**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R7 was admitted to the facility on [DATE] with diagnoses that include, Subarachnoid hemorrhage, Dementia, Palliative care, Anxiety, Depression, Muscle contracture of right and left knee. R7's Quarterly Minimum Data Set assessment dated [DATE] documents R7 is severely cognitively impaired. R7 is dependent for all cares and transfers. R7 requires substantial/maximum assist for bed mobility. R7 is at risk for pressure injuries but does not have a current pressure injury. R7 is always incontinent of bowel and bladder. R7 has an activated healthcare Power of Attorney (POA) and is currently on hospice. R7's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 8/16/24 documents, in part: Pressure ulcers CAA triggered secondary to potential and presence of actual pressure ulcer . Contributing factors include [activity of daily living]/functional mobility impairment, actual pressure ulcer, cognitive loss and use of medications that can contribute to skin breakdown, incontinence and pain. R7's Braden Score (Assessment used for predicting pressure score risk) dated 2/3/25 documents a score of 15 which indicates R7 is at moderate risk for developing a pressure injury. R7's At risk for pressure ulcers Care Plan dated 9/17/21 documents the following pertinent interventions: Keep bed linens wrinkle free. Observe skin for redness and breakdown during routine care. Follow community skin care protocol. Reposition with rounding and [as needed]. Air mattress, monitor air mattress function [every] shift. R7's SBAR (Situation, Background, Assessment and Recommendation) Professional Communication form dated 3/9/25 at 10:51 AM, documents, in part: Small open area to mid thoracic back region . started on 3/9/25 . The facility's 24-hour nursing report board dated 3/9/25 documents, in part: small open area on resident back (middle area) . Area cleansed, barrier cream applied, and area covered with dressing. R7's pressure injury packet includes an Incident witness statement form dated 3/9/25, which documents, in part: [Certified Nursing Assistant (CNA)] called me into resident's room stating resident was bleeding. A small open area was found on the mid-thoracic back region Hospice updated and family aware . R7's MD order dated 3/9/25 documents Zinc barrier cream- Every day cleanse small open area to mid back and apply zinc barrier cream. Cover area with foam dressing. Surveyor reviewed R7's skin assessments within R7's medical record. Surveyor did not locate an assessment of R7's open area to R7's mid back including measurements and a thorough description of the wound. On 3/18/25 at 1:05 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-H, who is the nurse who discovered R7's open area to R7's mid back on 3/9/25. Surveyor asked what the process is when a new skin integrity issue is found on a resident. LPN-H stated that LPN-H would let the Unit Manager know, fill out the pressure injury packet, inform the provider, family and hospice. Document the area in the electronic medical record and place the resident on the 24-hour board. Surveyor asked what is included in the first assessment. LPN-H stated the nurse who finds it will measure the wound and note the surrounding area skin. LPN-H stated that LPN-H would cleanse the area and treat the area. LPN-H would confirm treatment orders with the MD. Surveyor asked how R7's pressure injury was found. LPN-H stated that bleeding was noted and that is when the area was found. Surveyor asked if LPN-H knew what caused the open area. LPN-H stated that LPN-H thought it could be from added pressure where R7's Lidocaine patch was located. On 3/19/25 at 9:12 AM, Surveyor returned to LPN-H. Surveyor asked if LPN-H was able to complete an initial assessment of R7's open area. LPN-H stated that LPN-H did not complete an initial assessment. LPN-H indicated that R7 can be uncooperative at times and that played a part in the inability to complete the assessment. R7's progress note dated 3/10/25 at 12:59 PM documents: Resident is on the 24-hour board due to an open area on the mid-thoracic region. Area cleansed, barrier cream applied, and bandage placed. Will continue to monitor. Surveyor reviewed R7 skin assessments within R7's electronic medical record and did not locate an assessment of R7's wound until 3/13/25. On 3/13/25, R7 was assessed by the facility's Wound Nurse Practitioner (NP)-M. NP-M's Wound Care assessment dated [DATE], documents, in part: . Mid back (stage 2 pressure injury). Partial- thickness wound measuring 0.1 [centimeters (cm)] x 0.1 cm x [less than] 0.1 cm. 100% smooth red tissue . Status-new. Surveyor noted that the first thorough assessment of R7's pressure injury occurred 4 days after the wound was found. R7's Impaired skin integrity related to mid back pressure injury Care Plan, dated 3/13/25 documents the following pertinent interventions: Provide treatment as ordered. Wound APNP to follow. Assist with repositioning during rounding and cares . Surveyor noted that R7's care plan was not updated until 4 days after R7's wound was found. Surveyor reviewed R7's Treatment Administration Record (TAR). Surveyor noted that R7's pressure injury treatment was not documented as completed on 3/16/25. On 3/18/25 at 11:00 AM, Surveyor interviewed Registered Nurse, Unit Manager (UM)-C. Surveyor asked what is expected of a nurse who finds a new pressure injury. UM-C stated that the nurse should report the area immediately to a unit manager. The nurse should complete the skin packet (injury or pressure) and should enter a skin assessment in the electronic health record. UM-C stated the care plan should be updated. UM-C indicated that the nurse could do the initial assessment but stated that an RN is available at any time to assess a new skin concern. UM-C stated that any of the unit managers or the facility wound nurse is available. Surveyor asked what happens on weekends. UM-C stated that the manager on call would come in to assess a new wound if necessary. On 3/19/25 at 12:01 PM, Surveyor asked if R7's wound was assessed on 3/9/24. UM-C stated UM-C would look. UM-C stated that UM-C was not aware who was on call since it was a Sunday. UM-C stated that per the facility policy, facility staff have 24 hours to comprehensively assess the wound. Surveyor asked what standard of practice the facility uses that indicates a 24-hour timeline to assess a new wound. UM-C stated, state compliance. Surveyor asked if there is no assessment or measurements done when found, how would a nurse know if a wound was getting or better or worse. UM-C stated by the measurements. Surveyor asked when the care plan should be updated. UM-C stated that it is placed initially when found or discussed at the morning meeting the next day to make sure the interventions are appropriate. On 3/19/25 at 12:33 PM, UM-C returned to Surveyor with a document completed on R7. UM-C stated the facility completed a skin sweep where they completed a full skin assessment on every resident in the facility. UM-C handed Surveyor the document of R7's skin assessment. Surveyor reviewed the skin assessment dated [DATE] which documents, in part: . Pressure injury #1 mid back. 0.2 x 0.1 x 0.1. Stage 2. Surveyor noted the skin assessment completed on 3/11/25 was not in R7's electronic medical record. Surveyor noted the skin assessment did not include a comprehensive assessment including a description of the tissue and surrounding tissue of the pressure injury. On 3/19/25 at 12:55 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked when an assessment of a new wound should take place. DON-B stated it should be assessed when found and reported to the MD and POA. Treatment orders should be obtained. DON-B stated that the facility wound nurse should be updated so that the resident can be added to wound rounds which occur every Thursday. DON-B stated the nurse who finds the wound should complete a skin packet and incident report. Surveyor asked what should be included in the initial wound assessment. DON-B stated it should include the location, drainage, color of the wound, and measurement. DON-B stated that this information is documented in the skin packet and in the electronic medical record. Surveyor asked about the facility wide skin sweep. DON-B stated that the sweep was completed on 3/11/25. DON-B stated that it is a different electronic program than the facility's electronic health record. Surveyor asked if staff nurses would be able to see what is documented on the skin sweep. DON-B indicated that staff nurses would not be able to see the information from the skin sweep. Staff nurses need to use the facility's electronic medical record to view any documentation on residents. On 3/20/25 at 8:00 AM, Surveyor observed NP-M assess and change R7's mid back wound dressing. Surveyor noted a dressing with the date 3/19/25. NP-M removed the dressing. Surveyor noted a very small area of redness on R7's back. NP-M stated that the wound does not appear to be a pressure injury anymore. NP-M stated that that it looks more like a pimple or ingrown hair. NP-M put pressure around the area and expressed white matter. NP-M stated that NP-M will change the treatment to an antibiotic ointment. NP-M measured the area and stated the measurements remain the same as the previous week. NP-M informed Surveyor that the wound presented as a pressure injury last week but now appears to be an ingrown hair. On 3/20/25 at 9:42 AM, Surveyor informed DON-B of the concerns: that R7 had a new wound found on 3/9/25 and it was not assessed comprehensively until 3/13/25 when NP-M assessed the area as a stage 2 pressure injury. The skin sweep completed on 3/11/25 was not documented in the electronic medical record for all nursing staff to view. R7's care plan was not updated until 3/13/25 which was 4 days after the wound was found. R7's wound treatment was not documented as completed on 3/16 25. DON-B indicated that DON-B will investigate that and get back to Surveyor. On 3/20/25 at 10:56, DON-B indicated that R7 did not have an assessment completed on the new wound when it was found. DON-B agreed the care plan was not updated until 4 days after the wound developed. DON-B stated that the nurse who took care of R7 on 3/16/25 did not document that the treatment was completed. On 3/20/25 at 2:07 PM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B of the concerns with R7's wound: The wound was found on the 3/9/25 and was not comprehensively assessed until 3/13/25. R7's care plan was not updated until 3/13/25. R7's wound treatment was not documented as completed on 3/16/25. Uncorrected on Revisit Based on observation, interview, and record review, the Facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 3 (R6, R7, R8) of 3 residents reviewed for pressure injuries. *R6 developed a deep tissue injury (DTI) which was discovered on 2/19/25 by a Licensed Practical Nurse (LPN). There is no documentation that the DTI was evaluated by a Registered Nurse until the Wound Nurse Practitioner saw it on 2/27/25. Additionally, R6 did not have nutritional interventions attempted and R6's care plan was delayed in being updated. The DTI declined to a stage 3 pressure injury. *R8 developed a Stage 2 pressure injury to left buttocks on 3/10/25. The wound was not comprehensively assessed until 3/13/25. Treatment for the pressure injury was not obtained until 3/13/25 and R8's care plan was not updated until 3/13/25. *Facility staff documented R7 developed a new wound to R7's mid back on 3/9/25. The wound was not comprehensively assessed until 3/13/25 when the Wound Nurse Practitioner (NP)-M documented that the wound was a stage 2 pressure injury. R7's care plan was not updated with new interventions until 3/13/25, 4 days after the development of the pressure injury. On 3/16/25, R7's wound care was not documented as completed. Findings include: 1.) R6 was admitted to the facility on [DATE]with pertinent diagnoses that include type 2 diabetes mellitus, cardiomyopathy, heart failure, cognitive communication deficit, mild cognitive impairment, and vascular dementia. On 1/30/25, the following diagnoses were added: unspecified severe protein-calorie malnutrition and encounter for palliative care. R6's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/16/2024, documents a Brief Interview for Mental Status (BIMS) score of 04, indicating that R6 has severe cognitive impairment. The MDS documents that R6 was assessed to have no behaviors exhibited during the look back period. R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, R6 was assessed to have a mechanically altered diet. The MDS assesses no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS documents that no pressure injury was present, but that R6 is at risk of developing pressure injuries. R6 has an activated Power of Attorney (POA). R6's Significant Change MDS with an assessment reference date of 2/6/2025 does not document a BIMS assessment. The MDS documents that R6 was assessed to have no behaviors exhibited during the look back period. R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, R6 was assessed to have a mechanically altered diet. The