**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for 2 of 8 residents (Residents #1 and #3) reviewed for pressure ulcers. - The facility failed to conduct comprehensive skin assessments for Resident #1 resulting in the development and delayed treatment of a sacral wound unknown to staff until 12/17/2022. The wound measured 8.6 cm x 3.3 cm, circumference 28.38 cm, required debridement and hospitalization due to sepsis. -The facility failed to prevent the development of Resident #1's right heel and left trochanter pressure wounds. -The facility failed to follow physician orders to apply dry dressings on Resident #3's left buttock, sacrum and perineum pressure wounds every shift. An Immediate Jeopardy (IJ) was identified on 02/08/23 at 2:45 p.m. While the IJ was lowered on 02/10/23, the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of pattern as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents who are totally dependent on Staff for skin care and wound care at risk of developing new pressure wounds, worsening of existing wounds, decline in quality of care, infection and experiencing pain. Findings include: Resident #1 Record review of Resident #1's face sheet dated 1/18/23 revealed a [AGE] year-old female who admitted to the NF on 08/30/2022 with the diagnosis of dementia, Type 2 Diabetes Mellitus (blood sugar), hypertension (high blood pressure), muscle weakness, dysphagia 1/12/23, cognition communication deficit, acute hepatitis E, pressure ulcer right heel (12/16/22), pseudomonas 12/16/22, Proteus (mirabilis), 12/16/22 Escherichia and Klebsiella Pneumonia, hypokalemia, localized swelling mass and lump. Record review of Local Hospital admission Records for Resident #1 printed on 2/1/23 revealed the chief complaint was fall on 1/22/23 who presented to the emergency department via EMS after she was found on the ground after unwitnessed fall. Patient is bedbound she is a poor historian, so most information was gathered from EMS and the nursing home paperwork. Further record review of local Hospital Lab Records for Resident #1 printed on 2/1/23 revealed Resident #1 was positive for severe sepsis upon admission to the Emergency Room. Laboratory tests results revealed high lactic Acid at 4.2 with the normal range being 0.4-1.9 on 1/23/23 and [NAME] Blood Count was high at 19.4 and the normal range was between 4.5-11.0x10). The diagnosis was septic vs hemorrhagic shock, large sacral ulcer with osteomyelitis, Left hip pressure ulcer that could be source of infection .She has a bald spot on the back of her head and the sacral ulcer. Interview and record review on 2/2/23 at 12:30 p.m., with MDS Coordinator of Resident #1's Comprehensive Care plan dated 1/16/23 revealed there was no care plan for the sacral wound. Interview with MDS Coordinator revealed she did not know why Resident #1 was not care planned for the sacral wound, and she could not answer why. Further record review on 2/2/23 of Resident #1's Comprehensive Care plan dated 1/16/23 revealed a potential/actual infection related to: Wound abscess that was present on admission with interventions to observe for signs of increased infection, such as redness, warmth, drainage, increased pain, fever. Resident #1 is t increased risk for complication (bleeding, bruising, lab abnormalities) r/t use of Anticoagulant therapy secondary to given cardiac health with interventions to have labs as ordered, report abnormal labs to the MD, monitor/document/report to MD PRN signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, ;lethargy, bruising, blurred vision, loss of appetite, sudden mental status .Take precautions to avoid falls .I have bowel and bladder incontinence r/t Cognitive loss with risk of additional skin breakdown r/t incontinence with interventions to check resident every two hours and assist with toileting as needed dated 1/16/23. Resident #1 had ADL self-care performance deficit r/t dementia with interventions to bath/shower check nail length and trim and clean, bed mobility, dressing with one staff assisting. Eating provide milkshakes or liquid food supplements when the resident refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or a mug where appropriate and she requires one staff to assist with eating, toilet use, and transferring. Resident #1 was at risk for falls r/t dementia and she had an actual fall on 11/24/22 with swelling on left side of forehead, bruising to left cheek and left knee dated 11/24/22 with interventions to anticipate and meet residents needs, be sure the call light is within reach and encourage the resident to use it for assistance as needed and ensure she is wearing appropriate footwear. She has the potential for nutritional problems r/t diet restrictions, on puree diet and has diabetes and wounds. Resident #1 had vitamin supplements, to prevent deficiencies, extra protein and shakes to assist with wound healing, poor by mouth intake an antidepressant hoping to increase my appetite. The interventions are to maintain the diet ordered, monitor/document/report to MD PRN signs and symptoms of malnutrition: emaciation, muscle wasting, significant weight loss: 3 lbs. in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months dated 1/16/23, provide and serve supplements as ordered. Resident #1 has a pressure ulcer of the right heel, and left trochanter, treat wounds daily and be seen by wound care MD weekly with interventions to evaluate wound for size, depth, margins, document progress in wound healing on an ongoing basis. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Patterns BIMS Summary Score of 3 indicated severe mental impairment, no behaviors were noted, rejection of care was 0, functional status for bed mobility, transfer, toilet use and personal hygiene were extensive assistance with two staff assisting, dressing was extensive with one person assisting, walk in room and corridor, locomotion on unit and off unit were limited assistance with one person physically assisting, and eating was supervision with one staff assisting. Resident #1 required total dependence for bathing with one staff assisting and she ambulated with a walker, urinary continence was occasional and bowel continence was frequently incontinent. Resident #1 was identified for malnutrition and was revealed to have no pain, swallowing/nutritional status she had no problems identified, and loss of 5% or more in the last month or loss of 10% or more in last 6 mths was 0 indicating Resident #1 had not lost weight. Risk of Pressure ulcers/injuries were indicated but revealed 0/no for does resident have one or more unhealed pressure ulcers/injuries. -Record Review of Resident #1's progress note dated 8/30/22 revealed Right lateral thigh wound type is a nodule acquired on 8/30/22 before entering the facility. -Record Review of Resident #1's Wound Assessment Details dated and acquired on 12/15/22 revealed Wound #2, Wound Care Physician's initial exam treating deep tissue right heel 3.2 cm x 1.7 cm. Observation revealed the right heel Deep Tissue Injury was not identified on previous weekly skin assessments. Wound was not found to be unavoidable. -Record review of Resident #1's progress notes of Skin Only Evaluation dated 12/14/22 at 11:37 a.m. revealed Right heel deep tissue injury was documented measuring Length (cm): 3 Width (cm): 3 Depth (cm): 0 Wound exudate. Pressure ulcer staging: Deep tissue pressure ulcer / injury - persistent -Record Review of Resident #1's Wound Assessment Details dated and acquired on 12/22/22 revealed Wound #3, Wound Care Physician's initial exam treating sacral with right and left buttock pressure ulcer involvement 8.6 cm x 3.3 cm. There was no documentation about a sacral wound prior to 12/17/22. Wound was not found to be unavoidable. -Record Review of Resident #1's Wound Assessment Details dated and acquired on 1/19/23 revealed Wound #4, Wound Care Physician's initial exam treating left hip pressure ulcer measuring 2.3 cm x 2.1cm. Stage is unstageable pressure injury obscured full thickness skin and tissue loss, exudate amount is moderate and exudate type is serous. Wound was not found to be unavoidable. -Record Review of Resident #1's Wound Assessment Details dated 12/22/22 revealed there was no documentation of a left thigh wound or wound care. -Record review of Resident #1's SBAR Summary dated 9/26/22 at 11:19 a.m. written by LPN revealed Resident has pain and possible infection to left thigh wound, resident only has PRN Tylenol which is not effective Resident up most of night with increased and anxiety, resident wanting to go home, Resident has pain in left thigh wound and signs of possible infection to area. Record review of Resident #1's Weekly skin assessments ranging from the time of admission on [DATE] through 12/17/22 revealed no documentation related to a sacral wound. Record review on 01/24/2023 of Resident #1's weights revealed the following: 08/31/22: 162lbs 09/02/22: 163.5lbs 09/14/22: 161.5lbs 09/21/22: 157.5lbs 10/08/22: 153.5lbs 11/10/22: 150.3lbs 12/05/22: 147.5lbs 01/12/23: 135lbs Record Review of Antibiotics for Resident #1: 12/12/22 Order for Cipro 500 mg 1 tablet by mouth until 12/19/22. 12/14/22 Order for Amoxicillin 875 mg-125mg 1 tablet by mouth every 12 hours until 12/28/22 for e-coli infection of the right hip 12/20/22 Order for Rocephin 1 gram intramuscular for infection for 7 days (2.1 ml of lidocaine). 1/12/23 Order for Augmentin 875-125 1 tablet PO for wound infection for 14 days to end on 12/28/22 for the right hip. Record reviews of Physician Orders revealed: 1/2/23 Pill Supplements, shakes, and appetite stimulant Remeron were ordered. 1/12/23 Resident #1 was started on Vitamin C 500 mg 1 tablet by mouth for wound healing twice a day. 1/12/23 Multi Vitamin 1 tablet twice a day 1/12/23 Zinc Oxide once a day Record review of Resident #1's progress notes dated 9/26/22 at 11:19 a.m. revealed an SBAR Summary RN Assessment/LPN Appearance of resident - What I think is going on with the resident is: Resident has pain and possible infection to left thigh wound, resident only has PRN Tylenol which is not effective. Additional Nursing Notes as applicable: Resident up most of night with increased and anxiety, resident wanting to go home, Resident has pain in left thigh wound and signs of possible infection to area, updated NP on patient status, NP assessed patient, new order received for antibiotic treatment and routine pain control. Record review of Resident #1's progress notes dated 12/17/22 at 7:08 p.m., revealed LPN A documented in the Nursing progress note skin shearing bilateral buttock, slip skin visible. Orders for clean with normal saline pat dry calcium alginate and cover with a dry dressing. Record review of a wound care Dr. progress notes dated 12/22/22 revealed sacral wound with left and right buttock involved 8.6 x 3.3, circumference 28.38. On 12/29/22 Wound Care Doctor debrided wound. Wound care Doctor documented Resident #1 was -given a multi vitamin with minerals, Vitamin C, Zinc. Record review of Wound Care Doctor notes dated 1/19/23 revealed left Hip pressure ulcer was identified with drainage yellow slough 75% unstageable pressure injury, 2.3 L x W 2.1 circumference is 4.83. In an observation and interview on 1/18/23 at 10:37 a.m., with Resident #1 and CNA A Resident #1 was observed lying in bed and observation revealed her hair all over her head, it appeared to