**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, and facility document review, the facility staff failed to provide treatment and services for the prevention of an unstageable pressure ulcers for one of 13 residents, Resident #23. This was identified as harm. The facility also failed to accurately complete weekly skin observations for one of thirteen residents, Resident #15. Findings were: 1. Resident #23 was admitted to the facility with the following diagnoses, including but not limited to: Dementia with agitation, depressive disorder, anxiety, and psoriasis. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/01/2022. Resident #23 was assessed as having difficulty with both long and short term memory, as well as having difficulty with daily decision making skills. On 01/11/2022 at approximately 4:30 p.m., the hospice note section of the clinical record was reviewed. An IDG (interdisciplinary group) Comprehensive assessment dated [DATE] was observed. Under the section Client Orders (since last IDG meeting), was a new order, CLEANSE STAGE II PRESSURE ULCER TO LEFT AND RIGHT HIP, APPLY BETADINE, ALLOW TO DRY, APPLY HYDROGEL, AND LEAVE OPEN TO AIR DAILY, WEEKLY BY HOSPICE STAFF. There were no measurements or description of the wound within the documentation. Resident #23's medical record was reviewed. The physician orders included an order written 01/05/2023, which contained the following: Apply betadine to R (right) and L (left) greater trochanters BID (twice a day), allow to dry and leave open to air until healed. Weekly skin observations were observed in the clinical record. An observation was completed on 12/18/2022. Additional observations were not documented until 01/07/2023 (20 days later). Neither documented any areas on either of Resident #23's greater trochanters. The progress note section was reviewed. A note dated 01/04/2023 contained the following: Resident noted to have small, scabbed area on right hip approximately the size of a dime. Passed on to RN (registered nurse) Supervisor to assess and TX (treat) . The care plan was reviewed. A focus area noted, .at risk for pressure ulcers related to decreased mobility and incontinence ., included but was not limited to the following interventions: Assist with meals as needed. She must be fed at times; pressure reducing cushion to chair .; pressure reduction mattress to bed; weekly skin assessment by a licensed nurse. There were no entries, changes, or updates related to the pressure area on either of Resident #23's right or left greater trochanter. Review of the clinical record also included Resident #23's weights. From 06/09/2022 until 01/06/2023, Resident #23 lost a total of 23.55% of her body weight (107 lbs to 81.8) pounds from 06/09/2022 until 01/06/2023. No supplements or interventions had been implemented for weight maintenance or to promote wound healing. An end of the day meeting was held with the DON (director of nursing) and the administrator on 01/11/2023 at approximately 5:00 p.m. When asked about the documentation in the hospice note, the DON stated that the areas were scratches and not pressure areas, but added that she had not observed them. Concerns were voiced regarding Resident #23's significant weight loss and the development of pressure ulcers as identified by the hospice nurse. On 01/12/2023 at approximately 10:00 a.m., the areas on Resident #23's greater trochanters were observed by two members of the survey team. The DON and LPN (licensed practical nurse) #2, rolled Resident #23 to her left side exposing a pressure ulcer on to the right trochanter (hip). A round, open wound, covered in dark brown/black eschar (dead tissue) was measured by the DON per the survey team's request. The area of eschar measured 1.7 cm X 1.4 cm, the periwound was red and puffy. LPN #2 pressed on the red area, then stated that the area was not warm to touch, but did not blanch (lighten in color) when she applied pressure. Resident #23 voiced discomfort when LPN #2 pressed on the area. The entire area including the periwound measured as 3.0 cm X 3.5 cm. The area was directly over the right greater trochanter (hip). The DON stated, These started as scratches. There were elongated scratch marks near the pressure wound but not directly around it. When asked if she thought the scratches caused the areas or the areas caused the scratching, the DON did not answer. Resident #23 was turned to her right side and the left trochanter area was observed and measured by the DON as 0.8 cm X 0.4 cm. The area around the wound was not red or tender, when palpated by LPN #2. This area was also directly over the greater trochanter and was covered by light brown eschar (dead tissue). Elongated scratches were observed near the wound area but not directly over it. The DON stated, I haven't looked at these areas since the betadine was started .the nurse practitioner told us not to use the hydrogel that hospice suggested, just the betadine. When asked if the nurse practitioner or the physician had observed the areas, the DON stated, No. When asked if the nurse practitioner was available, the DON replied, She [nurse practioner] just took these patients over last week and she is off until the twenty-third LPN #2 stated, I saw the areas last week, they didn't look like that. When asked if there was a wound nurse in the facility, the DON stated, No. When asked who completed the skin observations for the residents, the DON stated, The charge nurse is supposed to do them every week and whenever there is a change. The hospice RN was contacted via telephone on 01/12/2023. When questioned, the hospice RN stated that the notes in the clinical record were summaries of her monthly visits. The hospice RN stated she would send the weekly visit notes to the facility for review. The hospice RN was asked if she did a complete body assessment each time she visited Resident #23. The hospice RN stated, No, I only do that if