MDS assesses that Weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months occurred and R6 was not on a physician prescribed weight loss regimen. The MDS assesses that no pressure injury was present, but that R6 is at risk of developing pressure injuries. R6 had multiple Braden Scale for Predicting Pressure Score Risk evaluations done. Braden evaluations dated 3/9/24, 8/20/24 and 1/31/25 documented that R6 was assessed to have a score of 10, indicating R6 is at very high risk of developing a pressure injury. R6's Braden evaluation dated 11/10/24 documents R6's risk of developing a pressure injury to be a moderate risk with a score of 16. R6's Pressure Ulcers/Skin Prevention care plan documents the following interventions: Follow community skin care protocol. Start 11/10/2021 Treatments, as indicated, see physician order sheet. Start 11/10/2021 Pressure reducing mattress on bed. Start 11/10/2021 Air mattress with bolsters, check for proper functioning Q (each) shift. Start 4/6/2022 Assist with repositioning when in bed and Broda chair during rounding and cares. Start 4/6/2022 cushion to w/c (wheelchair). Start 12/27/2022 Tubi grips on from hand to elbow in early am and off at bedtime. Hole cut for thumb. Start 8/9/2023 Prevalon Boots while in bed. Start 2/21/2025 (R6) has impaired skin integrity related to right lateral heel DTI (deep tissue injury) noted on 2/19/25 Goal: (R6) will be free from signs and symptoms of infection and will demonstrate optimal healing Interventions: Provide treatment as ordered. Start 3/11/25 Follow with wound APNP (Advanced Practice Nurse Practitioner). Start 3/11/25 Per wound rounds on 3/13/25, with wound APNP, wound is now classified as a stage III (3) pressure injury. Start 3/14/25 (R6) has impaired skin integrity related to right medial heel DTI noted on 3/6/25 Goal: (R6) will be free from signs and symptoms of infection and will demonstrate optimal healing Interventions: Provide treatment as ordered. Start 3/11/25 Follow with wound APNP. Start 3/11/25 R6's physician order dated 1/28/25 documents severe protein calorie malnutrition: hospice to eval (evaluate) and treat. R6's physician order dated 1/30/25 documents admit to (name of) Hospice Surveyor noted that R6's DTI was found on 2/19/25 and Prevalon boots were added on 2/21/25, which was 2 days after the DTI was identified. Surveyor noted that the rest of R6's care plan was updated 3/11/25 and 3/14/25. Surveyor noted that R6's the right medial heel has progressed to a stage 3 pressure injury, not the right lateral heel as documented in R6's care plan. R6's physician order dated 2/19/25 documents skin prep-topical every shift to be applied to right heel q (each) shift for protection and Heels to be elevated off bed with pillows-topical continuous for protection R6's progress note, written by Licensed Practical Nurse (LPN)-X dated 2/19/2025, at 3:39 pm, documents: bed bath given. A 5.2 cm (centimeter) x 4.5 cm darkened area was noted on right heel. On call RN (Registered Nurse) Supervisor aware and will assess. Heels elevated on pillows. Skin prep to be applied q shift R6's progress note, written by LPN-X dated 2/20/2025, at 2:52 pm, documents: on 2-19-25 a 1. cm x 2.0 cm, darkened area was found on resident's right heel during a bed bath and skin check. On call RN Supervisor was updated, (name of medical group) was updated, and POA (power of attorney) was updated. Skin prep ordered and a Prevalon boot to right foot. No pain to area Surveyor noted there was a discrepancy in R6's right heel measurements listed on 2/19/25 and on 2/20/25 when R6's medical doctor (MD) and POA were informed. On 2/19/25, a Skin Evaluation Form was completed for R6 by LPN-X. Documentation for the heel right is length 5.2 cm, width 4.5 cm, depth 0 cm. and the treatment of skin prep q shift, to be assessed by RN R6's physician order dated 2/20/25 documents Prevalon boot-topical every shift to be worn on right foot for protection On 2/20/25, a Skin Evaluation Form was completed for R6 by wound LPN-E. Documentation for the heel right is length 1.0 cm, width 2.0 cm, depth UTD (unable to determine) cm, cause is identified as pressure, tissue type is 0 = closed/resurfaced, exudate amount is 0 = none and stage is deep tissue injury The treatment section remained the same skin prep q shift, to be assessed by RN On 2/27/25, a Wound Care Assessment was completed by wound Nurse Practitioner (NP)-M, the right heel DTI documentation status is documented as new. Deep tissue pressure injury 0.9 x 2.5 cm. Intact, purple, no drainage. Peri wound is dry, intact. No sign/symptom infection. Surveyor noted this is the first documented comprehensive assessment of the wound by an RN. On 3/6/25, a Wound Care Assessment was completed by wound NP-M, the right heel DTI documentation is right lateral heel (DTI), deep tissue pressure injury 1 x 2 cm. Intact, purple, no drainage. Peri wound is dry, intact. No sign/symptom infection. Status- stable. A second pressure injury is discovered. Documentation is right medial heel (DTI), deep tissue pressure injury 0.5 x 1 cm. Intact, purple, no drainage. Peri wound is dry, intact. No sign/symptom infection. Status- new. On 3/13/25, a Wound Care Assessment was completed by wound NP-M, documentation is right lateral heel (DTI), deep tissue pressure injury 1 x 2 cm. Intact, purple, no drainage. Peri wound is dry, intact. No sign/symptom infection. Status- stable. Documentation for right medial heel (stage 3 pressure injury), full thickness wound measuring 1 x 1.5 cm. 100% granular tissue. Scant serosanguinous drainage. Peri wound is dry, intact. No sign/symptom infection. Status- decline. On 3/13/25, wound LPN-E completed the Skin Evaluation Form which documented the right lateral heel size is 1.0 cm x 1.5 cm x 0.1 cm and staged as a stage 3 pressure injury. The right medial heel size is 1.0 cm x 1.0 cm x UTD, and stage is deep tissue injury. Surveyor noted from 3/6/25 to 3/13/25 the DTI on the right medial heel declined to stage 3 as the measurements went from 0.5 x 1 cm to 1 x 1.5 cm. Surveyor noted wound LPN-E incorrectly documented the right lateral heel as the stage 3 pressure injury. Surveyor noted observing wound care on 3/19/25, at 8:38am, and the stage 3 pressure injury is on the right medial heel, as NP-M documented. Surveyor noted a delay in reporting of DTI to R6's physician and POA. Surveyor noted there was a delay in implementing R6's Prevalon boot as it was not added until 2/20/25, one day after R6's DTI was found. Additionally, Surveyor noted that there is no documentation that an RN assessed R6's heel until 2/27/25, seven days after it was initially discovered, and wound NP-M noted the DTI as new. Surveyor noted that on 3/6/25, a DTI to R6's right medial heel was also discovered. At the time, R6's wound documentation is changed from right heel to right lateral heel for the DTI found 2/19/25. On 3/13/25, the right medial heel DTI progressed to a stage 3 pressure injury per wound NP-M. R6's Interdisciplinary note, written by Registered Dietician (RD)-Y dated 1/29/25, documents: aware of current weight 107 pounds which reflects a significant weight loss of 10% in the past month. Intake appears to have decreased slightly but not significantly. Continues to accept 4oz ensure enlive TID between meals. Family has decided to proceed with hospice care. Will continue to monitor. R6's interdisciplinary note, written by RD-Y dated 3/18/25, documents monitoring wounds to RLE (right lower extremity) (venous ulcer-suspicious for cancerous lesion) and Right lateral heel (DTI). Both are stable. Patient admitted to hospice 1/30/25. Oral intake varies from poor to good although R6 has had an overall decrease as evidence by significant 13.85% weight loss in the past 6 months. R6 does receive 4 oz ensure enlive TID (three times per day) for additional calories/protein. Due to end stage diagnosis weight and wound changes unavoidable. Will continue to offer supplement and food/fluid as patient desires. Surveyor noted R6's RD note dated 3/18/25 was written a month after R6's right heel DTI was found and did not document that R6's right medial heel had progressed to stage 3. Surveyor noted R6 had a severe weight loss (more than 10%) over 6 months, not significant (less than 10%) as indicated in the 3/18/25 note. On 3/19/25, at 12:35pm, Surveyor interviewed RD-Y and asked about any intervention changes when R6's weight loss was detected, as Surveyor could not locate any in R6's medical record. RD-Y informed Surveyor that R6 was palliative care so RD-Y was not super aggressive in developing interventions for R6. RD-Y stated that in January RD-Y saw R6 and that R6 gets ensure. RD-Y stated that in January R6's family proceeded with hospice care. Surveyor asked if RD-Y updated R6's care plan and was told if a resident is losing weight the goal stays the same, to provide nutritional needs. RD-Y removed the part in the care plan about R6 not having a weight change. RD-Y stated the goal was to provide food and fluids to try to prevent further weight loss, this is for comfort. Surveyor asked about improving R6's nutrition and was told RD-Y did not implement further interventions because hospice was being discussed with the family. RD-Y saw a gradual decrease in R6's appetite, comfort was the goal. Surveyor noted R6 had no interventions that were attempted which could improve protein intake. Surveyor noted R6 had been on hospice previously from 9/30/21 to 9/14/22, 2 years ago. On 3/19/25, at 1:23pm, Surveyor interviewed Hospice RN-AA about weight loss and pressure injuries. Surveyor asked Hospice RN-AA about R6's pressure injury and who monitors it. Hospice RN-AA stated the facility cares for it and that pressure injuries are fairly common at the end of life, especially with R6's diagnosis due to the lack of protein. Surveyor asked if R6 needs a protein supplement or other interventions and was told not necessarily as pressure injuries are part of the decline. On 3/18/25, at 2:20pm, Surveyor interviewed wound LPN-E and was told the wound NP-M stages the wounds, LPN-E just puts in what NP-M says. If a skin issue is found and it is not by the wound rounding day with NP-M, LPN-E grabs a RN to stage and documents what they say. Surveyor asked if anyone was monitoring the right heel between 2/27/25 and 3/6/25 when the new DTI was discovered by wound NP-M. LPN-E stated yes, at the weekly bath skin check and when the skin prep was applied q shift. Surveyor asked if hospice followed the wound and was told no, they are aware and are given updates weekly, but they refer to the wound NP-M for treatments. Surveyor asked why there was no RN assessment on the 19th when the DTI was found and was told there were no managers here at that point, LPN-E believes they have 24 hours for RN to put eyes on it. On 3/18/25, at 3:20pm, Surveyor interviewed LPN-X, who found R6's right heel DTI. LPN-X informed Surveyor that R6's DTI was discovered during R6's skin check, 2/19/25, on bath day. LPN-X let the unit manager know over the phone and was told the wound team would look at it the next day. The wound was not open when it was found. On 3/19/25, at 10:25am, Surveyor interviewed wound LPN-E again after reviewing wound NP-M notes. Surveyor asked why the wound was found on 2/19/25, charted on by LPN-E on 2/20/25, and assessed by NP-M on 2/27/25 as new. LPN-E will look into the documentation. On 3/19/25, at 12:13pm, LPN-E got back to Surveyor that since wound NP-M was coming on the 20th, LPN-E printed wound rounds on the 19th before the DTI was found, so it was not on the sheet. After NP-M left, LPN-E remembered the DTI so took RN Unit Manager-C with to assess. Surveyor asked for documentation of the RN assessing the wound and was told it is noted in treatment section. Surveyor noted it reads to be assessed by RN in the treatment section. Surveyor asked about interventions to keep heels off bed before the DTI was discovered and LPN-E will look into. Surveyor noted no documentation was provided. On 3/19/25, at 12:47pm, Surveyor interviewed RN Unit Manager-C and was told they had been called the night before (2/19/25) about the new wound and took care of the assessment the next day. Surveyor noted no documentation was provided of the RN assessment. On 3/20/25, at 8:08am, Surveyor interviewed wound NP-M who stated the 2nd pressure injury developed because R6 always kicks boots off. Surveyor asked about interventions in place before the DTI was discovered and NP-M cannot speak to that. Surveyor reviewed the CNA Worksheet provided by Facility and R6 is a 2 person assist for transfers, bed mobility, dressing and bathing. It is not documented on the worksheet for R6 to be turned or repositioned on any schedule, float heels or wear Prevalon boots. On 3/20/25, at 10:18am, Surveyor interviewed R6's POA and asked if they had been notified of R6's weight loss. R6's POA responded that R6's weight loss had been mentioned casually. R6's POA stated they bring food in for R6 and R6 has no trouble eating the food. POA felt R6 gets lots of skin tears and feels the bad nutrition would affect skin integrity. On 3/20/25, at 2:06pm, Surveyor spoke with Director of Nursing (DON)-B about the concerns for R6 regarding the lack of RN assessment, lack of care plan interventions or nutrition supplementation that led to a DTI progressing to a stage 3 pressure injury. No further information was provided at the time of write up regarding no documentation that the DTI was evaluated by a Registered Nurse (RN) until the Wound Nurse Practitioner (NP) saw it on 2/27/25, R6 did not have nutritional interventions attempted and R6's care plan was delayed in being updated. Cross-reference F692. 