be dry and there was a bald spot on the back of her head. Resident #1 said the staff comb her hair once a day and that the staff give her showers. Resident #1 stated the staff brushed her teeth this morning. CNA A stated the staff brushed Resident #1's hair and give Resident #1 showers. CNA A stated Resident #1 had a pressure sore that is bad on the buttocks and the side. CNA A stated Resident #1's sacral pressure sore looked like she had a burn, and the skin was coming off and when CNA A stopped working on the hall for a few weeks (unknown exact time) and came back the sore was big. CNA A stated she was helping the Wound Care Nurse when she did the dressing for Resident #1's pressure sore and the Wound Care Nurse said the staff were not getting Resident #1 up and the Wound Care Physician cleaned Resident #1's wounds. CNA A stated Resident #1 was not eating well, but she tried to give Resident #1 health shakes and protein. CNA A explained Resident #1 had just received her pain meds and that is why she is sleeping. Observation revealed a fall mat by Resident #1's bed. CNA A stated Resident #1's hair is hard, but the CNA's comb it with a brush. Further observation revealed Resident #1 had lots of food in her teeth and it appeared that Resident #1 had broken teeth and the appearance that they were filed down. CNA A stated it looked like Resident #1's teeth were broken. CNA A stated she did not get her up today, but everyone can brush teeth. In an interview on 1/18/23 at 10:50 a.m., with CNA B she stated she fed Resident #1 this morning. CNA B stated that she did not brush Resident #1's teeth, but she used a disposable oral dental sponge to wipe Resident #1's teeth this morning. CNA B stated she did not know if Resident #1 has seen a dentist. In an interview on 1/18/23 at 11:20 a.m., the Wound Care Nurse stated Resident #1 was not eating and barely drinking a little bit. The Wound Care Nurse stated Resident #1 has declined and had the right hip abscess that started bothering her that is healing now. She stated from Resident #1 not eating and decreased moving she got a sacral wound, and the Wound Care Physician came to debride it and took the unstageable part off. The Wound Care Physician comes to the facility every Thursday and he debrided Resident #1's sacral pressure sore twice taking the tissue off. Resident #1 also has a pressure sore on the right and left hip. Resident #1 is on a puree diet and the staff feed her now and she is eating close to 75% of her food, but today she ate 50% of her food. The Wound Care Nurse stated Resident #1 does not get up because the Wound Care Physician did not want Resident #1 up and she does not lay on her back at all. In an interview on 1/18/23 at 11:45 a.m. with the DON she stated Resident #1 admitted to the facility with a right thigh wound and it would not go away no matter what they did. The DON stated Resident #1 had a small area on the left hip and sacral area which was debrided on 12/29/22 and Resident #1 was put on antibiotics. Resident #1's family member wanted an MRI of the wounds, but all the consults never got done because Resident #1's POA was never here and now a family member says she is here now. The DON stated she called the Nurse Practitioner and the Wound Care Physician, and the Wound Care Physician ordered lab work on the sacral and a hip x-ray. The DON stated Resident #1 did have poor dentition. She stated it was difficult to turn Resident #1, but she does have pain management on board. The DON stated Resident #1's family member kept insisting she go to the hospital. The DON stated the facility increased Resident #1's pain management over the weekend and the on-call Physician was contacted and he said no hospital and have the wound care Physician to come to see Resident #1. The DON said the sacral wound had just been debrided and the Wound Care Physician comes every Thursday and were patching the sacral wound with calcium alginate. In an interview on 1/18/23 at 12:31 p.m. with FM #1 stated the biggest concern the family had for Resident #1 is getting her the proper care she needs. FM #1 stated Resident #1 needs to be transferred to the hospital, but the DON stated the only person could request Resident #1 to go to the hospital was the POA. She stated the POA has been missing and Resident #1 has dementia. FM #1 stated Resident #1 said she was in pain. FM #1 stated she watched the Wound Care Nurse, and she was doing wound care to the outside of the wound, but the inside of the wound is being done once a week. FM #1 stated if the facility did not want to take Resident #1 to the hospital, can they take her to her own doctor. FM #1 Resident #1 had a boil in her leg area before, but now there is a lot of decline, and the pressure sores are all over her body and Resident #1 had only been here at the facility for 4 months. In an interview on 1/24/23 at 10:09 a.m. with the Wound Care Nurse she stated she had been the wound care nurse for a year and the facility had 8 in house pressure wounds and 15 total pressure wounds. The Wound Care Nurse stated Resident #1 admitted to the facility with a nodule to the right hip and after that it was painful for her, and she fell quite a bit and she stopped eating. The Wound Care Nurse stated Resident #1 had poor food intake, so they got her a speech pathologist assessment and changed her diet she believed from mechanical soft to puree and Resident #1 started eating more. The Wound Care Nurse stated she developed a sacral wound on December 22, 2022, and it was unstageable. The Wound Care Nurse stated she was doing wound care on the sacral pressure sore and putting calcium alginate until the Wound Care Physician came in. The Wound Care Nurse stated the Wound Care Physician used calcium alginate and a dry dressing to treat the sacral pressure sore and it was measured at 8.6 x 3.3 cm initially. The wound care nurse said she saw the wound for Resident #1 and then she was out sick for 8 days, she said she did not know what the facility staff had done while she was gone. The Wound Care Nurse stated the facility nurses are supposed to do the wound care while she was gone, but when she came back Resident #1's pressure sore looked the same. She stated the wound care doctor debrided the sacral wound on 12/29/22. In an Interview on 1/24/23 at 10:44 a.m. with the Speech Pathologist said he assessed Resident #1 on January 2nd, 2023, due to resident poor dietary intake. The Speech Pathologist stated during his assessment of Resident #1, he observed that Resident #1 was not chewing her food but instead, was pocketing food. He stated Resident #1 was able to swallow without difficulty and therefore changed Resident #1's diet from a regular diet to a puree diet and after changing Resident #1's diet to a puree diet intake went from 10% to 100 %. In a telephone interview on 1/24/23 at 11:07 a.m. with the Dietician regarding Resident #1 she stated she started working at the Nursing Facility in November 2022 and was aware of Resident #1's weights and had made some recommendations on December 19, 2022. The Dietician stated she made recommendations for house supplements twice a day and liquid protein. The Dietician stated she did discuss with the nurses about Resident #1's decrease in appetite and the medication Remeron takes about 60 days to get in the system to be effective. The Dietician stated the NF was going through some Administrative changes involving the DON. The Dietician stated it just appeared that Resident #1 had a poor dietary intake appetite and said a gastrostomy feeding was never mentioned to Resident #1's family. In an observation and interview on 2/1/23 at 9:00 a.m., with Resident #1 at local hospital she was observed sleeping and was difficult to awake. Resident #1 was on antibiotic IV(vancomycin) and she had a wound vac. In an observation and interview on 2/1/23 at 9:07 a.m. with LVN at local hospital she stated Resident #1 had a wound vac, and the Wound Care Nurse and Infection Control Physician change the wounds on Monday, Wednesday, and Friday. She stated the hospital was about to change the wounds at this time, so she was giving Resident #1 Morphine 4 mg. The LVN at local hospital stated Resident #1's wounds were because Resident #1 was not being turned. She stated the wound was huge. In an interview on 2/1/23 at 9:15 a.m. with local Hospital Dietician and LVN at local hospital and he stated Resident #1 was not eating and had just been sipping on ensure. The Dietician stated if Resident #1 did not increase in her eating, they will have to do a feeding tube. The LVN said she would attempt to get Resident #1 to eat more. The LVN said Resident #1 had wounds on her heals and that is why she said they were not moving Resident #1 from the sacrum all the way to the hip. The LVN stated the wounds did not happen overnight. In an interview on 2/1/23 at 9:30 a.m., with Local Hospital Wound Care Nurse she stated Resident #1's wounds can start within hours, but Resident #1's wounds were probably there for 6 months because her eating is not great and with mental health. The Wound Care Nurse at the local hospital stated the sacrum wound was not her only wound and Resident #1 had tunneling and that is based on laying on it and how she lays on it causing undermining and tunneling. The Wound Care Nurse said the hip wound on the left side was filled with chronic fat and the first thing to go is your skin. The Wound Care Nurse stated she saw Resident #1 in the ICU 2 weeks ago when Resident #1 first arrived. She stated when she saw the sacral wound, they immediately got the Doctor to get Resident #1 on the wound vac. The Wound Care Nurse stated the pressure sore is due to bed services, her not being turned and repositioned, skin break down, not eating, and psychosis. She stated Resident #1 is alert and oriented. Observation revealed the local hospital Wound Care Nurse measured the wound and it was 14.5x2cm. The Wound Care Nurse stated the wound is better since she saw Resident #1 in the ICU and that the tissue was healing. Observation revealed Resident #1 crying out for pain, but she had already received pain med's. Resident #1 was observed crying out stating momma, you just don't know. The Wound Care Nurse stated Resident #1 had already had 10 days on antibiotics and Resident #1 came into the ER septic (body's extreme response to infection) with high lactic acid. In an interview on 2/1/23 at 9:50 a.m. with Local Hospital Infectious Disease Physician he stated Resident #1 had another wound on her left hip that is chronic, and it smelled terrible. He stated the wound was cleaned in ICU and the sacral wound is terrible with a lot of undermining. The Local Hospital Infectious Disease Physician stated the facility did not wound vac the sacrum. Observation revealed the infectious disease physician looked at the wound on the left hip and he stated, and this Surveyor observed a huge hole on the inside of the wound the size of the index finger and thumb opened. The local hospital infectious Disease Physician stated he could not measure the left hip wound because it is inside. Observation revealed the Wound Care Nurse packing the hole and pulling it out to clean the wound. The Infectious Disease Physician stated Resident #1 has a PICC line and had been receiving antibiotics and he stated to keep giving Resident #1 Bactrim for the sacrum. Observation revealed