M. with Resident #298 in her room revealed the resident had the lunch meal in front of her. The meal consisted of baked chicken, mashed potatoes, peas, Jello dessert, a chef's salad, and grapes. There was not a fortified food noted on the resident's meal tray. Interview on 01/17/24 at 2:41 P.M. with RD #102 revealed she was on-site at the facility one time per week to review resident weights. RD #102 stated if a resident was weighed after she was on-site that week and revealed a significant weight change, she would not know until the following week unless the facility staff notified her of the change. RD #102 confirmed she had not been notified of Resident #298's significant weight loss identified on 01/05/24 until 01/10/24 when she was on-site at the facility and reviewed the weights (five days later). RD #102 stated she made recommendations to add fortified foods and weekly weights as interventions on 01/10/24 and informed the staff. RD #102 stated a re-weight would be suggested when a significant weight loss or gain was indicated to confirm the weights are accurate. RD #102 confirmed the diet recommendation was not implemented until 01/12/24 (two days later and seven days following the identification of a significant weight loss). RD #102 confirmed an order for weekly weights had not been implemented by the facility. Resident #298 was weighed again on 01/15/24 and revealed an additional five lb weight loss. The most recent weight was just reviewed by RD #102 today, 01/17/24, with additional recommendations made. Observations and interviews on 01/17/24 at 5:10 P.M. and 5:25 P.M. with Resident #298 in her room. During the interview, discussion with the resident included the list of fortified foods. Resident #298 stated she did not like yogurt or cottage cheese. Observed the resident's dinner tray had been placed in front of her and included: a Ritz cracker and cottage cheese plate, turkey, dressing, green beans, mashed potatoes, and a piece of cake with fruit topping. Resident #298 stated she would not eat the cottage cheese. Review of the meal ticket for the dinner meal on 01/17/24 revealed the meal ticket stated fortified food, no sweets, wants small portions, and decaf coffee. There were not any dislikes listed. Interview on 01/17/24 at 5:45 P.M. and 5:57 P.M. with the Director of Food Services (DFS) #86 confirmed the fortified food offered with the dinner meal was a cracker and cottage cheese plate. DFS #86 stated the list of fortified foods was not reviewed with the residents for preferences. DFS #86 stated the kitchen staff picked a fortified food for the meal and if a resident requested another option, the kitchen would provide it. DFS #86 stated she was not aware Resident #298 did not like yogurt or cottage cheese. DFS #86 stated she did not know who was responsible for monitoring the acceptance of the fortified food. DFS #86 stated the kitchen staff did not provide education to the residents regarding the importance of eating the additional fortified food and did not explain to the resident why the additional fortified food was added to the meal trays. DFS #86 offered Resident #298 another fortified food option following surveyor intervention and the resident accepted peanut butter crackers. Interview on 01/17/24 at 6:20 P.M. with the Administrator and Assistant [NAME] President (AVP) #101 confirmed the facility had not been monitoring the acceptance of the fortified food options and had only been monitoring resident intakes of the whole meal tray. The Administrator and AVP #101 confirmed the fortified foods list did not meet the selection indicated in the facility's policy. The Administrator and AVP #101 confirmed resident preferences should have been addressed with the residents related to the fortified food options. Review of the facility policy, Nutrition Recommendation Guideline, reviewed 12/01/21, revealed the policy stated, the dietitian reviews recommendations with the Director of Health Services (DHS) and Director of Food Services (DFS) if possible or a copy of the recommendations is provided for the Executive Director (ED), DHS, and DFS to review. Suggested discipline follows up on recommendations in a timely manner. Review of the facility policy, Guidelines for Weight Tracking, reviewed on 12/31/22, revealed the policy stated, residents who have a weight that seem out of normal range shall be re-weighed to determine the accuracy of the original weight. The physician, resident representative, and dietitian shall be notified of a weight variance of 5% in 30 days. Review of the facility policy, Fortified Foods, reviewed 10/02/23, revealed the policy stated, The Fortified Foods program focuses on provided a greater variety of food choices to better meet the unique nutritional needs and preferences of each resident. The Fortified Foods selection includes shakes, desserts, breakfast items, soups, and savory foods. When placed on Fortified Foods, a resident will receive a fortified food item of choice in addition to the regular menu meal. The Director of Food Services (DFS) will talk with residents to decide on what fortified food is preferred. At least two fortified food options should be available per meal, with one option to always be a fortified shake.