2.) R8 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R8's diagnoses include osteoarthritis, polyneuropathy, basal cell carcinoma, stage 2 left buttocks pressure injury. R8's Quarterly Minimum Data Set (MDS) completed on 2/1/25 documents that R8 is a partial/moderate assist with toileting, showering, dressing, and transferring. R8 is occasionally incontinent of urine and always incontinent of bowels. R8 has one stage 2 unhealed pressure injury. R8 is documented as having a Brief Interview for Mental Status (BIMS) score of 13, indicating R8 is cognitively intact. R8's Care Area Assessment (CAA) for Pressure Ulcer/Injury dated 11/14/24, documents R8 was admitted on [DATE]. R8 was admitted to (name of) hospital on [DATE] for weakness and falls. R8 has a past medical history for anxiety, depression, chronic pain, Chronic Obstructive Pulmonary Disorder (COPD), Gastroesophageal Reflux Disease (GERD), Hypertension (HTN), and shingles pain. R8 reports over the past few months she has had an increased number of falls. R8 has lived at an Assisted Living Facility (ALF) for the past 3 years. R8 is independent living until 3 weeks ago when she was moved to assisted living. R8 is having issues with falls and needed more help with medications and Activities of Daily Living (ADL)s. R8 has the following impairments: transfers, gait, balance, Range of Motion (ROM), strength, endurance/activity tolerance, safety awareness/judgment, fall risk, and pain in low back. Benefits for R8 at rehab will be additional physical therapy to address deficits. R8's care plan, dated 11/4/24, documents: R8 is at risk for pressure ulcers and other skin related injuries (dated 11/4/24). Interventions include: Braden Scale to be completed (dated 11/4/24). Keep bed linens wrinkle free and do not use excess pads (dated 11/4/24). Observe skin for redness and breakdown during routine care (dated 11/4/24). Use pressure relieving devices, cushion on wheelchair and off of heels, as indicated (dated 11/4/24). Follow community skin care protocol (dated 11/4/24). Treatments, as indicated, see physician order sheet (dated 11/4/24). Pressure reducing mattress on bed (dated 11/4/24). R8 has impaired skin integrity related to cancerous hyperpigmentation on old site from biopsy, present on admission (dated 11/11/24) Interventions include: Follows with wound Advanced Practice Nurse Practitioner (APNP) for monitoring (dated 11/11/24). R8 has stage 2 pressure ulcer buttock (dated 2/4/25) Interventions include: See Electronic Treatment Administration Record (ETAR) (dated 2/4/25). Follows with APNP for monitoring (dated 2/4/25). 2/20/25: left buttock pressure injury resolved: denuded fragile skin due to healed pressure area (dated 3/13/25). 3/13/25: left buttock pressure injury resurfaced, now stage 2 (dated 3/13/25). Provide treatment as ordered (dated 3/13/25). Assist with repositioning during rounding and cares (dated 3/13/25). Surveyor reviewed R8's medical recorder which documents the following: *Order placed on 11/6/24 to apply z-guard to coccyx every shift. *R8 received a bath on 3/10/25. Certified Nursing Assistant (CNA)- T performed the bath on R8 and documents R8 having a new reopened pressure wound to the left buttocks. *R8's Skin Evaluation form dated 3/12/25 documents, denuded fragile skin due to healed pressure area to the left buttocks. Treatment includes z-guard to coccyx every shift. *R8's Skin Evaluation form dated 3/13/25 documents, left buttocks denuded fragile skin due to healed pressure area. Treatment includes z-guard to coccyx every shift. *R8's Skin Evaluation form dated 3/13/25 documents, Stage 2 full thickness wound pressure injury to left buttocks. Resurfaced 100% smooth, red, granulation, serosanguineous drainage, and moderate exudate present. Cause is pressure. Treatment changed to cleanse with Normal Saline (NS), pat dry, followed by Foam Border Dressing (FBD) to be changed daily and as needed (PRN). Surveyor notes this was the second Skin Evaluation performed for R8 on 3/13/25 which was performed by Licensed Practical Nurse (LPN) Unit Manager/Wound Nurse- E who rounds with the wound care Nurse Practitioner (NP) on Thursdays. On 3/18/25, at 10:19 AM, Surveyor interviewed R8 who was sitting in the recliner on top of a pillow. R8[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the Facility did not ensure residents maintained acceptable parameters of nutritional status for 1 (R6) of 1 resident reviewed for weight loss. R6 experienced severe weight loss over a period of 6 months, during which time R6 developed pressure injuries. The weight loss was not prescribed, and no new interventions were implemented to prevent R6's weight loss. Surveyor was unable to locate any documentation that the Facility updated the Power of Attorney or R6's physician. Findings include: The facility policy and procedure titled, Nutritional Screening, Assessment, and Monitoring and last revised 11/2022, documents, in part: Policy Statement It is the policy of Ascension Living that a comprehensive nutritional assessment is completed upon admission, annually, or when a significant change occurs for each resident. Policy Interpretation and Implementation A. The RD (Registered Dietician) should complete a comprehensive nutritional assessment on each resident according to the admission date and MDS (Minimum Data Set) schedule, and clinical nutrition need. B. A validated malnutrition screening tool will be utilized to determine malnutrition risk, as per community policy. C. The individualized plan of care will be written and reviewed regularly when changes are noted. The plan of care will be shared with and agreed upon by the resident and/or representative. D. A member of the food and nutrition services team will participate in the IDT (Interdisciplinary Team) care planning process and meetings according to the community's policy . F. The dietitian will monitor regularly to ensure residents maintain acceptable parameters of nutritional status. G. Residents are offered a therapeutic diet when it has been determined that there is a benefit . Procedures C. Interval assessment / Progress note will be completed for the following but are not limited to: 1. Resident with a confirmed significant change in weight will receive a re-assessment as soon as possible but no longer than 5-days after notification, and the follow-up note will be done a minimum of weekly until weight stabilization occurs or there is a determination in the plan of care to discontinue weekly weights. 2. Resident with insidious weight loss (gradual unintended progressive weight loss over an extended time). 3. Residents with a new pressure injury will receive a re-assessment as soon as possible, but no longer than 5 days after notification, and the follow-up note will be done minimally monthly - until pressure injury is resolved . The Facility Policy and Procedure titled, Procedure: Assistance with Meals and last revised 1/1/2025, documents, in part: Purpose Statement It is the policy of Ascension Living that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation A. Dining Room Residents 1. All residents are encouraged to eat in the dining room for socialization . 4. Residents who require assistance with eating should be provided with self-help devices and/or provided help as needed. 5. Residents who are unable to feed themselves should be fed with attention to safety, comfort, and dignity . R6 was admitted to the facility on [DATE] with pertinent diagnoses that include type 2 diabetes mellitus, cardiomyopathy, heart failure, cognitive communication deficit, mild cognitive impairment, and vascular dementia. On 1/30/25, the following diagnoses were added: unspecified severe protein-calorie malnutrition and encounter for palliative care. R6's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/16/2024, documents a Brief Interview for Mental Status (BIMS) score of 04, indicating that R6 has severe cognitive impairment. The MDS documents that R6 was assessed to have no behaviors exhibited during the look back period. R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, R6 was coded to have a mechanically altered diet. The MDS documents no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS documents that no pressure injury was present, but that R6 is at risk of developing pressure injuries. R6 has an activated Power of Attorney (POA). R6's Significant Change MDS with an assessment reference date of 2/6/2025 does not document a BIMS assessment. The MDS documents that R6 was assessed to have no behaviors exhibited during the look back period. R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, R6 was coded to have a mechanically altered diet. The MDS documents that Weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months occurred and R6 was not on a physician prescribed weight loss regimen. The MDS documents that no pressure injury was present, but that R6 is at risk of developing pressure injuries. R6's care plan documents Nutritional Status, (R6) is at risk for impaired nutrition related to end stage diagnosis. Goal: (R6) will have nutritional needs met. (R6) is offered diet as prescribed, see physician order sheet. Start 11/10/21 Provide supplement as ordered. Start 11/10/21 Provide assist as needed. Start 12/27/22 Surveyor noted R6 had previously been on hospice from 9/30/21 to 9/14/22. R6 began hospice services again on 1/30/25. R6's care plan documents Dehydration/Fluid Maintenance. (R6) has a potential for fluid volume deficit related to . poor vision, may need staff assist with fluid intake use of diuretic for dx (diagnosis) of CHF (congestive heart failure). Goal: (R6) will be free from signs and symptoms of dehydration and will be well hydrated as evidenced by physical conditions. Keep fresh water, or beverage of preference, in reach. Start 4/4/22 Assess (R6's) preferred fluids and provide. Start 4/4/22 Offer 120 mL fluids with medication pass. Start 4/4/22 Staff to assist with all hot liquids and (R6) to drink hot liquids while sitting at table only. Start 4/4/22 Surveyor noted R6 did not have a diuretic currently prescribed. Surveyor noted there were no updates to R6's care plan when R6 was taken off hospice and when R6's diuretic was discontinued. Surveyor also noted that there were no new interventions when R6's weight loss was discovered. R6's physician order dated 10/21/22 documents Monthly weight - due on the first Wednesday of every new month. Document refusals . R6's physician orders dated 10/31/23 document diet: consistent carbohydrate, pureed diet . and diet: thin liquids. R6's physician order dated 1/28/25 documents severe protein calorie malnutrition: hospice to eval (evaluate) and treat. R6's physician order dated 1/30/25 documents admit to (name of) Hospice. While investigating a Facility Reported Incident Surveyor reviewed R6's electronic medical record (EMR) and found R6's weights progressively declined from 7/3/2024 to the last weight taken on 1/26/25. Prior to 7/3/24, R6's weight had been stable. On 7/3/24 R6's documented weight was 131.0 pounds. On 8/7/24 R6's documented weight was 124.2 pounds. On 9/4/24 R6's documented weight was 120.8 pounds. On 10/2/24 R6's documented weight was 119.4 pounds. On 11/6/24 R6's documented weight was 118.0 pounds. On 12/10/24 R6's documented weight was 119.0 pounds. On 1/15/25 R6's documented weight was 108.2 pounds. On 1/24/25 R6's documented weight was 105.9 pounds. On 1/26/25 R6's documented weight was 107.0 pounds. Surveyor noted that there is an active physician order for monthly weights. Despite this order, Surveyor noted that 1/26/25 was the last recorded weight for R6. Surveyor noted that R6 experienced a severe weight loss of 18.32% from 7/3/24 to 1/26/25 (6 months), 10.39% from 10/2/24 to 1/26/25 (3 months), and 10.8% from 12/10/24 to 1/26/25 (1 month). R6's annual Nutrition Risk Assessment dated 8/16/24, completed by Registered Dietician (RD)-Y, documents under the food and nutrition history section 4 oz ensure enlive TID (three times daily). R6's feeding ability is marked as extensive assistance. Surveyor noted per staff interviews (which follow) it was determined that R6 is totally dependent on staff for eating and drinking, RD-Y did not mark R6 as total dependence on assessment. Meal intakes (average) was marked as 51-75%. R6 has chewing difficulty and no swallowing problems per assessment. Surveyor noted R6 is missing many teeth per an interview with staff. At the time of the assessment the current weight was noted as 120.8 pounds (recorded in September by Facility) and the weight trend for last 6 months was marked as stable. Comments/recommendations