the wound was cleaned with Hydrogen Chloride, and he stated Resident #1 received 4 mg of morphine prior to her receiving wound care. The Infectious Disease Physician stated the hole of the wound on the hip is small, but its bigger underneath (tunneling) and he stated it was from friction and pulling and shearing force. The infectious disease physician stated that it was from Resident #1 turning, but the facility should have caught the wounds before they got to this point. In an interview on 2/1/23 at 10:30 a.m. with Local Hospital Case Manager he stated Resident #1 admitted to the hospital for head pain injury as the chief complaint and swelling from the Nursing facility. The Hospital Case Manager stated EMS transported Resident #1 due to an unwitnessed fall and she was found by staff. Resident #1 was stated to have wounds of Stage IV tunneling on sacrum, unstageable ulcer on right and left hip, blood pressure was low, lactic acid was high and Resident #1 had sepsis. In an interview and record review of Resident #1's clinical records on 2/1/23 at 12:33 p.m. with the DON she stated Resident #1 had dementia, was able to get up and transfer, and was getting up and walking down the hall unaided but was unstable. The DON stated Resident #1 had the right thigh wound that she admitted with. In an interview on 02/01/2023 at 1:08 p.m., with the Wound Care Nurse she stated she would have to look at Resident #1's records to see if she was on any supplements for weight loss. The Wound Care Nurse said on 12/22/22 after reviewing resident records said the Wound Care Physician began treating Resident #1's wound to the sacral area. The Wound Care Nurse said the WC Doctor began treating Resident #1's deep tissue injury to the right heel on 12/15/22. The Wound Care Nurse said the Wound Care Physician last saw Resident #1 on 01/19/22 because of resident sacral wound. The Wound Care Nurse said she had been the Wound Care Nurse since October of 2021 and at one time had attended some morning meetings for maybe 2 months in 2022. The Wound Care Nurse said she stopped attending the morning meetings because the DON told her she did not need to attend. The Wound Care Nurse said she did skin assessments Monday-Friday and the unit nurses do skin assessments on the weekends as well as dressing changes. In an interview on 02/01/2023 at 2:08 p.m. with CNA C she stated Resident #1 verbalized often that she was in a lot of pain saying oh baby I am hurting. CNA C stated Resident #1 never refused care from her. CNA C stated Resident #1 had a huge wound on her back side and was unable to turn self and depended on the staff to turn her. CNA C stated Resident #1 had a wound to her right thigh and a wound on one of her heels and that Resident #1 ate sometimes but not consistently, mostly not eating. CNA C stated she did report to the nurse Resident #1's lack of appetite. CNA C stated she could not remember the nurses name because she worked with different nurses. CNA C stated sometimes the dates on Resident #1's sacral wound was outdated especially on the weekends. CNA C stated Resident #1's wound had a foul odor. CNA C stated she worked the 6am-2pm and sometimes worked doubles. In an interview on 2/2/23 at 11:35 a.m. with CNA A she stated at first Resident #1's skin on her sacrum was kind of dark after Thanksgiving, 11/24/22, but when CNA A moved to work on a different hall Resident #1's sacrum looked like you have a burn and the skin come off. CNA A stated Resident #1 did not have a hole or anything. CNA A stated she thinks they started getting Resident #1 up and being in the wheelchair with the pressure from the seat Resident #1's pressure sore got worse and that is when they started wound care. In an interview on 2/2/23 at 11:40 a.m. with Anonymous Staff 2 she stated she had seen on the weekend if the wound care nurse is not here the nurses have to do the wound care. Anonymous Staff 2 stated the nurses were not doing wound care. The Anonymous Staff 2 stated she saw LVN C doing the wounds, and she just took the patch off and put on another one without cleaning the wound and putting on any medicine. Anonymous Staff 2 stated LVN C quit, but before she did, she saw LVN C not doing everybody's pressure sore leaving the building and hiding. Anonymous Staff 2 stated that it happened under DON B. In an interview on 2/2/23 at 11:45 a.m. with Anonymous Staff 3 she stated she told the Wound Care Nurse about Resident #1's skin was dark around December 1-5, 2022. Resident #1 would lay on her side because of the abscess on her right side. Anonymous Staff 3 stated Resident #1's skin was dark on her sacrum, but you could not see a wound, it was just a little spot a different color on her back. The Anonymous Staff 3 stated Resident #1 was always in pain and only ate a little bit. Anonymous Staff 3 stated Resident #1's eating depended on her pain or if Resident #1 liked the food and she started receiving health shakes so Resident #1 could heal. In an interview on 02/02/2023 at 11:50 a.m. with the ADON she stated the Wound Care Nurse did skin assessments and when the Wound Care Nurse was not at the facility, the nurses on the units had to do the skin assessments as well as on the weekends. The ADON stated later on, Resident #1 developed a wound to her sacral area and left hip and was eating okay but later Resident #1's dietary intake decreased, and the staff had to feed her. The ADON stated Resident #1 began to pocket her food and that was when Speech Pathologist got involved. The ADON said before Resident #1's sacral wound was debrided, the sacral wound looked like a stage 2 wound, and they completed a wound culture of the sacral wound. The ADON stated she did not know when Resident #1 developed the wound to her sacral area. The ADON stated a gastrostomy feeding was never discussed. She stated Resident #1 was in a lot of pain due to her right hip. The ADON stated Resident #1 never resisted care but was confused always trying to climb out of bed. In an interview on 2/2/23 at 12:30 p.m. with MDS Skilled Coordinator 1 she stated she could not explain what happened with the skin sheets and she stated they tried to pull them together. MDS Skilled Coordinator stated weight loss was not care planned, but it should have been. In an interview on 2/7/23 at 2:13 p.m. with Charge Nurse A she stated on the weekends when the wound care nurse is not here the Nurses do the wounds. Charge Nurse A stated if the dressing is intact, they need to leave the wound alone and sometimes the wound nurse comes on the weekend, and they tell her. Charge Nurse A stated if the dressing is intact and no drainage for the skin integrity you don't want to take it off, but if the Wound Care Nurse comes in later and a wound is draining (fluid or pus) then the Nurses will change the dressing on the wound. In an interview on 2/9/23 at 10:22 a.m. with the DON she stated Resident #1 got her wound debrided on 12/22/23. The DON stated Resident #1 did not have pain until you touched her and that is why they did the wedges for her. The DON stated the skin the documentation was there for December, and the nurses did contact the doctor and put something in place. The DON stated she did not see Resident #1's sacrum wound. The DON stated the systems go together when you are having a weight loss and nutrition deficiency and protein or calorie deficiency it goes hand in hand for additional skin breakdown. The DON stated you have to have those for the tissue and collagen to hold up. The DON stated she saw the failure when Resident #1 started to lose weight and started to trigger. The DON stated Resident #1's physician should have been notified, RP and dietary should have been notified to help. The DON stated the facility should have reached out to RP to ask if there is certain food Resident #1 likes and then she can have dietary to assist with getting food Resident #1 liked. In an Anonymous Staff 1 Staff 1 interview on 2/9/23 at 10:27 p.m. it was stated the staff are supposed to report any open wounds to your charge nurse and Resident #1's pressure ulcers could have been avoided. The staff stated the staff do not do what they should. The Anonymous Staff 1 stated if the Wound care nurse is not at the facility the nurses do not give appropriate wound care treatment. The Anonymous Staff 1 stated the nurses were observed taking the bandage off and putting a new bandage on the pressure ulcers without cleaning. The Anonymous Staff 1 stated Resident #1's wounds did not need to get like that, and the facility was aware Resident #1 needed a wound vac. You can't just change bandages on her and not put the wound treatm[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for two (Resident #1 and Resident #2) of eight residents reviewed for accidents, hazards, and supervision. -The facility failed to provide adequate supervision and psychiatric intervention for Resident #2 to prevent further injuries from falls and self-injury behaviors that resulted in multiple injuries including bruises, lacerations, and hospitalizations. -The facility failed to implement Physician recommendations on 2/7/23 of 1:1 and hourly checks, and train staff on protective helmet to prevent injuries to Resident #2. -The facility failed to adequately educate staff on caring for residents with aggression and self-harming behaviors. -The facility failed to care plan and put additional services in place for Resident #1 when she had a fall on 10/01/22, and a 2nd fall on 11/24/22. Resident #1 was no longer ambulate and causing her pain. An Immediate Jeopardy (IJ) was identified on 02/12/23 at 2:46 p.m. While the IJ was lowered on 02/13/23, the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of pattern as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents who are totally dependent on Staff for activities of daily living, supervision, and psychiatric assistance at risk of not being adequately supervised, no adequate intervention, worsening of existing wounds, decline in quality of care, experiencing pain and death. Findings include: Resident #2 Record review of Resident #2's face sheet dated 2/10/23 original admission date was 1/21/22 and admission date 2/3/23 revealed a [AGE] year-old male with unspecified protein-calorie malnutrition, hypertension, altered mental status, polyosteoarthritis (cartilage degenerating), muscle weakness, dementia, chronic obstructive pulmonary disease with acute exacerbation, shortness of breath, type 2 diabetes mellitus, cocaine dependence with cocaine-induced mood disorder, dizziness and giddiness and repeated falls. Resident was diagnosed with repeated falls (11/9/22) muscle weakness (1/21/22) dizziness and giddiness (11/9/22). Record review of Resident #2's Care Plan dated 12/6/22 revealed resident is a high fall risk due to shuffling gait and poor impulse control. Interventions were to ensure call light is within reach, encourage assistive device for locomotion, low bed, and fall mats with actual falls on 1/30/2022-Actual fall, no injury, 11/09/2022-Actual Fall #1, hematoma above right eye, abrasion to the top bridge of nose. ER Visit 11/09/2022-Actual fall #2, no injury. ER Visit, hospitalized , Date Initiated: 04/01/2022, follow facility fall protocol, PT evaluate and treat as ordered or PRN. Resident #2 also had the potential to be physically aggressive and the interventions were to analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and address for contributing sensory deficits, immediately remove from room, redirect, allow to calm down and to send resident to ER via police. Resident #2 was identified to have potential to be verbally aggressive r/t history of verbal aggression, threatens staff, voice is very loud and sometimes refuse my medications with interventions as Administer medications as ordered, observe/document for side effects and effectiveness, analyze of key times, places, circumstances, triggers, and what de-escalates unknown behavior and document, assess, and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Resident #2 had oral/dental health problems with no teeth and interventions: Resident #2 on a regular diet, Monitor/document/report PRN any s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions, and provide mouth care as per ADL personal hygiene. Record review of Resident #2's Quarterly MDS dated [DATE] revealed Cognitive Pattern BIMS Summary Score of 0, indicating severe cognitive impairment. Resident #2 has physical and verbal behavioral symptoms directed towards others daily, and other behavioral symptoms not directed towards and functional status revealed activity did not occur for locomotion on and off unit, walking in room and corridor, transferring occurred once or twice with two staff assisting, total dependence on one staff for dressing and personal hygiene, extensive assistance with mobility with two staff assistance and limited assistance by one staff with eating and total dependence on one staff for bathing. Active diagnosis included repeated falls and malnutrition. Record review of Resident #2's psychiatric visit note dated 8/26/22 revealed resident was seen today for the management of psychotropic medications and side effects, and to monitor the effect of medication and for dosage adjustment. The patient's psychotropic medication is beneficial in this case to control their psychiatric symptoms and to manage the patient's condition, to prevent relapse or hospitalizations and to improve restorative potential. Patient reports to I feel better Staff reports no behavioral problems. Resident #2 was found to be alert and oriented x2 and appeared calm and cooperative, and reports feeling better and eating and sleeping fairly. Patient denies depressed/sad or anxious moods. Staff denies any disorganized behaviors. Staff reports compliance with plan of care . No medication side effects reported. No active psychosis noted. Record review of Physician Orders dated 00/00/00 revealed Resident #2 was taking the following medications: Lisinopril 5 mg tablet 1 tablet by mouth QD Senna 8.6 mg tablet 1 tablet by mouth QD Thiamine 100 mg tablet 1 tablet by mouth QD Metoprolol Succ ER 50 mg tablet by mouth QD Acetaminophen 325 mg tablet give 2 tablets by mouth every 6 hours PRN Effexor XR 75 mg capsule 1 by mouth QD Depakote Dr 250 mg tablet 1 tablet by mouth TID Zyprexa 7.5 mg tablet 1 tablet by mouth Q HS Trazodone 100 mg tablet take 1 at bedtime Clonazepam 0.5 mg tablet give 0.5 tablet by mouth BID Anxiety/Aggression: Clonazepam 0.25 mg TID Insomnia: Trazodone 100 mg QHS Depression: Effexor 75 mg QD Mood disorder: Depakote 250 mg TID and Zyprexa 7.5 mg QD Record review of Post fall risk evaluation dated 12/29/22 at 10:13 p.m., revealed Resident #2 was alert and oriented x 3, had 3 or more falls in the last 3 months, ambulatory/incontinent, The risk for falls goal was resident will be free from falls and the interventions were assist resident with ambulation and transfers, utilizing therapy recommendations, determine residents ability to transfer, evaluate falls risk on admission and PRN, if fall occurs, alert provider, initiate frequent neuro and bleeding evaluation per facility protocol, if resident is a fall risk initiate fall risk precautions Record review of Post fall Evaluation dated 12/29/22 at 10:16 p.m. revealed Resident #2 had an unwitnessed fall in his room and the reason for the fall was not evident and he obtained injuries of skin tear right forearm 2cm x 2cm, skin tear on his neck 2 cm x 2cm, provider was notified, and resident was laying on the mat at bedside, positioned on his right side. Resident #2 was assisted back to bed with neuro checks started. Record review of Post fall evaluation dated 12/31/22 at 7 p.m. revealed a witnessed fall in the hallway and Resident #2 was in a hurry/rush, Provider was notified, and bruising was found. Record review of fall risk evaluation dated 12/31/22 at 7:43 p.m. revealed Resident #2 had intermittent confusion and has had 3 or more falls in past 3 months. Resident #2 was identified as chair bound-requires restraints and assist with elimination. The risk for falls goal was resident will be free from falls and the interventions were assist resident with ambulation and transfers, utilizing therapy recommendations, determine residents ability to transfer, evaluate falls risk on admission and PRN, if fall occurs, alert provider, initiate frequent neuro and bleeding evaluation per facility protocol, if resident is a fall risk initiate fall risk precautions Record review of fall risk assessment dated [DATE] revealed Resident #2 had 3 or more falls in the past 3 months and scored a 23 on the assessment meaning he was a high risk for falls. The date of unwitnessed fall was 1/2/23 at 4:08 a.m. that occurred in Resident #2's room and injury laceration on the left temple did occur due to the fall and Resident #2 was transferred to local hospital and Provider was notified. Record review of Resident #2's Local Hospital records dated 1/5/23 revealed he was admitted due to chief complaint of head injury. He became combative and began hitting his head on the wall and had multiple self-inflicted face and head injuries. Hospital treatment as follows: Start Klonopin 0.5 mg by mouth twice daily, restart Effexor 150 mg by mouth daily, start Depakote 500 mg 2 times daily, restart abilify 10 mg by mouth nightly, start klonopin 0.5 mg by mouth every 8 hours PRN, Discharge Seroquel, continue Haldol 2 mg every 6 hours as needed IV, order urinalysis, VPA level and ammonia level and monitor mood and behaviors and adjust medication and if behaviors and agitation continue, they will follow up with psych transfer. Record review of multiple Hospital records with admissions dated 1/5/23, 1/31/23, and 2/6 revealed resident was seen due to falls and/or banging his head. Diagnoses included contusion of the face, head injury, and forehead contusion and nose fracture. Psychiatric consult was completed, and medications were adjusted during hospital visit on 1/5/23. Resident #2 was given helmet to wear 24/7 at discharge on [DATE]. Record review of multiple facility progress notes revealed Resident #2 had unwitnessed falls with injuries requiring hospitalizations on 11/24/22 and 1/. Record review of Resident #2's Discharge from local hospital on 2/6/23 revealed Resident #2 was confused, and the instructions was to be sure someone was with the confused person at all times. They should not be left alone or unsupervised . Resident #2 was seen for contusion of the head and dementia, and he had confusion and a scalp bruise. CAT scan and put helmet on Resident #2 24 hours a day was included in the discharge from local hospital documents. Record review of Resident #2's progress note dated 2/6/23 at 6:45 a.m. revealed, resident was on the floor covered in blood, blood all over the floor, bedding, and the walls. He was bleeding from his left eye and was unable to stop bleeding. Sent to ER. Record review of Resident #2's progress note dated 2/6/23 at 12:48 p.m. revealed received from hospital on stretcher, immediately very agitated, trying to roll off bed onto mats with helmet in place, yelling help repeatedly. Record review of Physician's progress note dated 2/7/23 revealed patient noted to have a lot of bruising in his face and head. He had been hitting his head on purpose. Resident is on ABH cream, Haldol, and Depakote, and still having issues harming himself by hitting his head on the bed board. Diagnosis of recurrent falls. Resident has headgear to protect head. Ideally one to one sitter needed, and if not need to check at least every hour. Resident's behavior is complicating his safety. Resident had extensive bruising, swelling, tenderness and scrapes to face/eyes, often bleeding. Extensive excoriations, skin tears to extremities, bruising to limbs. Record review of progress note written by DON dated 2/8/23 at 9:36 p.m. revealed Resident #2 was found nonresponsive. Charge Nurse unable to get apical pulse, CPR was initiated, DON called 911 at 5:06 p.m. and his time of death was 5:42 p.m. In an interview on 2/10/23 at 10:44 a.m. with Resident #4 he stated Resident #2 was his roommate and he stated Resident #2 fell and he did not have his helmet on because the staff took it off. Resident #4 stated the staff took off Resident #2's helmet and went out the door. Resident #4 stated it was not nice, and he told them not to take it off. Resident #4 stated he did not know the name of the staff, but it was a CNA and Resident #2 fell and hit his head closer by the door. Resident #4 stated there was blood on the floor. Resident #4 stated Resident #2 would wear the helmet even while he was in the bed. Resident #4 stated the CNA stated they were too busy to watch Resident #2 and they had to go. Resident #4 stated he complained that Resident #2 did not have the helmet on, and no one listened to him. Resident #4 stated Resident #2 stated he kept saying he needed help and that he was hurting. Resident #4 stated Resident #2 was in pain all the time and sometimes the staff would not feed Resident #2. Resident #4 stated the staff brought Resident #2 his food and said here is your food but Resident #2 could not feed himself. Resident #4 stated the CNA's stated they did not have time and it was not right. In an interview on 2/10/23 at 11:26 a.m. with the Director of Rehab she stated Resident #2 had frequent falls and Physical Therapy screened him several times and he was not able to follow any cues or follow any directions. The Director of Rehab stated they did an evaluation on 1/21/22 and the last time Resident #2 came from the hospital he came back with a helmet. Physical Therapy did not put any measures in place from a therapy standpoint. She stated the facility could not restrain Resident #2. The Director of Rehab stated the facility lowered Resident #2's bed all the way to the floor, did the mats on both sides of his bed, organized Resident #2's room so he did not have anything to fall on, but the wall was there. In an interview on 2/10/23 at 12:14 p.m. with LVN D she stated she was working the 6 a.m. to 2 p.m. shift and the unknown night nurse asked her to come with her to Resident #2's room and he was on the floor bleeding from the top of his eye. LVN D stated there was a dressing on the left eye and Resident #2 took it off and LVN D tried to stop the bleeding but could not, so they called EMS for help. LVN D stated Resident #2 went to the hospital on 2/6/23 and came back from the hospital with a helmet. LVN D stated she saw Resident #2 on 2/7/23 and he was wearing the helmet. LVN D stated on 2/7/23 Resident #2 was calm and doing the same moving around in the room and usually on the fall mat. LVN D stated Resident #2 gets a little agitated or in pain and sometimes Resident #2 responded