they are in the bed .if they are in the dining room, eating, or in activities, I don't do that I will look at their arms and their legs but that's it. The weekly hospice visit note dated 01/04/2023 was received and contained the following: RT-GREATER TROCHANTER, PU (pressure ulcer) STAGE II .LENGTHxWIDTHxDEPTH 1.4 X 0.8 X 0 .GRANULATION TISSUE-NONE; EDGES-NOT ATTACHED; SHAPE-ROUND .EPITHELIAZATION 100%; TOTAL NECROTIC TISSUE SLOUGH 0-25%; TOTAL NECROTIC TISSUE ESCHAR 0-25%. LT GREATER TROCHANTER PU STAGE II .LENGTHxWIDTHxDEPTH 0.5 X 0.3 X 0 .GRANULATION TISSUE-<75 & >25%; EDGES-DISTINCT; SHAPE-ROUND .EPITHELIAZATION 25-<50%; TOTAL NECROTIC TISSUE SLOUGH 0-25%; TOTAL NECROTIC TISSUE ESCHAR 0-25%. The note also included, STAFF REPORT PATIENT HAS NEW AREAS TO BOTH HIPS .LAID DOWN BY FACILITY STAFF .AREAS TO BILATERAL HIPS WERE ASSESSED .NEW ORDERS .CLEANSE STAGE II PRESSURE ULCER TO LEFT AND RIGHT HIP, APPLY BETADINE, ALLOW TO DRY, APPLY HYDROGEL AND LEAVE OPEN TO AIR DAILY, WEEKLY BY HOSPICE STAFF . The facility policy regarding pressure ulcers was requested and presented. Per the DON the policy Pressure Ulcer and Skin Care was used by the nursing facility as well as the assisted living facility. Per the policy, Residents with pressure ulcers should be documented weekly using (name of form) . The DON is responsible for weekly verifying that the appropriate treatment is administered as ordered and that documentation and evaluation reflect the current status of each pressure ulcer. The interdisciplinary care plan for the resident must identify current resident problems, goals, and actions directed towards the prevention and/or resolution of pressure ulcers .When a pressure ulcer is reported or identified the charge nurse must visually assess the affected area on the resident and complete the initial assessment of each pressure ulcer . The above conversation with the hospice nurse was discussed with the DON. She stated, I will talk to her, she is supposed to assess the residents every time she sees them. The DON was asked to present any additional information she had regarding Resident #23's bilateral pressure ulcers. During a meeting with the DON and the administrator at approximately 12:30 p.m., the above findings were was discussed. Concerns were voiced that Resident #23's pressure ulcers had been allowed to deteriorate to an unstageable (unidentified wound severity) status, without any change in intervention/treatment or the needed assessments. The facility staff were informed that the survey team was recommending this at a harm level. No further information was obtained prior to the exit conference. 2. Resident #15 was admitted to the facility with the following diagnoses including but not limited to: Arthritis, heart disease, vascular dementia, and hard of hearing. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/24/2022. Resident #15 was assessed as cognitively intact for daily decision making, with a summary score of 15 out of 15. Resident #15's clinical record was reviewed on 01/11/2023 at approximately 2:00 p.m. The following orders were observed: Apply corn pad to opened wound between 3rd and 4th digits, change every 3 days; skin prep to left outer ankle scabbed area BID until healed. Resident #15's care plan was reviewed. The following was observed: Category: Pressure Ulcer .experiences incontinence and is at risk for skin breakdown/pressure injury .Goal: will not have any new pressure injury/skin breakdown over the next review. Interventions included but were not limited to: Report any signs of skin breakdown .weekly skin assessments by a licensed nurse. The weekly skin observations for Resident #15 were reviewed, neither of the wounds identified above were documented on the weekly skin observation sheets. The DON was interviewed on 01/12/2023 at approximately 11:30 a.m. and asked about the observation sheets and what should be on them. The DON stated, Both the areas between her toes and the area on her ankle should be addressed on the observation sheets until they are healed .they are supposed to be done weekly. When asked if they should be included on the care plan, the DON stated, Yes. At approximately 11:40 a.m., the areas between Resident #15's toes and the area on the outside of her left ankle were observed with the DON. Salonpas pain patch was observed stretching across the top of her right foot and corn pads were observed between her toes as ordered. The DON stated, These areas between her toes are where they got red and moist. When asked if the areas between her toes was related to the Salonpas pushing her toes together, the DON stated, No. The area on the left outer ankle was observed as a round area covered in eschar (necrotic/dead tissue), approximately the size of a dime. When asked if the area to the ankle was pressure related, the DON stated, No, it started out as a scratch. She was asked if the physician or nurse practitioner had looked at the areas. She stated, No. The above findings were discussed during a meeting with the DON and the administrator at approximately 12:30 p.m. Concerns were voiced that weekly skin observations had been documented for Resident #15, but none of her current wounds to her right ankle and foot were included or identified. No further information was obtained prior to the exit conference on 01/12/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to implement interventions for a significant weight loss for one of 13 residents, Resident #23. During a six month time span from 06/09/2022 until 12/07/2022, Resident #23 lost 21.50% (23 pounds). Resident #23 was not assessed by the registered dietician at the facility, nor were any interventions put in place to address her significant weight loss. This was identified as harm by the survey team. Findings were: Resident #23 was admitted to the facility with the following diagnoses, including but not limited to: Dementia with agitation, depressive disorder, anxiety, and psoriasis. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/01/2022. Resident #23 was assessed as having difficulty with both long and short term memory, as well as having difficulty with daily decision making skills. On 01/11/2023, at approximately 9:00 a.m., Resident #23 was observed sitting in the dining room. CNA (certified nursing assistant) #1 was at her side. Her divided plate in front of her was empty, she was drinking orange juice from a cup with a lid and a straw. When asked what Resident #23 had eaten, CNA#1 stated, 100 percent, eggs, toast, bacon. When asked what assistance she needed, CNA#1 stated, I remind her to eat and help her if she needs it she does pretty good. On 01/11/2023, at approximately 12:30 p.m., Resident #23 was observed in the dining room, while eating her lunch. Again, Resident #23 consumed 100% of her meal, with assistance. Resident #23's clinical record was reviewed on 01/11/2023 at approximately 1:30 p.m. The physician orders were reviewed. Resident #23 was ordered a regular diet. No dietary supplements were ordered. Her weights from June 2022 through January 2023 were as follow: 06/09/2022 107 lbs 07/14/2022 106.4 lbs 09/01/2022 92.8 lbs 10/07/2022 91.8 lbs 11/09/2022 91.2 lbs 12/07/2022 84 lbs 01/06/2023 81.8 lbs On 01/11/2022 at approximately 4:30 p.m., the hospice note section of the clinical record was reviewed. An IDG (interdisciplinary group) Comprehensive assessment dated [DATE]. Documentation included: LUMAC (Left upper mid arm circumference) is down 2 cm this recert period. No weights are available but patient's clothes are baggy. She is thin and frail. Facility staff report she is eating 0.5-0.75 cups per meal .She is eating 25% of offered meals. She will often forget to eat and periodically require to be fed partial meals. She is requiring caregivers to place only one utensil on the table as needed, which she often uses her hands . The note also included the identification of Stage II pressure ulcers on her bilateral greater trochanters. Resident #23's care plan was reviewed. A focus area documented .at risk for pressure ulcers related to decreased mobility and incontinence ., and included but was not limited to the following interventions: Assist with meals as needed. She must be fed at times; document nutritional intake; Offer and encourage fluids often throughout the day. Another focus area documented .dependent with ADL's [activities of daily living] included the following interventions: Set up meal trays and give assistance with all meals as needed. She will attempt to feed self at times. The Registered Dietician (RD) notes were reviewed. The last RD note was written 11/02/2022 and contained the following: No weights due to hospice enrollment. She is nonambulatory and is transported via wheelchair, she is alert and orient to self. Her diet order is Regular. Resident tested positive for COVID in August .will continue with her nutrition plan of care as ordered . An end of the day meeting was held with the DON (director of nursing) and the administrator on 01/11/2023, at approximately 5:00 p.m. Concerns were voiced regarding Resident #23's significant weight loss and the development of pressure ulcers, which were identified by the hospice nurse on 01/04/2023. On 01/12/2023 at approximately 8:30 a.m., Resident #23 was observed in the dining room eating breakfast. CNA (Certified nursing assistant) #1 was at her side. He stated that Resident #23 had eaten 100% of her breakfast. The breakfast observation was discussed with the DON at approximately 8:45 a.m. Asked if there was a reason why residents receiving hospice were not offered supplements or fortification of their food, the DON stated, I understand what you are saying. I spoke with the hospice nurse this morning. She said hospice doesn't pay for supplements. I told her that didn't matter, we could take care of that here. I am going to contact [hospice RN Name redacted] to get an order for some Ensure Clear .she drinks better than she eats some days. When asked if the facility RD was involved at all, as her notes indicated no weights were available due to Resident #23 being enrolled in hospice, the DON stated, I get their weights for the MDS, the RD has access to those. I don't know what happened. The hospice RN was contacted via telephone on 01/13/2023. When questioned, the hospice RN stated that the notes in the clinical record were summaries of her monthly visits. Asked about Resident #23's weight loss and whether or not an RD from hospice had seen her, the hospice RN stated, We don't have an RD. Asked if she had looked at Resident #23's weights, the hospice RN stated, No, I don't have access to those. We usually expect them to lose weight when they are in hospice. Concerns were voiced that although Resident #23 is in hospice, review of her intake as documented by the facility from November to the present showed that she was eating 51-75% and 76-100% at most meals. Of the last 75 meals documented, only 14 documented that Resident #23 had eaten less that 50%. The hospice RN stated, I document what they tell me. I don't really look at their intake sheets .we don't do supplements. During a meeting on 1/13/23 with the DON and the administrator, at approximately 12:30 p.m., the above findings were discussed. Concerns were voiced that Resident #23's had suffered a significant weight loss without intervention from the facility. Although Resident #23 required assistance, observation by the survey team and documentation in the facility clinical record indicated that she was eating. The facility RD had not recommended any interventions nor had she identified a significant weight loss, although the weight loss was documented in the medical record. The facility staff was informed that the survey team was recommending this deficient practice at a harm level. No further information was obtained prior to the exit conference.