were Resident seen for annual review . Intake fair at meals. Mostly fed at meals. Weight 120.8 pounds, stable the past 6 months. No new interventions needed at this time. Currently free of pressure injury. Will continue to monitor. Surveyor noted the 7/3/24 weight was 131.0 pounds, and the weight used for assessment is 120.8 which is a loss, not stable. On 8/20/24, R6 had a compliance visit with R6's internal medicine doctor. The follow-up note reads monitor behaviors, dementia, progressive decline, right lower extremity wound. Continue ongoing plan of management/care with close monitoring. R6's quarterly Nutrition Risk Assessment dated 11/14/24, completed by RD-Y, documents under the food and nutrition history section 4 oz ensure enlive TID remained and encourage fluids with medication pass was added. On 11/11/24 a nursing order was added to R6's physician orders to encourage fluids with medication pass - 3 times per day. Provide resident with 240ml with each medication pass. Surveyor noted in an interview with RD-Y it was indicated that this was added due to a nursing initiative. Feeding ability remained extensive assistance and meal intakes (average) were marked again as 51-75%. Chewing difficulty was indicated and no swallowing problems were noted. R6's current weight is recorded as 118 pounds and the weight trend in the last 6 months was marked as stable. Comments included resident seen for quarterly review . Intake fair at meals. Needs assistance at meals. Weight 118 pounds, stable the past 6 months. No new interventions needed at this time. Currently free of pressure injury. Will continue to monitor. Surveyor noted that R6's 7/3/24 weight was 131.0 pounds, and the weight used for assessment is 118.0 which is a loss, not stable. R6's monthly visit note from (name of NP group), written by the APRN-BC (Advanced Practice Registered Nurse-Board Certified) after a face-to-face visit on 11/20/24, documents (R6) is a [AGE] year-old . being seen today for a follow-up visit. Chart and medications reviewed. Patient and staff interviewed. (R6) is compliant with medication regimen. (R6) is transferred by Hoyer lift and enjoys spending time sitting in Geri chair with the other residents. Weight this month is 118.0 pounds, which is down from 125 pounds in June 2024 and down from 127.2 pounds in November 2023. Staff continue to assist with meals. Discussed weight loss with nurse manager. Voicemail left for daughter/POA. Will discuss potential hospice services with POA given weight loss. Surveyor noted that R6's weight is being recorded as trending down and the information is shared with Facility staff by (name of nurse practitioner (NP) group) APRN-BC. An email, written on 11/26/24, from Register Nurse (RN) Unit Manager-C to R6's POA was provided to Surveyor. The email documents .we did have a care conference last week, (name of NP group) was present as well. I attempted to reach out and contact you during the meeting. I left a message. I'm sorry to hear you didn't receive a notice prior to the meeting . Surveyor noted there is no mention of R6's weight loss. This email was provided when Surveyor requested documentation that R6's POA was updated by the Facility regarding R6's weight loss. R6's follow up visit note from (name of NP group), written by APRN-BC after a face-to-face visit with R6 on 12/9/24, documents (R6) is a [AGE] year old . being seen today for a follow-up visit. Chart and medications reviewed. Patient and staff interviewed. (R6) is compliant with medication regimen. (R6) is transferred by Hoyer lift and enjoys spending time sitting in Geri chair with the other residents. (R6's) most recent weight is 118.0 pounds, which is down from 125 pounds in June and down from 127.2 pounds in November 2023. Staff continue to assist with meals. Voicemail message left for daughter/POA to discuss potential hospice services with POA given weight loss. R6's clinical note written by the (name of NP group) APRN-BC on 12/18/24, which was communicated with POA and Registered Nurse at Facility documents .(R6) most recent weight is 119.0 pounds, which is down from 125 pounds in June 2024 and down from 127.2 pounds in November 2023. Staff continue to assist with meals and R6 drinks ensure. Discussed vascular dementia, weight loss/protein calorie malnutrition with daughter/POA and nurse manager. (R6) has a painful lower extremity venous ulcer full thickness wound and a chronic scab to the right side of nose. Daughter/POA notes that this area on right lower extremity has been an area of concern by dermatologist in the past - likely a skin malignancy. POA also reports she would like comfort goal of care for (R6). Plan for a hospice referral due to vascular dementia, weight loss and protein calorie malnutrition. POA is in agreement. Order given to Nurse Manager. R6's clinical note written by the (name of NP group) APRN-BC on 1/16/25, which was communicated with Nurse Manager at Facility documents Chart review completed. Met with (R6) who is resting comfortably in bed. (R6) states is tired and would like to sleep . Spoke with Nurse Manager and reviewed. Daughter had wanted dermatology consult for chronic wound on right shin and this was being scheduled. Called and spoke with daughter/POA. Discussed chronic wound to right shin and concern for its removal and biopsy which could possibly create an even larger wound area, and if grafting was needed would actually create 2 wounds. Also discussed weight loss, recorded weight show (R6) has lost another 10 pounds in the last month, current weight 108 pounds. POA under impression that biopsy could be completed at SNF (skilled nursing facility). Discussed that was not possible and (R6) would need to be sent for outpatient . POA has decided does not want dermatology referral and would like wound team at SNF to continue treating the wound as they have been. Discussed hospice referral . At the end of the conversation POA did agree to have a hospice evaluation for (R6) and have hospice contact her to discuss and answer all her questions. Called and spoke with 1st Floor Nurse Manager- who will cancel dermatology referral . (R6's) progress note, written by RN Unit Manager-C dated 1/17/2025, documents Writer spoke with (name of NP group), who had followed up with family regarding dermatology consult. POA has decided that is not the route she wants to go. POA stated would prefer to move towards hospice . Surveyor noted no documentation of the Facility discussing weight loss with POA or R6's physician was located. On 1/17/2025, R6 was seen by the APNP (Advanced Practice Nurse Practitioner) for a monthly follow up appointment. The Chief Complaint section documents APNP monthly compliance visit - dementia with decline, anxiety, plans for hospice. Surveyor noted was not able to find documentation of the weight loss being discussed with APNP in the evaluation or nursing concerns. R6's Interdisciplinary note, written by RD-Y, dated 1/29/25, documents aware of current weight 107 pounds which reflects a significant weight loss of 10% in the past month. Intake appears to have decreased slightly but not significantly. Continues to accept 4oz ensure enlive TID between meals. Family has decided to proceed with hospice care. Will continue to monitor. Upon admission to hospice the hospice provider completed a Hospice Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report which has the following pertinent orders dated 1/30/25. Skilled nursing to educate patient/family on dietary modification to improve overall nutrition as tolerated including Providing small, frequent meals, offer small amounts of fluids frequently, offer but do not force food/fluids. Skilled nursing to educate caregivers on offering, but not forcing food/fluids. Surveyor noted these hospice orders were not integrated into R6's care plan. On 3/19/25, at 1:23pm, Surveyor interviewed Hospice RN-AA about monthly weights. RN-AA stated that facilities in general do monthly weights, when on hospice, facilities can stop taking weights. Hospice can request for them to take weights though. Surveyor asked RN-AA what interventions were in place for R6 weight loss. Hospice RN-AA told Surveyor weight loss is a normal part of the process with R6's hospice diagnosis of unspecified severe protein calorie malnutrition with prognosis of 6 months or less if the disease runs its normal course. Per RN-AA even if R6 took in more calories R6 would lose weight due to the diagnosis. It is completely normal with R6's diagnosis and being on hospice in general for weight loss to occur. Surveyor asked about the Interdisciplinary Group orders for skilled nursing to educate patient/family on dietary modification to improve overall nutrition as tolerated including Providing small, frequent meals, offer small amounts of fluids frequently, offer but do not force food/fluids. Skilled nursing to educate caregivers on offering, but not forcing food/fluids. Per RN-AA skilled nursing refers to the hospice RN and they should educate staff how to offer food and fluids. This is part of the normal decline, a resident will not eat/drink as much because it is part of the dying process. Surveyor asked if resident is actively dying and was told no declining now. Surveyor asked if small frequent meals should be an order and was told no not necessarily. Staff should offer fluids at regular intervals and feed at mealtime, RN-AA was not sure if R6 gets snacks. RN-AA informed Surveyor it is fairly certain R6 is not eating much as that is part of R6's end of life diagnosis. Surveyor asked RN-AA about R6's pressure injury and who monitors it. RN-AA stated the facility cares for it and that pressure injuries are fairly common at the end of life, especially with R6's diagnosis due to the lack of protein. Surveyor asked if R6 needs a protein supplement or other interventions and was told not necessarily as pressure injuries are part of the decline. R6's significant change Nutrition Risk Assessment dated 2/6/25, completed by RD-Y, documents under the food and nutrition history section 4 oz ensure enlive TID and encourage fluids with medication pass remained. Feeding ability remained extensive assistance and meal intakes (average) were changed to 26-50%. Chewing difficulty was indicated and no swallowing problems were noted. R6's current weight was recorded as 107 pounds and the weight trend in the last 6 months was recorded as significant weight loss. Comments/Recommendations are written as (R6) seen for significant change assessment . Intake fair-poor at meals. Needs assist at meals. Weight 107 pounds, weight loss of 9% times 1 month noted from December to January. Family has opted for hospice care. No new interventions needed at this time. Right shin venous/stasis wound noted. Will continue to monitor. On 3/19/25, at 12:35pm, Surveyor interviewed RD-Y and asked about any intervention changes when R6's weight loss was detected, as Surveyor could not locate any in R6's medical record. RD-Y informed Surveyor that R6 was palliative care so RD-Y was not super aggressive in developing interventions for R6. RD-Y stated that in January RD-Y saw R6 and that R6 gets ensure. RD-Y stated that in January R6's family proceeded with hospice care. Surveyor asked if RD-Y updated R6's care plan and was told if a resident is losing weigh the goal stays the same, to provide nutritional needs. RD-Y removed the part about R6 not having a weight change from the care plan. RD-Y stated the goal was to provide food and fluids to try to prevent further weight loss, this is for comfort. Surveyor asked about improving R6's nutrition and was told RD-Y did not implement further interventions because hospice was being discussed with the family. RD-Y saw a gradual decrease in R6's appetite, comfort was the goal. Surveyor noted R6 had no interventions attempted which could provide comfort for R6 and prevent further weight loss. Surveyor noted R6 had been on hospice previously from 9/30/21 to 9/14/22, 2 years ago. R6's progress note written by Licensed Practical Nurse (LPN)-X dated 2/19/2025, at 3:39pm, documents bed bath given. A 5.2cm (centimeter) x 4.5cm darkened area was noted on right heel. On call RN (Register Nurse) Supervisor aware and will assess. Heels elevated on pillows. Skin prep to be applied q shift. R6's progress note, written by LPN-X dated 2/20/2025, at 2:52pm, documents on 2-19-25 a 1.0cm x 2.0cm, darkened area was found on resident's right heel during a bed bath and skin check. On call RN Supervisor was updated, (name of medical group) was updated, and POA was updated. Skin prep ordered and a Prevalon boot to right foot. No pain to area. Surveyor noted there was a discrepancy in R6's right heel measurements listed on 2/19/25 and on 2/20/25 when R6's physician and POA were informed. Surveyor noted that on 3/6/25, a DTI to the right medial heel is also discovered and on 3/13/25, the right medial heel DTI progressed to a stage 3 pressure injury. Surveyor notes no documentation of nutritional interventions are found. R6's interdisciplinary note, written by RD-Y dated 3/18/25, documents monitoring wounds to RLE (venous ulcer-suspicious for cancerous lesion) and Right