like he was in pain with his body like he was in pain. LVN D stated she looked Resident #2 in the eyes and asked him about pain, and he was agitated. LVN D stated they just monitored him to make sure he was not hurting himself and he was wearing the helmet up until she left. LVN D stated she was told not provide care to Resident #2 by herself and she usually got the DON to assist her. LVN D stated she was not trained on how to handle Resident #2's behavior and if she saw Resident #2 banging his head or throwing himself on the floor, she would get the DON. LVN D stated she had not been given any specific guidance on how to handle Resident #2 in particular other than in the training if Resident #2 was kicking get someone else to help her. LVN D stated she did not know what Resident #2's Care plan said. In an interview on 2/10/23 at 11:56 a.m. with CMA A she stated Resident #2 started declining last year around Christmas and that was the first time Resident #2 fell he was screaming and being aggressive and throwing himself on the floor out of the bed. CMA A stated they would put Resident #2 in the bed, and he would get himself out of the bed. CMA A stated Resident #2 sometimes refused meds, and he continued declining, and he got worse. CMA A stated Resident #2 continued falling and they kept sending him to the hospital, screaming every night. CMA A stated Resident #2 would crawl out of his room and into the hallway. CMA A stated Resident #2 was only on Depakote and lorazepam, but she thinks the med's did not work in her opinion and the nurse and everyone was aware. CMA A stated she spoke with the NP a couple of times and the NP said she did not know what else to do with Resident #2. CMA A stated she made comments sometimes that Resident #2 needed to be in a psychiatric hospital, but they kept sending Resident #2 back. CMA A stated Resident #2 was mentally and psychologically was declining, always banging his head on the wall, he would always be all over the room and he would get back on the floor after the put him back in bed. CMA A stated she had never seen a person go down like that, it was very sad. CMA A stated Resident #2 would not eat, and he was always rocking on the floor. She stated the staff put Resident #2 in the bed and he would fall out the bed. CMA A stated the last time Resident #2 went to the hospital he got a helmet, but it was not that long before he passed on 2/8/23. CMA A stated Resident #2 had the helmet on 2/6/23 that the hospital gave him, and he had it on at all times because of his body movement he was hurting himself. CMA A stated she never saw Resident #2 take it off or tried to remove it. CMA A stated when she worked on the 2 p.m. to 10 p.m. shift she was doing her showers and she noticed the DON came out and gave Resident #2 oxygen. CMA A stated Resident #2 started gasping for air then and she went to do her showers and when she came out, they were trying to give Resident #2 air. CMA A stated the DON gave Resident #2 the oxygen at about 3:45 and 4:15 p.m. CMA A stated the DON told CNA E to clean Resident #2 up and to take off the helmet and clean him up because he had blood on his eye. CMA A stated the DON gave Resident #2 the oxygen and CMA A left to give showers and she does not know if the DON gave the oxygen. CMA A stated the first time the DON went in there it was around 230 and the 2nd time was 3:45 p.m. to 4:15 p.m. when everyone went in with crash cart. CMA A stated they took the helmet off to clean it, but she does not know why he had blood, but he had a helmet the entire shift. CMA A stated it was only the DON, CNA E, and her around Resident #2 at that time. CMA A stated Resident #2 was in his bed while giving him oxygen, and they put Resident #2 on the floor on a board to do CPR. CMA A stated she does not know who called 911, she did not hear a code being called because she was in the shower. In a further interview on 2/10/23 at 12:42 p.m. with CMA A she stated CPR was around supper time while they were passing the trays from 5 p.m. to 5:15 p.m. and she stated that she forgot what the time was. CMA A stated CNA E was working with CMA A that day and she worked a double. CMA A stated that day Resident #2 did not go to the hospital on 2/8/23 and she could not get Resident #2's blood pressure at 8:30 to 8:45 in the morning on 2/8/23. CMA A stated she could not give Resident #2 his blood pressure meds that day and she documented at 10:30 a.m. in the MAR. CMA A stated she was also a CNA and worked that day as a CNA. CMA A stated CPR was in progress around suppertime, 911 was called, but he was not sent out. In an interview on 2/10/23 at 12:56 pm. with CNA E she stated the DON called her in Resident #2's room to clean him up and he already had oxygen on his face. Resident #2 had a little dried-up blood because he had a cut on his eye at 3:30 p.m. CNA E stated it was around 4:30 p.m. to 4:40 p.m. before dinner the Restorative Aide A and Restorative Aide B were doing weights and they found Resident #2 unresponsive, he was not moving or responsive. She pulled a double. She was not the last person to leave the resident. CNA E stated when she left Resident #2's room around 330 he was talking and moving around when she saw him. CNA E stated the DON took Resident #2's helmet off and told him to clean him up and wash Resident #2's face off. CNA E stated the DON found Resident #2 with unlabored breathing herself. CNA E stated CMA A needed help doing showers, so she went to help her. CNA E stated no one notified the physician but she assumed the DON did. She does not know anything about him being hospitalized on [DATE]. CNA E stated Resident #2 had a cut by his eyebrow on the left side. CNA E stated she believes someone put the helmet back on Resident #2 because he was wearing it. She is not sure who put it back on. In an interview on 2/10/23 at 1:05 p.m. with CNA G she stated when Resident #2 came to the facility he was able to sit up and transfer by himself and one night Resident #2 fell in the bathroom and went to the hospital. When Resident #2 came back to the facility, Resident #2 was shaking and moving a lot, no longer transferred and became total care. CNA G stated the facility put Resident #2 in the Psychiatric hospital and was eating 100% one day and the next day Resident #2 refused meals, ate a little bit, and then stopped eating. CNA G stated Resident #2 went to the hospital a lot because he fell. CNA G stated they report it to the nurse, and they put Resident #2 back in bed but Resident #2 does not want help. CNA G stated the CNA's put Resident #2 back in bed all the time, and 2 or 3 weeks ago he became total care. CNA G stated she was not at the facility when Resident #2 fell twice on the 10 p.m. to 6 a.m. about 2 mths ago. In an interview on 2/10/23 at 1:15 p.m. with MDS Skilled Coordinator she stated at about 3:30 p.m. to 4 p.m. she took over the hall and close to 5 p.m. the CNAs came to get her and said Resident #2 was not breathing. The MDS Skilled Coordinator stated she could not get a carotid artery, and had to get Resident #2 on the floor, and he was full code so MDS Skilled Coordinator started CPR on him. She stated CMA A and a Med aide on 2 p.m. to 10 p.m. and CMA A took over doing CPR after so long. The MDS Skilled Coordinator stated they had just finished cleaning Resident #2 up the blood in his hair from the sutures and they had to clean his brief and put him back in bed. MDS Skilled Coordinator stated Resident #2 had a fall a few days before she is not sure what day, but she was not aware of a fall on 2/8/23. The MDS Skilled Coordinator stated Resident #2 was care planned for falls, behavior, medications, ADLS, if they need assistance, visuals outside of what they need help for and the interventions for his behaviors, they try to redirect Resident #2. MDS Skilled Coordinator stated Resident #2 did not have a helmet on when she went to get Resident #2 out of the bed to do CPR. The MDS Skilled Coordinator stated the DON stated she removed Resident #2's helmet to clean his hair between 3:30 p.m. and 4 p.m. and right before 5 p.m. MDS Skilled Coordinator went to do CPR and Resident #2 was not wearing the helmet. The MDS Skilled Coordinator stated she reviews orders when the resident returns from the hospital, if the hospital records were available, she does review the orders. The MDS Skilled Coordinator stated she did not see the helmet on his 2/6/23 hospital discharge order, but they usually address care plan in the morning meetings if they have a new admission, she looks for it. The MDS Skilled Coordinator stated the helmet should have been addressed and she did not know the specifics of when he should wear it. The MDS Skilled Coordinator stated the helmet is not in the care plan. The MDS Skilled Coordinator stated she was not aware Resident #2 had unlabored breathing earlier. The MDS Skilled Coordinator stated she started the SBAR after everything later in the evening for the CPR. She stated Resident #2 had no heart rate, no spontaneous respiration so they used the AAD machine where they stopped using CPR, get away from the patient, and give 2 breaths and when EMS came, they took over CPR. MDS Skilled Coordinator stated Resident #2's roommate was in the bed next to him. CNA A helped MDS Skilled Coordinator get Resident #2 to the floor and put back board under him and there was a memory foam mat on the floor and more people came with the crash cart. MDS Skilled Coordinator stated the DON called 911 and she got the code status. MDS Skilled Coordinator stated the Wound Care Nurse was also helping to do chest compressions and in between they got the O2 hooked up, but he did not have secretions, so she did not suction. MDs Skilled Coordinator stated it the responsibility of the Administrator to report to the State and she can too. MDS Skilled Coordinator stated facility incidents are reported by Administrator, DON, and SW typically in the facilities she has been in. In an interview on 2/10/23 at 1:38 p.m. with the DON she stated on the 2 p.m. to 10 p.m. she was missing a nurse on 2/8/23 and she did a walk through with the nurse and Resident #2 was sitting up on the side of the bed yelling and angry and was trying to pull up a curtain and put himself on the floor. The DON stated Resident #2 had a laceration on his eye and he was reaching up and trying to remove it and CNA tried to clean it. The DON stated she tried to get a Blood Pressure, 90 was the pulse and SATS were 96 but it would not read. The DON stated she reached to get it through the ear lobe and Resident #2 was hollering and yelling saying it was not his fault it was in self-defense, but she laid Resident #2 down and he calmed down. The DON stated the CNA cleaned Resident #2 up from the blood from his eye. The DON stated Resident #2 was reaching, gabbing, put himself on the floor, he would get out and go down the hallway, the psychiatric hospitals all denied him, and the Nursing facility staffing one on one could not be done. The DON stated Resident #2 went back and forth to the hospital about 4 or 5 times, and psych came to the facility. The DON stated the staff on the hall got the crash cart, the MDS nurse stepped in, and DON got 911, they started CPR procedures and got Resident #2 on the floor, she got paperwork ready, and they did full CPR. The DON stated they got the defibrillator pads on him and the