lateral heel (DTI) (Deep tissue injury). Both are stable. Patient admitted to hospice 1/30/25. Oral intake varies from poor to good although (R6) has had an overall decrease as evidence by significant 13.85% weight loss in the past 6 months. R6 does receive 4 oz ensure enlive TID for additional calories/protein. Due to end stage diagnosis weight and wound changes unavoidable. Will continue to offer supplement and food/fluid as patient desires. Surveyor noted R6's RD note dated 3/18/25 was written a month after R6's right heel DTI was found and did not document the R6's right medial heel had progressed to stage 3. Surveyor noted R6 had a severe weight loss (more than 10%) over 6 months, not significant (less than 10%) as indicated in the 3/18/25 note. Surveyor noted no further assessment completed related to R6 oral intake decreasing, for instance determination of what food R6 likes and may be more likely to consume. Surveyor noted was unable to locate any documentation why, with only a slightly decreased intake, R6 would suffer severe weight loss. Surveyor noted that R6 had no new interventions identified for R6's weight loss other than hospice services. On 3/18/25, at 1:50pm, Surveyor interviewed LPN-H who confirmed R6 is supposed to get monthly weights. On 3/18/25, at 2:20pm, Surveyor interviewed wound LPN-E who stated R6 has lots of issues. Regarding weight loss, R6 is on hospice so decline is expected. If resident is on hospice facility staff do not do weights unless hospice orders them. Surveyor noted an active physician order for monthly weights dated 10/21/22. On 3/18/24, at 3:20pm, Surveyor interviewed LPN-X regarding weight loss. LPN-X states that the unit nurse manager tracks weights. R6 is on hospice, is fed by staff and accepts food but is not a big eater. Weight loss was happening before R6 was on hospice. R6 has very few teeth so gets a soft diet. Prefers food warm and with coffee. Surveyor noted on 12/10/21 R6's POA elected eye care from the Facility provider, dental was not selected. On 3/19/25, at 1:54pm, Surveyor interviewed RN Unit Manager-C who stated that the RD monitors weights and then staff talk at the daily meetings about this information. On 3/20/25, at 8:08am, Surveyor interviewed Certified Nursing Assistant (CNA)-J about how R6 is set up for meals and was told R6 is a total assist of puree diet. Staff feed R6 every meal. Staff stop and give sips of water during the day. If R6 refuses or will not finish the whole meal it is entered in the charting as the percent eaten. R6 has been a total assist a long time, more than a year. On 3/20/2025, at 9:53 am, Surveyor interviewed RN Unit Manager-C and asked for evidence the Facility informed R6's POA or physician of the weight loss. Surveyor noted only (name of NP group) notes were provided that showed POA being updated by (name of NP group) APRN-BC. Surveyor asked for evidence R6 was being fed all 3 meals and was told the January intake forms were provided to Surveyor, RN Unit Manager-C knows there are holes in the documentation, however, assures Surveyor that they check whenever they work that everyone is being fed appropriately. Surveyor noted while reviewing the intake forms many time slots (holes) were left blank hence not documented if a meal was attempted. In 31 days, 44 meals were not recorded and 49 were documented on. Surveyor asked what happens with the hospice plan of care report and was told staff are to read it for reference. When asked if the small meals and snacks should have been added to the care plan the response was RN Unit Manager-C felt the ensure between meals was the snack and resident could eat as much of meal as wanted. On 3/20/25, at 10:00am, Surveyor interviewed RD-Y again. Surveyor asked why there is a difference in charting. The MDS reads R6 is totally dependent, [NAME] reads max assistance, meal ticket has needs assist and RD assessments show extensive assistance. Per RD-Y extensive assistance has no set definition other than the resident needs someone with them the whole time. The meal ticket with needs assist means the resident needs to be fed. Surveyor asked why R6 had a puree diet and was told the altered diet had been in place even before the current order. Per RD-Y, R6 loves puree and has never complained. Surveyor asked why RD-Y referred to weight loss as significant when it is severe and was told it is the verbiage RD-Y uses, RD-Y does not use the severe category like Surveyors. Again, Surveyor clarified that no interventions were attempted in the last 6 months when weight loss occurred and was told none were added. On 3/20/25, at 10:18am, Surveyor interviewed R6's POA and asked if they had been notified of R6's weight loss. R6's POA responded that R6's weight loss had been mentioned casually. R6's POA stated they bring food in for R6 and R6 has no trouble eating the food. POA felt R6 gets lots of skin tears and feels the bad nutrition would affect skin integrity. On 3/20/25, between 12:40pm and 12:55pm, Surveyor observed R6 being assisted to eat by LPN-H. R6 stated help me multiple times during the observation, LPN-H would ask what can I help you with and R6 would reply food. R6 was assisted to drink coffee between bites of food. Surveyor requested labs from the RN Unit Manager-C and was provided labs done on 2/16/25 and 2/17/25. On 3/20/25, at 1:30pm, Surveyor asked RN Unit Manager-C for labs prior to the 2025 labs provided and was told labs had not been completed in quite a while because R6 was on hospice, off hospice and back on again, labs had not been done in over a year. On 3/20/25, at 2:45pm, Surveyor interviewed MD-Z and asked if there was a significant weight change in a resident should they be notified and was told not directly. MD-Z makes rounds at several facilities, staff should contact the on-site NP who will then contact MD-Z if there are concerns. Surveyor asked if MD-Z was aware R6 had weight loss and was told MD-Z last saw R6 in February and knows R6 lost 10 pounds in one month. Surveyor asked if any interventions should have been started and was told the family was thinking about hospice. With R6 having advanced dementia and the leg wound MD-Z would expect a decline, R6 gets ensure and was eating fair to good, MD-Z felt the RD could handle. On 3/20/25, at 2:06pm, Surveyor spoke with Director of Nursing (DON)-B regarding R6's weight loss. DON-B stated they were not aware of the issue. Surveyor stated no interventions being put in place is a concern and was told during daily clinical report significant changes are brought up, nursing would not be involved with nutrition interventions. Surveyor also stated that the RD charted R6's weight as stable in assessments when weight loss was occurring. Surveyor told DON-B they had requested documentation that R6's POA or MD had been updated about the weight loss by the Facility and none had been provided. Surveyor also discussed the intake forms not being charted on daily so there is no evidence R6 is being fed three meals a day. After the weight loss a pressure injury developed. No further information was provided at the time of write up regarding the severe weight loss R6 experienced that was not prescribed. No new interventions were implemented to prevent R6's weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure residents received care, consistent with professional standards of practice, and the necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing for that 1 (R3) of 3 residents reviewed for pressure injuries. * R3 did not receive pressure injury treatments for a pressure injury that was discovered during admission. There was no evidence that R3's physician was notified of R3's newly discovered pressure injury and there was a delay in implementing pressure relieving interventions and pressure injury treatments for R3. During this delay, R3's pressure injury increased in size and the condition deteriorated while they were not receiving treatment and interventions. Findings include: The facility procedure titled Pressure Injury Assessment/Treatment dated as last approved July 2024 documents (in part): .The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified pressure injuries, alterations in skin integrity, and the prevention of acquiring additional pressure injuries . Interventions/ Care Strategies: Pressure injury treatment requires a comprehensive approach, including and not limited to: C. Preventative measures to reduce the risk of further tissue loss. E. Interventions that increase the potential for healing. 1.) R3 was admitted to the facility on [DATE] with a diagnoses that includes history of fall, open reduction and internal fixation surgical procedure for fracture intertrochanteric fracture to the femur, protein - calorie malnutrition, Parkinson's disease and neurocognitive disorder with Lewy bodies. R3's initial MDS (minimum data set) with an assessment reference date of 2/1/2025, documented a BIMS (brief interview mental status) score of 7 which indicates severely impaired cognition for R3. R3 is assessed as being substantial to maximal assist for rolling left and right and is dependent for chair/bed to transfers & toilet transfer. R3 is assessed as always being incontinent of urine and bowel. R3's pressure injury/skin prevention care plan dated 1/28/2025 documents under the interventions section: Observe skin for redness and break down during routine care, treatments- as indicated- see physician order sheet, pressure reducing mattress on bed. Use pressure relieving devices, cushion on wheelchair and off heals, as indicated. R3's discharge report from the hospital dated 1/28/2025 does not document any wound treatment or an open area to R3's heel. R3's initial skin assessment dated [DATE] and completed by RN-I documents: Pressure injury to left upper heel. Tissue type granulation. Light exudate. Measurements 0.2 x 0.3 x 0.1(centimeters); Under the stage it section it documents, further assessment required. Surveyor reviewed R3's electronic medical record and was unable to locate any evidence that R3 received treatment to R3's left upper heel pressure injury from 1/28/25 to 1/30/25. Surveyor also was unable to locate any interventions that were put in place to reduce pressure for R3's newly discovered pressure injury as documented on 1/28/25. Surveyor was unable to locate any evidence that R3's physician was notified and consulted of R3's pressure injury to the left upper heel as documented on 1/28/25. R3's initial visit document dated 1/29/25 and completed by a Nurse Practitioner (NP) documents: Skin-no masses, no rashes, no lesion on exposed skin, dressing to right hip, clean dry and intact. Surveyor could not find any documentation, related to a physician or NP being updated on the pressure injury observed on admission. The NP note dated 1/29/25 did not include any details on the pressure injury to R3's left upper heel as documented on 1/28/25. R3's MAR (Medication Administration Record) and TAR (Treatment Administration Record) does not document any wound treatment for R3 from 1/28/25 to 1/30/25. R3's skin assessment dated [DATE] documents: Full thickness wound/ pressure injury to left upper heel. Tissue type 100% slough. Moderate exudate. Measurements 0.8 x 0.5 x 0.1 under stage it documents, Unstageable slough and or eschar. R3's pressure injury care plan documents new interventions put in place as of 1/30/25 which included: Prevalon boots on while in bed, every shift; air mattress, Prevalon boots, repositioning, and provide treatment as ordered. R3's physician order dated 1/31/25 documents: Change dressing to left heel - once every day, cleanse with normal saline, pat dry, followed by Medi-honey, followed by dressing, change daily and as needed. Surveyor noted that from 1/28/25 to 1/30/25, no documented pressure relieving interventions were put in place. Surveyor noted that from 1/28/25 to 1/30/25, R3 did not receive any treatments to his left upper heel pressure injury. R3's left upper heel pressure injury showed a decline in wound health, as there was an increase in the wound size and a decline in the wound bed of the pressure injury. On 2/10/2025, at 11:56 AM, Surveyor interviewed Registered Nurse (RN)-G regarding pressure injuries. RN-G stated that if there was a new open area discovered, RN-G would measure the area, and call the MD (medical doctor) to update them. RN-G stated the expectations after finding a pressure injury would be to place orders received in the medical record. RN-G informed Surveyor that an update to the next shift would also be expected, as staff would place the concern on the follow up board, so upcoming shifts know to monitor and document on the new concern or condition. On 2/10/2025, at 1:41 PM, Surveyor interviewed Licensed Practical Nurse (LPN) Manager-C who stated that if a new area is discovered on admission, the floor nurse would contact the MD. The floor nurse would be expected to get new orders for treatment. LPN Manager-C stated the facility expects any new orders received to be started and to be documented in the resident's medical record. LPN-C stated the only way LPN Manager-C would know if there is a new pressure injury area is by going back and reviewing progress notes and assessments. LPN Manager-C informed Surveyor that there is nothing in the electronic health record that triggers or notifies LPN Manager-C of new pressure injuries. LPN Manager-C informed Surveyor that LPN Manager-C was the person that was responsible for reviewing residents on the third floor, but that LPN Manager-C does not review residents every day. Surveyor requested R3's wound documentation and was provided with R3's facility skin evaluations. Surveyor was advised that LPN Manager-C is the wound care nurse and was informed that LPN Manager-C is not wound certified and rounds with a wound nurse practitioner (NP) on a weekly basis. Surveyor was informed that the wound NP is the one who completed R3's wound assessments and measurements with LPN Manager-C. On 2/10/2025, at 1:53 PM, Surveyor informed LPN Manager-C of the above findings. Surveyor informed LPN-Manager-C that R3 had no treatment in place or MD update documented that Surveyor could locate in R3's medical record. LPN Manager-C stated no dressing was in place on 1/30/2025 when LPN Manager-C completed wound assessment. LPN Manager-C stated to have looked at R3's physician orders and stated that Prevalon boots were ordered. Surveyor explained to LPN Manager-C that this order wasn't started until after 1/30/2025. Surveyor explained there was a lack of documented updates to to R3's physician and no documented treatment completed from admission until 1/30/25. Surveyor verbalized the concern that during the days of no treatment or interventions there was documented decline to R3's pressure injury. On 2/10/2025, at 2:07 PM, Surveyor interviewed LPN Manager-C whom stated LPN Manager-C was not able to find any documentation that R3's physician was updated or that new treatment orders by RN-I (the nurse that completed initial wound assessment) that documented that R3 received treatment or had interventions in place for R3's left upper heel pressure injury were put in place after R3's pressure injury was discovered upon admission. On 2/10/2025, at 2:37 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked DON-B if three was any additional information regarding concerns that R3's physician was not updated and the noted delay in treatment to R3's left upper heel pressure injury. DON-B stated expectations of nursing staff is to update MD on new areas and to document any new orders received. DON-B stated that DON-B would need to look through R3's medical record and get back to surveyor. On 2/11/2025, at 10:15 AM, Surveyor observed wound care for R3. Surveyor was able to confirm the documentation of R3's left upper heel pressure injury. On 2/11/2025, during the daily exit meeting, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B, of the above findings. NHA-A and DON-B stated that the wound communication to management was being addressed. No additional information was provided as to why R3 did not get care, consistent with professional standards of practice, and the necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing for residents reviewed for pressure injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure one out of two sampled residents (Resident (R)185) reviewed for tube feeding was provided with tube feeding administration in accordance with physician's orders. The facility failed to administer the prescribed formula and failed to ensure medication (pills) were crushed. R185 was hospitalized on [DATE] with a clogged feeding tube. The facility staff administered R185 medications in a pill form that were not sufficiently crushed which clogged the feeding tube. R185 was hospitalized and a surgical procedure was necessary to unclog the feeding tube due to the pill lodged in the tube. Findings include: Review of the facility's Enteral Nutrition (tube feeding) policy dated 01/2024 and provided by the facility revealed, Adequate nutritional support through enteral feeding should be provided to the resident as ordered . The nurse should confirm that there are appropriate orders for oral (PO) intake or restrictions for nothing by mouth (NPO), as appropriate . Review of the undated Profile Face Sheet in the Electronic Medical Record (EMR) under the Profile tab revealed R185 was admitted to the facility on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the digestive tract, cellulitis (a bacterial infection that affects the deep layers of the skin and underlying tissue) of the abdominal wall, dysphagia (impaired swallowing), and with a gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach). Review of the Physician's Orders from 11/04/24 - 11/12/24 in the EMR under the Orders tab revealed orders for: Nothing by mouth initiated on 11/06/24. Osmolite 1.2 tube feeding formula, 75 milliliters (ml) per hour continuous feeding, check for placement and function every shift dated 11/04/24; and May crush appropriate medications dated 11/04/24. Observations and interview revealed R185 was not administered the tube feeding formula ordered by the Physician, Osmolite 1.2, as follows: During an observation on 11/11/24 at 2:56 PM, R185 was lying in bed and was administered Jevity 1.2 tube feeding solution at 75 ml an hour. During an observation on 11/13/24 at 2:30 PM, there was a supply of Jevity 1.2 and Jevity 1.5 tube feeding formula in the kitchen storeroom. There was no Osmolite tube feeding solution in the storeroom. Review of the Manufacturer's website ([NAME] Nutrition), https://www.abbottnutrition.com/our-products/jevity-1_2-cal, Jevity 1.2 tube feeding formula provides 285 calories per 8 fluid ounces (237 mL), with 13.2 grams of protein, 9.3 grams of fat, 40.2 grams of carbohydrates, and 4 grams of dietary fiber per serving; it is considered a high-protein, fiber-fortified formula designed for tube feeding, and contains a full spectrum of vitamins and minerals to meet nutritional needs Review of the Manufacturer's website ([NAME] Nutrition), https://www.abbottnutrition.com/our-products/osmolite-1_2-cal, Osmolite 1.2 tube feeding formula provides feeding formula provides 285 calories per 8 fluid ounces (237 mL), with 13.2 grams of protein, 9.3 grams of fat, 37.5 grams of carbohydrates, and no dietary fiber per serving. The primary difference is the absence of fiber in Osmolite 1.2 versus Jevity 1.2. Review of the Medication Administration Record (MAR) dated November 2024 and provided by the facility documented Osmolite 1.2 was administered, when Jevity 1.2 was administered. During an interview on 11/13/24 at 2:20 PM, the Registered Dietitian (RD) stated she started R185's nutritional assessment on 11/05/24 and completed it on 11/08/24. The RD stated Jevity was the facility's house formula, and the facility did not have Osmolite in stock. The RD stated Jevity had fiber and was generally a better formula. The RD stated she assessed R185's tube feeding regimen of 75 ml/hour of Jevity 1.2 when completing her nutritional assessment. The RD stated this was a new feeding tube for R185 and the Jevity 1.2 formula at 75 ml/hour met his nutritional needs. The RD reviewed the EMR and physician's orders and confirmed the physician's order currently read Osmolite 1.2 was prescribed and not Jevity 1.2. The RD stated the order should have been changed. The RD stated nursing had consulted with her about administering Jevity instead of Osmolite and she told nursing Jevity would be okay. During an interview on 11/12/24 at 3:18 PM, Licensed Practical Nurse (LPN)3 stated R185 had been administered Jevity 1.2 since admission. LPN3 stated the current order called for Osmolite 1.2. LPN3 stated she was not sure if the formulas were comparable. During an interview on 11/13/24 at 10:16 AM, the Director of Nursing (DON) stated R185's tube feeding order called for Osmolite 1.2. The DON verified the order should have been corrected to reflect Jevity 1.2 Review of a nursing Interdisciplinary Note dated 11/11/24 at 9:11 PM, Resident's G-tube was occluded. Writer was unable to administer medication or tube feeding. Multiple attempts were made to unclog but were unsuccessful. Paged on-call provider through (name of medical practice) and spoke with NP (Nurse Practitioner) [name]. Writer was advised to flush with Coca-Cola; if it didn't work, then to send patient to [name] ER [emergency room]. Attempts were unsuccessful. Writer contacted charge nurse [name] and on call manager, [name] to advise that patient was being sent out. [Name] ambulance arrived at approximately 1930 [7:30 PM] and patient was transported to [name] ER. Observations on 11/11/24 - 11/14/24 at 7:45 PM revealed R185 did not return to the facility from the hospital. During an interview on 11/12/24 at 3:18 PM, LPN3 stated she was informed in shift change report on this date that R185's G tube was clogged and he had been sent to the ER. LPN3 stated R185 had resided in the facility for a couple weeks and he came with staples down his abdomen for surgery due to a crimped colon. LPN3 confirmed R185 had been getting a continuous tube feeding regimen of Jevity 1.2 administered via a pump at 75 ml/hour. LPN3 stated she checked for placement and residuals on her shift and administered water flushes as ordered. During an interview on 11/13/24 at 10:16 AM, the DON stated R185's feeding tube was clogged, and he was sent to the ER. She stated there was no additional information regarding R185's status. Review of the hospital Gastroenterology Consult dated 11/12/24 at 7:49 AM revealed, Clogged G-tube etiology to clog not clear .Ct scan of the abdomen recommended to assess the G-tube site . This tube was placed surgically less than a month ago so the tract from the stomach to the wall is possible not quite mature for GI to feel comfortable about changing it at the bedside and even endoscopically (plus that puts him at risk for sedation with a procedure). Given that this was a surgically placed G-tube with sutures in place . we would feel more comfort having surgery . attempting to unclog or replace this G-tube given that it was surgically placed . Review of the hospital General Surgery Consult dated 11/12/24 at 2:18 PM and provided by the facility revealed, Chief Complaint: G tube issue . [R185] . was admitted to [name of hospital] from 09/25/24 to 11/04/24 and during his hospital stay he underwent exploratory laparotomy with lysis of adhesions and gastrostomy tube placement on 10/17/24 with [name of physician] for small bowel obstruction who presents today from [nursing home name] due to malfunctioning G tube . I attempted flushing the tube at the bedside and it did not flush. It appeared there was a blockage in the distal tube. The surgeon proceeded with the exchange of the feeding tube at the bedside. The surgeon documented, Ok to resume tube feeds at this time. Surgery will sign off. Please call for any questions or concerns. Please crush pills completely prior to administering as the tube was blocked by pill within the distal tube. During an interview on 11/14/24 at approximately 3:00 PM, the DON was shown the surgeon's report indicating a pill had not been crushed and that it was the source of the clogged feeding tube. The DON, who just obtained the report from the hospital, stated she had not read the report and was not aware of this. During an interview on 11/14/24 at 06:01 PM, the DON stated R185's pills should have been crushed; there was a physician's order to crush them. The DON stated she had not yet interviewed any of the nurses to find out what happened with the administration of his pills. The DON verified the tube became clogged in the facility; nursing staff passed all R185's medications via his feeding tube, and if a pill was not crushed, the facility was responsible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for residents with non-pressure injuries and changes of condition for 2 (R1 and R46) of 2 residents reviewed. *R1 was admitted with gangrenous fingertips and the areas were not comprehensively assessed or treated on admission. The Nurse Practitioner (NP) applied a band aid to one finger that then became infected when it was not monitored for three days requiring antibiotics. *R46 was sent to the hospital and no documentation was found of an assessment describing the change of condition that occurred requiring hospitalization. Findings: The facility policy and procedure entitled Skin Identification, Evaluation and Monitoring dated 1/2022 states: Upon admission: The Licensed Nursing Associate: A. Complete physical skin evaluation, document findings. If a skin condition is present on admission: 1. Initiate protective dressing; 2. Notify health care provider of findings and for further treatment orders; 3. Notification/Education of resident and resident representative of findings and physician orders; 4. Document evaluation in the medical record. B. Initiate preventative and/or treatment intervention, as indicated. D. Document findings, notifications and interventions. Weekly: A. Complete a General Skin Check to evaluate for changes in skin integrity. B. Document in medical record the finding of general skin check. 