exact time 911 was called is 2/8/23 at 5:01 p.m. and the facility did full compressions for 15 min before EMS came and they called for the time of death, and the justice of the peace 20 minutes was the protocol. The DON stated Resident #2 was diagnosed with Acute psychosis for attempt to self-harm, they medicated Resident #2 and sent him back to the facility and they reached out to the psychiatric hospitals, the physician saw Resident #2 on 2/7/23. The DON stated she reads the Physician notes, but she does not always see them right away, and she did not go back to check Resident #2's physician note. The DON stated the physician stated they needed to get Resident #2 to behavioral health, and look into injections, but the physician did not relay that he wanted Resident #2 to have one on ones. The DON stated the helmet Resident #2 came back on 2/6/23 from the hospital with was for falling because he constantly tried to hit his head. The DON stated the helmet was to be worn to prevent injury. She stated the physician came on 2/7/22 and asked how long can they keep Resident #2 at the facility. The DON stated Resident #2's bed was low, they removed everything from around him, bilateral floor mat, padding around his bed, but he still crawled out into the hallway. The DON stated Resident #2 did fight, so she always told the Staff to get someone to go with them. The DON stated Resident #2 had a big change in him and he kept going back to the hospital. Resident #2 was calmed because he had 2 mg of Ativan, but no matter what they tried to Resident #2 he still had behaviors. The DON stated they offered snacks, the SW brought him soda, people to come talk to him, but they did not staff for anyone to have one to one. The DON stated no, she did not get a one to one, she could not do that for long. The DON stated they sent Resident #2 to acute care, and they would send him back. The DON stated she did not assign the staff a specific amount of time to check on him, but they went to check Resident #2 a lot, but there was no specific training for Resident #2. The DON stated she did not know the physician said check Resident #2 every hour. The DON was asked when the physician notes come into medical records department whose responsibility is it to go back to look for the notes from the physician and for a patient this complex is it necessary to review Resident #2's physician notes. The DON stated she did not know when the physician notes hit the system, they go straight to medical records dept for loading and she does not get alerts. The DON stated she spoke with physician, but he did not say anything about the one to one or hourly checks, but he did talk about a Haldol injection. The DON stated on 2/6/23 Resident #2 went out to the hospital and LVN D tried to stop the bleeding and resident #2 went to the hospital with a laceration and returned the same day, facility physician came on 2/7/23 and made rounds with him. She stated Resident #2 was not hospitalized on [DATE], and she denied him having a fall. The DON stated she was not aware of documentation that Resident #2 was in the hospital on 2/8/3 5:33 p.m. and stated the staff documented it wrong and he was not hospitalized . The DON stated the Administrator is responsible for reporting to the State and stated she had not reported anything to the State. She stated she knows falls with major injury, and abuse allegations are all reportable and she did not report anything because she thought it had to be a major fall like head injury. The time frame to report is 24 hrs. for a major injury or an allegation it's a 2-hr. window. The DON stated Resident #1 had multiple falls. The DON stated she does not know why multiple staff would report that Resident #2 had trouble breathing, he did have COPD and the diagnosis of shortness of breath. The DON stated Resident #2 had been messing with the laceration above his eye, so they cleaned his hand, and his helmet was right along the line where the laceration was. The DON stated on 2/6/23 progress note said there was blood all over the bed, floor, she said Resident #2 busted the stiches, but she does not know how it happened. The DON stated Resident #2 did not tell her what happened, she told the nurse to put pressure on it and twice he pulled out the stitching, but she did not think it was reportable. In an interview on 2/10/23 at 2:14 p.m. with the Administrator she stated Resident #2 passed away on 2/8/23 and she was in the building then. The Administrator stated Resident #2 was found around 5 p.m. in the afternoon and MDS Skilled Coordinator started the CPR. The Administrator stated Resident #2 had multiple falls, lots of agitation. The Administrator stated Resident #2 started out in the wheelchair and he kept throwing himself down, trying to stand up when he could not, so they put Resident #2 on the lower bed and the fall mats. The Administrator stated Resident #2 was all over the place, crawled around in his room, so they had the matts everywhere. The Administrator stated they could not tie Resident #2 down or restrain him, he was on multiple medications that helped, but was not totally effective. The Administrator stated Resident #2 had ABH crème, but it did not completely get rid of behaviors, and she thought he had something going on neurologically and that's why they had so many meds to help keep him not be so agitated all the time. The Administrator stated the interventions the facility had to keep Resident #2 from harming himself or the staff was to have closer monitoring, bed close to far, and meds. The Administrator stated the interventions progressed they were doing, medications were adjusted several times, bed to the floor, mats, he may fall but won't hurt himself. The Administrator stated the facility used ongoing monitoring, but there was no set time and no specific training for Resident #2's behaviors. The Administrator stated they have an IDT team who reviews physician progress notes and that consists of the MDS Coordinators, DON and all nurses, the whole IDT team recommended. The Administrator stated she did not know about the physician recommending one on one or about an every [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 (Resident #1) of 8 residents reviewed for weight loss. -The facility failed to identify and initiate timely intervention to prevent weight loss and help promote skin integrity when Resident #1 experienced continuous significant weight loss of 27 lbs. in approximately 4 mths from 8/30/22 to 1/12/23 and resulted in multiple skin breakdown, sepsis, and hospitalization. The percentage of weight loss in the last 3 mths was 12.05% indicating severe weight loss. An Immediate Jeopardy (IJ) was identified on 02/08/23 at 2:45 p.m. While the IJ was lowered on 02/10/23, the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of pattern as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents who are totally dependent on Staff for all ADL's at risk of nutritional deficit, weight loss, skin breakdown, pain, and an overall decline in quality of care. Findings include: Resident #1 Record review of Resident #1's face sheet dated 1/18/23 revealed she admitted to the NF on 08/30/2022 with the diagnoses of dementia, Type 2 Diabetes Mellitus, hypertension, muscle weakness, dysphagia 1/12/23, cognition communication deficit, acute hepatitis E, pressure ulcer right heel (12/16/22), pseudomonas 12/16/22, Proteus (mirabilis), 12/16/22 Escherichia and Klebsiella Pneumonia, hypokalemia, localized swelling mass and lump. Record review of Resident #1's Comprehensive Care plan dated 1/16/23 revealed a potential/actual infection related to: Wound abscess that was present on admission with interventions to observe for signs of increased infection, such as redness, warmth, drainage, increased pain, fever. Resident #1 is t increased risk for complication (bleeding, bruising, lab abnormalities) r/t use of Anticoagulant therapy secondary to given cardiac health with interventions to have labs as ordered, report abnormal labs to the MD, monitor/document/report to MD PRN signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, lethargy, bruising, blurred vision, loss of appetite, sudden mental status .Take precautions to avoid falls .I have bowel and bladder incontinence r/t Cognitive loss with risk of additional skin breakdown r/t incontinence with interventions to check resident every two hours and assist with toileting as needed dated 1/16/23. Resident #1 had ADL self-care performance deficit r/t dementia with interventions to bath/shower check nail length and trim and clean, bed mobility, dressing with one staff assisting. Eating provide milkshakes or liquid food supplements when the resident refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or a mug where appropriate and she requires one staff to assist with eating, toilet use, and transferring. Resident #1 was at risk for falls r/t dementia and she had an actual fall on 11/24/22 with swelling on left side of forehead, bruising to left cheek and left knee dated 11/24/22 with interventions to anticipate and meet resident's needs, be sure the call light is within reach and encourage the resident to use it for assistance as needed and ensure she is wearing appropriate footwear. She has the potential for nutritional problems r/t diet restrictions, on puree diet and has diabetes and wounds. Resident #1 had vitamin supplements, to prevent deficiencies, extra protein and shakes to assist with wound healing, poor by mouth intake an antidepressant hoping to increase my appetite. The interventions are to maintain the diet ordered, monitor/document/report to MD PRN signs and symptoms of malnutrition: emaciation, muscle wasting, significant weight loss: 3 lbs. in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months dated 1/16/23, provide and serve supplements as ordered. Resident #1 has a pressure ulcer of the right heel, and left trochanter, treat wounds daily and be seen by wound care MD weekly with interventions to evaluate wound for size, depth, margins, document progress in wound healing on an ongoing basis. The care plan did not address weight loss or the sacral wound. Record review of Resident #1's Quarterly Minimum Data Set, dated [DATE] revealed Cognitive Patterns BIMS Summary Score of 3 indicating severe mental impairment, no behaviors were noted, rejection of care was 0, functional status for bed mobility, transfer, toilet use and personal hygiene were extensive assistance with two staff assisting, dressing was extensive with one person assisting, walk in room and corridor, locomotion on unit and off unit were limited assistance with one person physically assisting, and eating was supervision with one staff assisting. Resident #1 required total dependence for bathing with one staff assisting and she ambulated with a walker, urinary continence was occasional and bowel continence was frequently incontinent. Resident #1 was identified for malnutrition and was revealed to have no pain, swallowing/nutritional status she had no problems identified, and loss of 5% or more in the last month or loss of 10% or more in last 6 mths was 0 indicating Resident #1 had not lost weight. Risk of Pressure ulcers/injuries were indicated but revealed 0/no for does resident have one or more unhealed pressure ulcers/injuries. Record review and interview on 2/2/23 at 12:30 p.m. with MDS Skilled Coordinator regarding Resident #1's Comprehensive Care plan dated 1/16/23 revealed there was no care plan for Resident #1's weight loss, but it should have been. The MDS Coordinator stated nursing would do the skin and weight loss, but she was not able to explain why it was not done. She also said the sacral wound was not care planned for, and she could not answer why. Record reviews of Physician Orders revealed no interventions until January 2023: 1/2/23 Pill Supplements, shakes, and appetite stimulant Remeron were ordered. 