1. If wound is present and previously identified: a. Document integumentary findings. i. Appearance of the wound, including measurements; ii. Treatment applied/initiated per health care provider order in the medical record. 2. If new wound is identified: a. Initiate protective dressing; b. Notify health care provider of findings and for further treatment orders. 3. Notification/Education of resident and resident representative of finding and physician orders; 4. Document evaluation in the medical record. C. Update plan of care with each intervention. 1. R1 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, malnutrition, heart disease, diabetes, dysphagia, and gangrene. On the admission Minimum Data Set (MDS) assessment dated [DATE], R1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact. R1's Power of Attorney (POA) was activated while in the hospital. The arterial gangrenous wounds to the fingers were not coded on the MDS assessment. R1 needed extensive assistance with all activities of daily living and received all nutrition through a gastrostomy tube. The hospital Discharge summary dated [DATE] stated the hospital course was complicated by vasopressor-induced ischemia of bilateral fingers. R1 was seen by the wound care and surgical team and R1 refused amputation of fingers at that time. The discharge exam indicated the distal fingertips bilaterally appeared dusky and gangrenous with dry gangrene of the right fourth digit and loss of muscle bulk. The discharge diagnosis stated: Dry gangrene of the fingertips due to vasopressor induced ischemia -patient refused amputation; hand surgery consult if pt (patient) becomes agreeable. On 6/30/2022 on the Skin Evaluation Form, nursing charted the right fingers 1 through 4 had dry gangrene with necrotic tissue on all four fingertips. No measurements or descriptors were documented for any of the fingertips. The treatment documented was open to air. On 6/30/2022 on the Skin Evaluation Form, nursing charted the left fingers 1 through 4 had dry gangrene with necrotic tissue on all four fingertips. No measurements or descriptors were documented for any of the fingertips. The treatment documented was open to air. On 7/1/2022 at 12:17 AM in the progress notes, nursing charted R1 arrived at facility in no apparent distress from the hospital. R1 was oriented to the room and call light. New orders were received. R1 was alert and oriented times three with no complaints of pain and gastrostomy tube was patent. The Nursing Comprehensive admission Observation/Evaluation form was initiated on 7/1/2022 at 12:19 AM. The Skin/Nails section of the form indicated the fingernails were long. A separate Skin Condition Form for all Skin Documentation was to be completed and was documented on the Skin Evaluation Form on 6/30/2022. On 7/1/2022, R1 had a telehealth visit with the Physician Assistant (PA). The PA charted R1's extremities had no edema, clubbing or cyanosis and the skin had no masses, rashes, or lesions on exposed skin. The assessment and plan section of the documentation stated R1 had Gangrene, not elsewhere classified: Dry to fingertips, due to vasopressor induced ischemia. s/p (status post) wound team and surgical consult. Patient refused amputation. Consult hand surgery if patient becomes agreeable. On 7/2/2022 on the Skin Evaluation Form, nursing charted the site to be the Finger left #2 and the description stated, 8 of 10 finger tips have dry gangrene. No measurements or descriptions of the wounds were documented. On 7/2/2022 at 9:13 PM in the progress notes, nursing charted R1's fingers remain with black tips. On 7/5/2022, R1 had a telehealth visit with the PA. The PA charted R1 believes she had bleeding from the fingers last night, however none has been noted by nursing staff overnight or currently. R (1) states she has ongoing pain to the fingers, is made aware that recommendation is to consult with hand surgeon which patient has declined, nursing staff is made aware to f/u (follow up) with local wound cares. The PA charted R1's extremities had no edema, clubbing or cyanosis, but had gangrene to fingertips. The assessment and plan section of the documentation stated R1 had Gangrene, not elsewhere classified: Dry to fingertips, due to vasopressor induced ischemia. s/p (status post) wound team and surgical consult. Patient refused amputation. Consult hand surgery if patient becomes agreeable. Continue local wound cares. On 7/5/2022, an order was entered to monitor for bleeding from gangrenous digits on hands every shift. On 7/6/2022 at 4:05 AM in the progress notes, nursing charted R1's fingers bilaterally remained discolored per usual, and the skin remained intact. On 7/6/2022, R1 had an order to paint the gangrenous tissue to the digits on the right and left hand with betadine daily. On 7/8/2022 on the Skin Evaluation Form, Registered Nurse (RN)-C charted the right fingers had gangrene with 100% eschar and bloody drainage. No measurements of the wounds were documented. The treatment was betadine paint to gangrenous tissue on digit number 1, 2, 3, and 4. On 7/8/2022 on the Skin Evaluation Form, RN-C charted the left fingers had gangrenous tissue on digits with 100% eschar. No measurements of the wounds were documented. The treatment was betadine paint to gangrenous tissue on digits 2, 3, 4, and 5. On 7/9/2022 at 9:11 PM in the progress notes, nursing charted: digit number 3 right hand. band aide is stuck to the eschar. An SBAR (Situation, Background, Assessment, Recommendation) was completed at that time. The nursing notes on the SBAR stated the resident reported that a band aid was placed on the finger 2-3 days ago and was hurting. The band aid was stuck and attached to the eschar. The current treatment was betadine to fingers. The digit number 3 is open, pink skin with white area, black eschar on the top side. R1 complained of pain and acetaminophen was given. The supervisor was notified for assist in examining and the director of nursing was notified and was contacting the wound care nurse. New orders were received for iodosorb, adaptic, and a 4x4 gauze to the digit. On 7/9/2022 at 10:38 PM on the Skin Evaluation Form, nursing charted the right finger #3 had eschar peeling off and was open and red with swelling. No measurements were documented. The treatment to the area was iodosorb, adaptic, and a 4x4. On 7/9/2022 at 11:00 PM on the Skin Evaluation Form, DON-B initially charted the right finger #2 was the location of the wound, but then amended the area and charted the right finger #3 had eschar lifting off of the finger that was dry gangrene. The wound measured 2 cm x 3 cm x 0.2 cm with eschar surrounding the wound. The wound had a moderate amount of purulent yellow foul-smelling drainage. The wound base was not described. The treatment order to the area was to cleanse with wound spray, pat dry, apply iodosorb and oil emulsion, cover with 4x4 and secure with tape daily and as needed. The treatment order in the Treatment Administration Record on 7/9/2022 stated Left second finger cleanse with wound spray, pat dry, and apply iodosorb and oil emulsion, cover with a 4x4 and secure with tape daily and as needed. Surveyor noted the finger that had the open area was the right middle finger. On 7/10/2022, R1 had an order for Doxycycline 100 mg every 12 hours for 10 days for finger infection. On 7/10/2022 at 1:12 AM in the progress notes, nursing charted no weeping was observed from the right hand third finger. On 7/10/2022 at 1:01 PM in the progress notes, nursing charted no bleeding was noted to digits. On 7/10/2022 at 5:55 PM in the progress notes, nursing charted betadine was applied to bilateral fingers and the treatment was done to digit #3. On 7/11/2022, R1 had an in-person visit with the PA. The PA documented R1 was seen in the room resting in bed comfortably. The PA had been updated by the wound NP and DON that concern had been raised regarding infection to a finger and had been started on oral antibiotics for management. The PA charted R1's extremities had no edema, clubbing or cyanosis; gangrene to fingertips, the right middle finger dressing was clean, dry, and intact. The Assessment and Plan section stated: Gangrene, not elsewhere classified: Dry to fingertips, due to vasopressor induced ischemia. s/p (status post) wound team and surgical consult. Patient refused amputation. Consult Hand surgery if agreeable - family & patient are still discussing per recent care conference. Continue local wound cares; wound NP follows at facility. On 7/11/2022 at 5:36 PM in the progress notes, nursing charted betadine was applied to bilateral fingers and the treatment was done to digit #3. On 7/12/2022 at 10:12 AM, Surveyor asked R1 if R1 had any pain. R1 stated she had pain to her fingers. R1 held up both hands. Surveyor observed blackened eschar to the right second (pointer) finger, the right fourth (ring) finger, the left second (pointer) finger, the left fourth (ring) finger, and the left fifth (pinky) finger. The right third (middle) finger had a 4x4 gauze wrapped around it and the finger could not be visualized. On 7/12/2022 at 10:52 PM in the progress notes, nursing charted: bilateral fingers and dressing to the right completed and tolerated well. On 7/13/2022 on the Skin Evaluation Form, RN-C documented the fingers on the right hand had 100% eschar with bloody drainage. The documentation did not indicate how many fingers were bleeding or where they were bleeding from. The wounds were not measured or described. The treatment was betadine paint to the gangrenous tissue on digit numbers 1, 2, 3, and 4. On 7/13/2022 on the Skin Evaluation Form, RN-C documented the fingers on the left hand had 100% eschar. The treatment was betadine paint to the gangrenous tissue on digit numbers 2, 3, 4, and 5. The wounds were not measured. On 7/14/2022 at 12:36 PM in the progress notes, nursing charted R1 was seen by writer and wound care NP for gangrene to digits of bilateral hands. Continue current treatment orders at this time. On 7/14/2022 on the Skin Evaluation Form, RN-C documented the right finger #3 had eschar lifting off of the finger with dry gangrene. The area measured 2 cm x 3 cm with no depth and purulent yellow foul-smelling drainage. The wound where the eschar had lifted was not described. At the daily exit with the facility on 7/14/2022 at 3:01 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B R1 did not have a comprehensive assessment of the fingers that had gangrene, with no measurements of any of the areas until the right third finger had eschar pulled off when removing a band aid. Surveyor asked DON-B where the band aid come from and who put a band aid on R1's finger. DON-B thought R1's daughter put the band aid on but was not completely sure. DON-B stated R1 was told the fingers could not get wet. Surveyor requested NP-D's wound care notes. On 7/18/2022, Surveyor was given a copy of NP-D's wound care note dated 7/6/2022. On 7/6/2022, R1 had an initial wound visit by the wound NP. NP-D charted R1 developed vasopressor induced ischemia of fingers, refused amputation. Today patient is seen lying in bed, she asks what time it is repeatedly. She has some awareness of the condition of her fingers will need amputation, but pending her agreement. We will keep her as comfortable as able, and steer off infection as best as able. The Physical Exam section of the notes stated: left hand digits 1-2-3-4 -dry gangrene, paint with Betadine daily. Right hand digit #3, ring finger, open area, will cover with Band-Aid at this point, observe daily. Left hand (sic) digits 2-3-4-5 -dry gangrene, paint with Betadine daily. Hand-written on the printed copy of the Wound Care Assessment form provided to Surveyor was a statement indicating the second finger, not the ring finger, had the open area. No measurements of the affected fingertips were documented. On 7/18/2022 at 8:43 AM, Surveyor went to see R1 to get a better assessment of which fingers had gangrene. The documentation of the gangrenous areas was not easily understood or comprehensive. Surveyor made the following observations of R1's fingers: RIGHT HAND: -Second (pointer) finger had eschar from the tip of the finger measuring approximately 2.5 cm on the palm side of the finger. -Third (middle) finger had eschar from the tip of the finger to the first knuckle and an open area on the inner aspect below the first knuckle measuring approximately 3 cm x 2 cm. The wound did not look infected. -Fourth (ring) finger had eschar from the tip of the finger to the first knuckle all the way around the finger including the fingernail. LEFT HAND: -Second (pointer) finger had eschar from the tip of the finger to the first knuckle all the way around the finger including the fingernail. -Fourth (ring) finger had eschar from the tip of the finger measuring approximately 1 cm on the palm side of the finger and below the nail on the outer aspect of the finger. -Fifth (pinky) finger had eschar from the tip of the finger measuring approximately 1 cm on the palm side of the finger and a small amount of the fingernail. Surveyor noted the right first (thumb) finger, the right fifth (pinky) finger, the left first (thumb) finger, and the left third (middle) finger did not have any eschar. In an interview on 7/18/2022 at 9:47 AM, Surveyor asked RN-C what the expectation for wound charting was, such as how often and what should be documented. RN-C stated at the minimum, the floor nurses should document any treatment done and any signs or symptoms of infection or pain with treatment. RN-C stated weekly the wounds should have measurements and a wound description of each area. RN-C stated wound rounds are done weekly by RN-C and NP-D. RN-C stated NP-D does the treatment on rounds and RN-C takes notes. RN-C stated all wounds are looked at weekly except for surgical incisions. Surveyor asked RN-C why there were no measurements for each finger that had gangrene. RN-C stated they had not been measuring R1's wounds due to the extensiveness of it and R1's skin was not the best. RN-C stated he did not know how you would record all the different areas. Surveyor asked RN-C if a resident had a wound to the left knee, the right heel, and the right elbow, would each area be documented individually or would they all be put together in one Skin Assessment. RN-C stated each wound would be charted on individually. Surveyor asked RN-C why each finger would not be considered a separate area. RN-C stated he was not sure, and that he did not know he had to separate them out. RN-C stated he did not know how to chart the individual fingers in the computer charting system. RN-C stated the wounds were circumferential, so he did not know how to document that. Surveyor asked RN-C if RN-C could document the wounds were circumferential, just like RN-C had stated. RN-C said yes. RN-C stated the problem with the computer charting is that when they put the site description in, there is not enough space to put the information; the documentation is really hard to put in. RN-C stated he copied the descriptor from one of the nurses where she put digit #3 and RN-C did not know how she got that to be designated; RN-C stated he was still learning the charting system. Surveyor asked RN-C if RN-C had put the band aid on R1's finger. RN-C stated he thought NP-D had put the band aid on because R1 was trying to use a scissors to cut eschar off. RN-C stated he did not know NP-D had put the band aid on until he saw the NP note last week. (Surveyor had asked for the NP note dated 7/6/2022 on 7/14/2022 and it was provided on 7/18/2022. The NP note was not available prior to Surveyor asking for it.) In an interview on 7/18/2022 at 10:23 AM, Surveyor shared the concern with DON-B R1's gangrenous fingers were not comprehensively assessed on admission and have still not been individually documented on. Surveyor shared with DON-B the difficulty in following the wound documentation with digit numbers and finger names not matching. DON-B stated it was hard for her to follow the documentation as well. DON-B stated the nurses got confused as to what to call the fingers, like is it one thumb and four fingers? Surveyor asked DON-B why the fingers were not documented on individually. DON-B stated, I don't know. DON-B stated she looked at R1's fingers with the floor nurse when R1 was admitted but did not document anything at that time. DON-B stated the nurses are having a hard time with the computer program and RN-C does not know the program. DON-B stated Licensed Practical Nurses (LPNs) know not to stage things, but they have too many people putting notes in different places when it comes to skin. Surveyor shared with DON-B the observations made by Surveyor of R1's fingers with the description of each finger with approximate measurements. Surveyor shared the concern with DON-B that the documentation was very vague as to what fingers were affected by the gangrene and did not match the observations made by Surveyor of what fingers were affected and how many fingers were affected. DON-B stated the documentation of the assessments of the fingers was messy. In an interview on 7/18/2022 at 2:17 PM, NP-D stated on 7/6/2022, NP-D saw R1 had gangrenous fingers and did not want amputation so NP-D wanted to protect those fingers as best she could. NP-D stated R1 wanted to get scissors to cut off the black tissue. NP-D stated R1 was using the hand for writing so NP-D put a band aid on the ring finger to protect it because you do not want to lift the eschar off the finger. Surveyor clarified with NP-D which finger NP-D was referring to. NP-D held up the right hand and indicated the middle finger. NP-D stated NP-D does not wear rings so was not sure which finger was the ring finger. NP-D stated a little bit of the eschar lifted off the right middle finger and could see some viable tissue underneath and was hoping to save the fingers. NP-D stated R1 was getting betadine to eight digits on 7/6/2022 and when there was the change of condition on the right middle finger, NP-D made sure the treatment was different for that finger. NP-D stated gangrene stays pretty stable; if the finger became redder than what it was or if it started to open even more, that would be an emergent situation. NP-D stated you cannot measure the areas; you have to wait to have the gangrene dry up on its own and then take the scab off. NP-D stated betadine is used to dry it out. NP-D stated if there was an open ulcer, then they would measure it. Surveyor asked NP-D if an order was put in to change the band aid to prevent infection. NP-D stated she would assume someone would have noticed the band aid and changed it, but NP-D did not think the band aid caused the infection. Surveyor asked NP-D if NP-D had told anyone NP-D had put a band aid on R1's right middle finger. NP-D stated she felt someone would have seen it and changed the band aid. DON-B had been present for the interview with NP-D on 7/18/2022 at 2:17 PM. After NP-D left the interview, Surveyor asked DON-B if the band aid applied to R1's right middle finger should have had an order to change the band aid or remove the band aid on a specific date. DON-B stated no one knew NP-D had put a band aid on R1's finger and would not have known to remove it or change it. DON-B stated it was not until R1 complained of pain to the finger that the band aid was removed. Surveyor shared the concern with DON-B that R1's finger became infected after the band aid was applied and the area underneath was not monitored for three days. DON-B agreed the band aid should not have been applied with no follow up or knowledge by the rest of the staff. DON-B stated she totally understood Surveyor's concern. No further information was provided at that time. 2. The Facility Policy and Procedure Guidelines for Charting and Documentation last approved 01/2022 (which was the only policy the facility provided to Surveyor related to assessments) documented (in part) . .Purpose: The purpose of charting and documentation is to provide: A. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc (etcetera) and the progress of the resident's care. B. Nursing service personnel with a record of the physical and mental status of the resident. Nursing Summaries and/or Assessments: When charting nursing summaries or making assessments, include (as they may apply) the following information: P. Unusual Occurrence/Significant Events: Describe the condition(s). Indicate whether the condition(s) improved or worsened. Q. Vital signs: Indicate whether or not the resident's vital signs were fluctuating, elevated, or stable. R46 was admitted to the facility on [DATE] and had diagnoses that included Metastatic Breast Cancer, Coronary Artery Disease, Anxiety Disorder, Chronic Kidney Disease stage 3 and Hypertension. R46's Quarterly Minimum Data Set (MDS) with an Annual Reference Date of 3/25/22 documented a Brief Interview for Mental Status score of 15, indicating R46 to be cognitively intact. Facility progress notes dated 5/12/22 at 2:21 PM documented: Resident is c/o (complaining of) SOB (shortness of breath), N/V (nausea and vomiting) and diarrhea. NP (Nurse Practitioner) aware. (named hospital) is hospital of choice, they have been called and given report. Surveyor noted there was no evidence or documentation a comprehensive assessment of R46 was completed to include a respiratory assessment, lung or cardiac assessment, bowel assessment or vital signs related to R46's complaints. There was no SBAR (Situation, Background, Assessment, Recommendation) completed. Facility progress notes dated 5/12/22 at 2:32 PM documented: Resident has been visibly unsatisfied and upset with the building not having air condition working. Building is very hot and unbearable for resident. Resident was non compliant with medications except for Oxycontin and cancer medication. Resident refused all other medications. Resident felt very dizzy, overheated and thought she might have a heart attack. Staff at (facility) called ambulance per request from resident to be sent to (named hospital). Resident was sent out via ambulance at 2:10 PM. The nurse that entered the above progress note was an agency nurse and was not available for interview. Surveyor noted there was no evidence or documentation of an assessment of R46 to include a respiratory assessment, lung or cardiac assessment, bowel assessment or vital signs related to R46's complaints. There was no SBAR (Situation, Background, Assessment, Recommendation) completed. Facility progress notes dated 5/13/22 at 7:40 AM documented: Resident was aware that an ambulance had been called to take her to (named hospital) per her request. Resident became behavioral because she didn't want to wait, so she called 911 on her own. The police and ambulance arrived at the same time as the ambulance that had originally been called for transport. The nurse that entered the above note was on vacation, thus was not available for interview. Facility progress notes dated 5/13/22 documented: Spoke with RN (Registered Nurse) at (hospital). (R46) had a Cardiac work up which was negative. They are still running other tests and currently expect her to be there two more nights. Facility progress notes dated 5/16/22 documented: Spoke with RN at hospital. (R46) will be having more scans and a bone biopsy completed today. They are working on transferring her off the cardiac floor and to the oncology floor. CXR (chest X-ray) and nuclear medicine scan showed pulmonary nodules and metastasis to the spine. Cardiology has signed off. They expect her to be there at least 2 days yet. Facility progress notes dated 5/20/22 documented: Spoke with RN at hospital. (R46) has been moved to the oncology floor. Biopsy of the iliac crest was positive. Had US (ultrasound) of gallbladder, liver and pancreas today, no results as of yet. Testing and treatment is ongoing. SW (Social Worker) is involved. No planned discharge date at this time. R46 re-admitted to the facility on [DATE]. The Hospital Discharge Summary documented (in part) . .Presented on 5/12/22 with c/o (complaints of) chest/abdominal pain. ED (Emergency Department) EKG (Electrocardiogram) and troponin negative. CT (Computed Tomography) abdomen and pelvis found to show extensive sclerotic foci t/o (throughout) visualized skeleton, liver lesions concerning for metastatic disease. Metastatic carcinoma consistent with primary breast cancer with metastasis iliac crest and liver. Due to advanced age, multiple comorbidities, oncology did not feel patient was good candidate for chemotherapy. Followed by palliative medicine but not ready to transition to hospice at this time. On 7/14/22 at 9:39 AM Surveyor spoke with Director of Nursing (DON)-B regarding R46's discharge to the hospital on 5/12/22. DON-B stated: I was there the day she went out and was involved. She was insisting she wanted to go out, unfortunately she had done this several times before, and the hospital would send her back with no findings. That day, before she went out, she was not in any distress, she was sitting at the reception eating and drinking. Surveyor advised DON-B the facility progress notes documented R46 complained of SOB, N/V, diarrhea, and there was no evidence an assessment was completed on R46. DON-B stated: There should be an SBAR. DON-B reviewed R46's medical record and was unable to locate an SBAR. Surveyor advised DON-B of facility documentation indicating R46 reported feeling dizzy, lightheaded and though she might have a heart attack. Surveyor asked DON-B if she would you expect the nurse to do an assessment. DON-B stated: Yes. I would expect the nurse to do, and document an assessment. I was not aware of the statement she thought she might have a heart attack. She (R46) may have been exaggerating because she was upset about the heat. But I can tell you, she was not in any distress. I spoke to her several times that day and saw her in the cooling area. Before she was sent out, she was sitting at the reception desk eating and drinking, and was not in any distress. Surveyor advised DON-B of concern an assessment was not completed on R46 based on the residents' voiced complaints. DON-B stated: I understand what you're saying. The bottom line is yes, I expect an assessment to have been done. On 7/14/22 at 2:17 PM Surveyor advised DON-B of concern the facility did not complete an assessment on R46 prior to hospitalization. No additional information was provided.