1/12/23 Resident #1 was started on Vitamin C 500 mg 1 tablet by mouth for wound healing twice a day. 1/12/23 Multi Vitamin 1 tablet twice a day 1/12/23 Zinc Oxide once a day Record review of Resident #1's weight records from 8/31/22 to 1/12/23 indicated revealed Resident #1 lost 27 pounds.: 08/31/22: 162lbs 09/21/22: 157.5lbs 10/08/22: 153.5lbs 11/10/22: 150.3lbs 12/05/22: 147.5lbs 01/12/23: 135lbs Record review of Resident #1's progress notes revealed there were no progress notes indicating Resident #1's weights were trending from 8/30/22 to 1/18/23. In an observation and interview on 1/18/23 at 10:37 a.m. with Resident #1 and CNA A Resident #1 was observed lying in bed on her right side. Resident #1 stated the staff brushed her teeth this morning. CNA A stated the staff brushed Resident #1's hair and give Resident #1 showers. CNA A stated Resident #1 was not eating well, but she tried to give Resident #1 health shakes and protein. Further observation revealed Resident #1 had lots of food in her teeth and it appeared that Resident #1 had broken teeth and the appearance that they were filed down. CNA A stated it looked like Resident #1's teeth were broken. CNA A stated she did not get her up today, but everyone can brush teeth. In an interview on 1/18/23 at 10:50 a.m. with CNA B she stated she fed Resident #1 this morning. CNA B stated that she did not brush Resident #1's teeth, but she used a sponge to brush Resident #1's teeth this morning. CNA B stated she did not know if Resident #1 had seen a dentist. In an interview on 1/18/23 at 11:20 a.m. with Wound Care Nurse she stated Resident #1 was not eating and barely drinking a little bit. The Wound Care Nurse stated Resident #1 went down and had the right hip abscess that started bothering her that is healing now. She stated from Resident #1 not eating and decreased moving she got a sacral wound, and the Wound Care Physician came to debride it and took the unstageable part off. The Wound Care Physician comes to the facility every Thursday and he debrided Resident #1's sacral pressure sore twice taking the tissue off. Resident #1 also has a pressure sore on the right and left hip. Resident #1 is on a puree diet and the staff feed her now and she is eating close to 75% of her food, but today she ate 50% of her food. The Wound Care Nurse stated Resident #1 does not get up because the Wound Care Physician did not want Resident #1 up and she does not lay on her back at all. In an interview on 1/24/23 at 10:09 a.m. with the Wound Care Nurse she stated she had been the wound care nurse for a year and the facility has 8 in house pressure wounds and 15 total pressure wounds. The Wound Care Nurse stated Resident #1 admitted to the facility with a nodule to the right hip and after that it was painful for her, and she fell quite a bit and she stopped eating. The Wound Care Nurse stated Resident #1 had poor food intake, so they got her a speech pathologist assessment and changed her diet she believed from mechanical soft to puree and Resident #1 started eating more. The Wound Care Nurse stated she developed a sacral wound on December 22, 2022, and it was unstageable. The Wound Care Nurse stated she was doing wound care on the sacral pressure sore and putting calcium alginate until the Wound Care Physician came in. The Wound Care Nurse stated the Wound Care Physician used calcium alginate and a dry dressing to treat the sacral pressure sore and it was measured at 8.6x3.3 cm initially. The wound care nurse said she saw the wound for Resident #1 and then the Wound Care Nurse got Covid and was gone for 8 days. The Wound Care Nurse stated she did not know what the facility staff had done while she was gone. The Wound Care Nurse stated the facility nurses are supposed to do the wound care while she was gone, but when she came back Resident #1's pressure sore looked the same. She stated the wound care doctor debrided the sacral wound on 12/29/22. In an Interview on 1/24/23 at 10:44 a.m. with the Speech Pathologist he assessed Resident #1 on January 2nd, 2023, due to resident poor dietary intake. The Speech Pathologist stated during his assessment of Resident #1, he observed that Resident #1 was not chewing her food but instead, was pocketing food. He stated Resident #1 was able to swallow without difficulty and therefore changed Resident #1's diet from a regular diet to a puree diet and after changing Resident #1's diet to a puree diet intake went from 10% to 100 %. In a telephone interview on 1/24/23 at a.m. 11:07 a.m. with Dietician regarding Resident #1 she stated she started working at the Nursing Facility in November 2022 and was aware of Resident #1's weights and had made some recommendations on December 19, 2022. The Dietician stated she made recommendations for house supplements twice a day and liquid protein. The Dietician stated she did discuss with the nurses about Resident #1's decrease in appetite and the medication Remeron takes about 60 days to get in the system to be effective. The Dietician stated the NF was going through some Administrative changes involving the DON. The Dietician stated it just appeared that Resident #1 had a poor dietary intake appetite and said a gastrostomy feeding was never mentioned to Resident #1's family. In an observation and interview on 2/1/23 at 9 a.m. with Resident #1 at local hospital she was observed sleeping and was difficult to wake. Observation revealed Resident #1 was on antibiotic IV(vancomycin) and she had a wound vac. In an interview on 2/1/23 at 9:15 a.m. with local Hospital Dietician and LVN at local hospital and he stated Resident #1 was not eating and had just been sipping on ensure. The Dietician stated if Resident#1 did not increase in her eating, they will have to do a gastrostomy tube. The LVN Nurse said she would attempt to get Resident #1 to eat more. The LVN Nurse said Resident #1 has wounds on her heals and that is why she said they were not moving Resident #1 from the sacrum all the way to the hip. The LVN Nurse stated the wounds did not happen overnight. In an interview on 2/1/23 at 9:30 a.m. with Local Hospital Wound Care Nurse she stated Resident #1's can start within hours, but Resident #1's wounds were probably there for 6 months because her eating is not great and with mental health. The Wound Care Nurse at local hospital stated the sacrum wound was not her only wound and Resident #1 had tunneling and that is based on the laying on it and how she lays on it causing undermining tunneling. The Wound Care Nurse said the hip wound on the other side was filled with chronic fat and the first thing to go is your skin. The Wound Care Nurse stated she saw Resident #1 in the ICU 2 weeks ago when Resident #1 first arrived. She stated when she saw the sacral wound, they immediately got the Doctor to get Resident #1 on the wound vac. The Wound Care Nurse stated the pressure sore is due to bed services, her not being turned and repositioned, skin break down, not eating, and psychosis. She stated Resident #1 is alert and oriented. In an interview on 02/01/2023 at 1:08pm with the Wound Care Nurse she stated she would have to look at Resident #1's records to see if she was on any supplements for weight loss. The Wound Care Nurse stated she was aware that Resident #1 was losing weight and told the nurse on the unit who were also aware of Resident #1's weight loss. The Wound Care Nurse stated she did not attend any morning meetings or QAPI meetings only the DON. The WCN said on 12/22/22 after reviewing resident records said the Wound Care Doctor began treating Resident #1's wound to the sacral area. In an interview on 02/01/2023 at with 1:25 p.m. the DON regarding morning meetings and QAPI meetings said the morning meetings were conducted Monday through Friday with each Department Head discussing admissions, discharges, etc. The DON said another meeting is held with staff discussing skilled residents. The DON said QAPI meetings were held each month discussing triggers such as falls, infections, weight loss, certain medications, etc. The DON said Resident #1 was ambulatory with an unsteady gait. The DON said Resident #1 had decrease in mobility after 1st fall in the month of October 2022 and really noticed a big decline 11/24/23. The DON said Resident #1 could reposition self but not purposely. The DON said she could not explain why the Dietician did not see Resident #1 sooner. In an interview on 02/01/2023 at 2:08pm with CNA C she stated Resident #1 verbalized often that she was in a lot of pain saying oh baby I am hurting. CNA C stated Resident #1 never refused care from her. CNA C stated Resident #1 had a huge wound on her back side and was unable to turn self and depended on the staff to turn her. CNA C stated Resident #1 had a wound to her right thigh and a wound on one of her heels and that Resident #1 ate sometimes but not consistently, mostly not eating. CNA C stated she did report to the nurse Resident #1's lack of appetite. CNA C stated she could not remember the nurses name because she worked with different nurses. In an interview on 02/02/2023 at 11:50 a.m. the ADON stated Resident #1 began to pocket her food and that was when Speech Pathologist got involved. The ADON stated a gastrostomy feeding was never discussed. She stated Resident #1 was in a lot of pain due to her right hip. The ADON stated Resident #1 never resisted care but was confused always trying to climb out of bed. Interview on 02/02/2023 at 12:25 p.m. with MDS Skilled Coordinator said regarding Resident #1, was not being care planned for weight loss but should have been. The MDS Skilled Coordinator stated she did not know why Resident #1 was not being care planned for weight loss. In a telephone Interview on 02/02/2023 at 6:00 pm with Nurse Practitioner (NP) she stated regarding Resident #1, she would have to review resident records to see who ordered which antibiotics. The NP said Resident #1 had infections to her wounds. The NP said she had just started working at the NF when the NF staff informed her that Resident #1's mental status had declined, chronic wounds, not eating, and she therefore gave an order for a hospice consult. In an interview with the DON on 2/7/23 at 1:23 p.m. she stated she took over as DON on 1/12/23, but prior to this she was the ADON. The DON stated a lot of Resident #1's weight loss happened after her fall on 10/1/22, but the biggest change after Resident #1's 2nd fall in November. The DON stated she checked all 3 care plans and Resident #1 was not care planned for the 1st fall on 10/1/22. The DON stated the Wound Care Nurse does the skin assessments on Mondays and she does the residents at different times. The DON stated she has seen The Wound Care Nurse do all the skin assessments in 1 day, but she told her that she needs to try not to do that. In an interview on 2/9/23 at 10:22 a.m. with the DON stated stated the systems go together when you are having a weight loss and nutrition deficiency and protein or calorie deficiency it goes hand in hand for additional skin breakdown. The DON stated you have to have those for the tissue and collagen to hold up. The DON stated she saw the failure when Resident #1 started to lose weight and started to trigger. The DON stated Resident #1's physician should have been notified, RP and dietary should have been notified to help. The DON stated the facility should have reached out to RP to ask if there is certain food Resident #1 likes and then she can have dietary to assist with getting food Resident #1 liked. In an interview on 2/9/23 at 11:16 a.m. with the Dietician she stated for weight loss they go by 5% loss in 30 days and 10% loss within 180 days. The Dietician stated they pull the weight report if the dietician is not consulted, she looks at their diet, diet texture, any restrictions and she will look at the task part to see the amount percent of what the resident were eating which is what the CNA's document. They look in their orders to see if they have any supplements ordered. The Dietician stated she speaks with the resident to see if they are eating okay, do they like the food and they get the residents story. She stated they get the residents food preferences and from there start making changes for food and if their weight loss is significant, they add supplements if their intakes are poor. They see weight loss monthly so if they continue to lose weight, they will see them the next month and get the resident's story again and modify supplements as needed. The Dietician stated she cannot speak what happened before she started working at the facility and her first day at the building was November 14th and when they start at a building, they gather a list of high-risk residents. The Dietician stated the high-risk category is weight loss, wounds, tube feeders, and dialysis residents. The Dietician stated she started pulling reports on 11/28/22 and this was her first day of PCC access. She stated Resident #1 she did not appear to have a wound on her first day of charting, she came in again and December weights were not in on December 2nd. The Dietician stated the 2nd visit on 12/18/22 resident weights were in, and she did see Resident #1. The Dietician stated Resident #1 did trend down in the weights and was categorized with a pressure wound. The Dietician stated she recommended to discontinue Resident #1's low concentrated sweet restriction to promote intakes, recommended house shakes twice a day and 30 cc's in liquid protein for wound support. The Dietician also recommended weekly weights for 4 weeks to monitor, but in between that time and the next time she did not get any consults for anything about her. He Dietician stated she does not know why she did not get any consults for Resident #1. The Dietician stated she saw Resident #1 again on 1/20/23 and noticed she continued to lose weight, and this time Resident #1 had an appetite stimulant, Vitamin C, zinc, liquid protein for wound support as well as health shakes 4 times a day for weight support. The Dietician stated she got more food preferences from Resident #1 tried to modify her food. The Dietician stated she looked at Resident #1's body, but not her teeth. She stated Speech therapy, or the nurses look at the teeth and the nurses will consult speech. The Dietician stated she did not know Resident #1 was a diabetic because they had her on a regular diet. In an interview on 2/9/23 at 11:39 a.m. with the Administrator she stated as far as weight variances she thinks the communication was not there for the Restorative Aides. The Administrator stated they did the weights, documented, but there was a failure between them and informing the nurse of the weight variances for Resident #1. The Administrator stated she knows the Wound Care Nurse was doing the skin checks on Resident #1 weekly and the treatment on her hip daily, so she cannot answer why Resident #1 broke down on the sacral area because she is not clinical. The Administrator stated by the time they caught the sacral area the wound care physician had to do a debridement. The Administrator stated the CNA would inform the nurse verbally that they checked a resident, and they found a reddened area, but it was not in writing, but now they are going to use the shower sheets. The Administrator stated the CNA's will present what they found to the Nurses in writing, and they will all see that. The Administrator stated she audits the staff by smart sheets, and they have had this since October 1st when solutions took over and when they have their morning and afternoon meeting, they go through their smart sheets. The Administrator stated she got behind because there were so many smart sheets and they got on to make sure the assessments were complete. The Administrator stated she was going through the assessments to make sure they are getting done by the charge nurses, MDS coordinators and the DON. Record review of Facility's Policy on Provision of Quality Care dated 2022 revealed, Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Record review of facility's policy on Weight Monitoring dated 2021 revealed, Based on residents comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the residents' specific nutritional concerns and preferences .Interventions will be identified, implemented, monitored (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status .Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) b. 7.5% change in weight in 3 months (90 days) 10% change in weight in 6 mths (180 days) .The physician should be informed of a significant change in weight and may order nutritional interventions . Record review of facility's policy on Nutritional Management dated 2022 revealed, The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Acceptable parameters of nutritional status refers to factors that reflect that an individual's nutritional statis is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values. Interventions will be individualized to address the specific needs of the resident. On 2/8/2023 at 2:45 PM, an Immediate Jeopardy (IJ) was identified. The Administrator was notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. After several revisions, the POR submitted by the Administrator was accepted on 2/9/23 at 11:10 AM. The POR revealed: Plan to remove Immediate Jeopardy Resident #1 is no longer in the facility. Resident discharged to the hospital on 1/22/23. All residents at risk for weight loss have the potential to be affected by the deficient practice. A facility-wide audit of current weights was initiated on 2/8/23 to ensure no unidentified residents were triggering for a significant weight loss. Any new significant changes in weight will be identified immediately, physician will be notified, and appropriate intervention will be implemented, diet orders will be reviewed for those triggering for a significant weight loss. The audits were conducted by the DON. No new significant weight losses have been identified at this time. The audit will be completed on 2/8/23. DON will review Point Click Care Dashboard - Clinical Alerts and follow up on residents triggering for 25% or less for 2 or more meals in 24 hours. Staff interviews will be conducted by the DON or designee for residents triggering for these alerts to ensure interventions are put in place immediately. On 2/8/23 Charge Nurses were provided education by the DON regarding completing documentation for residents with significant weight loss. Documentation required will be the Weight Watchers UDA Assessment. Training also included ensuring physician notification occurs and orders implemented immediately, if applicable. DON was provided education by the Regional Director of Clinical Services on 2/8/23. Residents at risk for weight loss will be weighed on a weekly basis, weights will be reviewed by the DON or designee each week. Significant weight losses will be reported to the Physician immediately upon notification. Significant Weight Loss is 5% in 30 days and 10% in 180 days. Registered Dietician will review residents triggering for a significant weight loss during her visits and the DON will ensure recommendations are followed. This process has been in place since our new DON started on 1/12/23. DON will review the Nutrition Report in PCC weekly to identify residents with a decrease intake, residents triggering will be weighed. DON or other designee will complete the Resident Care Conference Significant Weight Loss Smartsheet each week after weekly weights are conducted to log and track weight losses and ensure physician notification occurs, dietician was notified, orders are being followed and the care plan is in place. Restorative aides are proficient in obtaining resident weights each week, competency will be completed with both aides on 2/8/23. Restorative aides will not be allowed to work or weigh residents until they are proficient in weighing residents. Ad-Hoc QAPI meeting was held on 2/8/23 to review the alleged deficiency and the review of the trainings provided to the nurses as listed above. The medical director was involved with the review and the plan of removal. The Administrator will be responsible to ensure the plan is completed by 2/8/23. Staff will not be allowed to work until they are trained. Monitoring of the plan of removal included: Following acceptance of the facility's Plan of Removal, the facility was monitored from 2/9/23 to 2/10/23. The surveyor confirmed the facility implemented their plan of removal sufficiently from 2/9/23-2/15/23 to remove the IJ by: -Observation revealed Resident #1 did not return to the facility. -Interviews were conducted with the Wound Care Nurse and the DON revealing skin assessments were conducted for all 83 residents. -Interviews were conducted with 2 MDS Coordinators revealed they were in-serviced on Care Plans and ensuring all pressure ulcers were care planned. Record review of facility in-services revealed training for: -Ad-Hoc QAPI completed on 2/8/23 -Use of Mechanical Lift for Weight completed on 2/8/23 -Sit to Stand Scale completed on 2/8/23 -Meal Consumption documentation completed on 2/9/23 -Weight loss and nutrition support completed on 2/8/23 -Communication with MD regarding new skin issues completed 2/8/23 -Dieticians consult binder at Nurses Station completed on 2/10/23 -Quality of Care-Weight loss Management completed on 2/8/23 -Interviews were conducted with Administrator, DON, Wound Care Nurse, 2 Restorative Aides, 5 LVN, 3 CMA, 13 CNA revealed all staff demonstrated knowledge and understood QAPI did review the facility's deficiency and training was provided to nurses regarding weight loss and skin alterations, restorative were trained on procedures using the sit to stand scale and, use of mechanical lift for weight loss, CNA's and Nurses were trained on meal consumption documentation and how to determine percentages for meal consumption, how to review clinical alert dashboard for residents triggering for 25% or less for 2 or more meals in 24 hrs., weekly weights will be utilized to monitor residents at risk of weight loss and all staff were informed about the Dietician consent binder available at the Nurses station. On 2/10/23 at 2:26 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems.