**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 44's admission Record, the admission Record indicated Resident 44's admitting diagnoses included epilepsy (a chronic brain disorder that causes seizures [episodes of abnormal electrical activity in the brain]). During a review of Resident 44's active physician orders, dated 10/2/2024, the orders indicated staff were to apply padded siderails to prevent injury related to diagnosis of epilepsy. During a review of Resident 44's care plan titled Has a seizure disorder, dated 4/10/2024, the care plan indicated Resident 44 was to have padded siderails on both sides of his bed to prevent injury. During an observation on 12/2/2024 at 10:00 a.m., at Resident 44's bedside, observed Resident 44 bed with quarter-length siderails on both sides. The siderails were not padded. During an observation on 12/2/2024 at 8:47 a.m., at Resident 44's bedside, observed Resident 44's bed with quarter-length siderails on both sides. The siderails were not padded. During a concurrent observation and interview, on 12/3/2024 at 2:53 p.m., at Resident 44's bedside, with Certified Nursing Assistant (CNA) 2, Resident 44's bed was observed. CNA 2 stated she did not know Resident 44 was at risk for seizures or had a history of seizures. CNA 2 stated Resident 44 did not have padded siderails. CNA 2 stated the purpose of padded siderails was to protect Resident 44 from injury. During a concurrent interview and record review, on 12/3/2024 at 2:57 p.m., with RN 1, Resident 44's physician orders were reviewed. RN 1 stated Resident 44 was supposed to have padded siderails. RN 1 stated Resident 44 did not have padded siderails, and stated the purpose of the siderails was to prevent injury. RN 1 stated the absence of padding on the siderails increased the potential for Resident 44 to sustain injury if he had a seizure. 4. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to facility on 5/2/2024 and re-admitted on [DATE] with diagnoses of diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN, high blood pressure), history of falling, and seizure. During a review of Resident 6's H&P, dated 5/3/2024, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision making was mildly impaired. The MDS indicated Resident 6 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completed activity) with oral hygiene and upper body dressing; moderate assistance (helper did less than half the effort) for toileting hygiene, lower body dressing, and personal hygiene, and substantial/maximal assistance (helper did more than half the effort) for showering /bathing and putting on/ taking off footwear. During a review of Resident 6's Order Summary Report, dated 11/5/2024, the report indicated an order, dated 7/5/2024, to apply padded side rails while in bed to prevent injury related to diagnosis of seizure. During a review of Resident 6's care plan titled The resident has a seizure disorder, revised 5/23/2024, the care plan indicated the goal was for Resident 6 to be free from injury from seizure activity. The care plan indicated staff's interventions included to apply padded side rails while in bed to prevent injury. During an observation on 12/2/2024 at 10:14 a.m., in Resident 6's room, observed Resident 6 lying on the bed with no padded side rails. During an observation on 12/3/2024 at 3:09 p.m., in Resident 6's room, observed Resident 6 lying on the bed with no padded side rails. During a concurrent observation and interview on 12/3/2024 at 3:24 p.m. with Licensed Vocational Nurse (LVN) 3, in Resident 6's room, observed Resident 6 s lying on the bed with no padded side rails. LVN 3 stated Resident 6 should have padded side rails. 5. During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was originally admitted to facility on 7/13/2024 and re-admitted on [DATE] with diagnoses of DM, HTN, epilepsy, and dementia (a progressive state of decline in mental abilities). During a review of Resident 35's H&P, dated 10/3/2024, the H&P indicated Resident 35 did not have the capacity to understand and make decisions. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35's cognitive skills for daily decision making was intact. The MDS indicated Resident 35 required substantial/maximal assistance with upper body dressing; and was dependent with eating, oral hygiene, toileting hygiene, showering /bathing self, lower body dressing, putting on/ taking off footwear, and personal hygiene. The MDS indicated Resident 35 required substantial/maximal assistance to roll left and right; and was dependent to sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, and tub/ shower transfers. The MDS indicated Resident 35 had impairment on the upper extremity (arm) and used a wheelchair for mobility. During a review of Resident 35's Order Summary Report, dated 10/5/2024, the report indicated an order, dated 10/1/2024, to apply padded side rails while in bed to prevent injury related to seizure. During a review of Resident 35's care plan titled The resident has a seizure disorder, revised 10/25/2024, the care plan indicated the goal was for Resident 35 to be free from injury related to seizure activity. The care plan indicated staff's intervention was to apply padded side rails. During an observation on 12/2/2024 at 11:38 a.m., in Resident 35's room, observed Resident 35 lying on the bed with no padded side rails. During an observation on 12/2/2024 at 3:04 p.m., in Resident 35's room, observed Resident 35 lying on the bed with no padded side rails. During an observation on 12/3/2024 at 8:50 a.m., in Resident 35's room, observed Resident 35 lying on the bed with no padded side rails. During a concurrent observation and interview on 12/3/2024 at 2:41 p.m. with LVN 3, in Resident 35's room, observed Resident 35 lying on the bed with no padded side rails. LVN 3 stated Resident 35 should have padded side rails to prevent head injury from seizure activities. LVN 3 stated the charge nurse was responsible for ensuring the presence of padded side rails. During a review of the facility's P&P titled Safety and Supervision of Residents, revised on 7/2017, the P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated to implement interventions to reduce accident risks and hazards shall include ensuring interventions were implemented. The P&P indicated staff shall ensure that interventions were implemented correctly and consistently to monitor the effectiveness of interventions. Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 17 and Resident 44) were free from avoidable accidents and accident hazards when the facility: 1. Did not conduct an Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) assessment following Resident 17's fall on 6/14/2024. 2. Did not develop or implement person-centered interventions to prevent Resident 17 from having repeated falls on 6/21/2024 and 8/3/2024. 3. Did not conduct an IDT in a timely manner, after Resident 44 fell on 5/19/2024, to prevent further falls. 4. Did not develop new, person-centered, fall prevention interventions following Resident 44's fall on 5/19/2024 and subsequent falls on 8/22/2024 and 9/14/2024. 5. Failed to conduct an accurate IDT assessment on 6/24/2024 and provide individualized recommendations to prevent Resident 44 from further falls. 6. Failed to provide padded siderails for Resident 44, Resident 6, and Resident 35 as ordered by the physician. These deficient practices resulted in Resident 17 having two falls on 6/21/2024 and 8/3/2024. On 8/3/2024, Resident 17 sustained a laceration (a cut, tear, or opening in the skin) to the back of her head, a right parietal scalp hematoma (a collection of blood between the skin and skull bone on the side of the head), and fractures (broken bones) to the sacral (area near the low back and upper buttocks) and lumbar (lower back) regions, which led to a hospitalization at a general acute care hospital (GACH) for evaluation and treatment. This deficient practice also resulted in Resident 44 falling on 8/22/2024, where he sustained a forehead abrasion (a partial thickness wound caused by damage to the skin). Resident 44 fell a third time on 9/14/2024 (within 23 days from the previous fall) and complained of moderate pain (pain that can't be ignored for more than a few minutes but can be managed with effort) to his head. This deficient practice also placed Residents 44, 6, and 35 at risk for injuries. Findings: 1. During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 17's admitting diagnoses included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), dementia (a progressive state of decline in mental abilities), history of falling, lack of coordination, and abnormalities of gait (manner of walking) and mobility. During a review of Resident 17's History and Physical (H&P), dated 8/11/2024, the H&P indicated Resident 17 did not have the capacity to understand and make decisions. During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 10/29/2024, the MDS indicated Resident 17 had severe cognitive impairment (problems with the ability to think, learn, remember, and make decisions). The MDS indicated Resident 17 required partial to moderate assistance from staff to transition from a sitting to standing position, transferring from bed to chair or chair to bed, and to transfer on and off the toilet. The MDS indicated Resident 17 required partial to moderate assistance to walk 150 feet once standing. During a review of Resident 17's Fall Risk Evaluation, dated 1/30/2024, the assessment indicated Resident 17's score was 11 (a score of 11 or higher indicated a risk for falls). During a review of Resident 17's care plan titled At risk for fall related to history of fall, weakness, dementia, osteoarthritis, osteoporosis, created 2/15/2024, the care plan indicated staff were to encourage Resident 17 to call for assistance. During a review of Resident 17's Change of Condition (COC) assessment, dated 6/14/2024, the COC assessment indicated on 6/14/2024 Resident 17 was found on the floor in her room. The COC assessment indicated Resident 17 told staff she fell. The COC assessment indicated Resident 17 reported a pain score of 7 (scale of 1 to 10, with 10 being excruciating pain) to the right side of her head. The COC assessment indicated Resident 17 was transferred to the GACH following the fall. During a review of Resident 17's Fall Risk Evaluation, dated 6/17/2024, the evaluation indicated Resident 17's score was 13. During a review of Resident 17's COC assessment, dated 6/21/2024, the COC assessment indicated Resident 17 had a history of fall on 6/14/2024, and 6/21/2024 with minor injury (injury unspecified). The COC assessment did not indicate any new fall interventions. During a review of Resident 17's IDT Assessment, dated 7/29/2024, the IDT assessment indicated Resident 17 had a fall on 6/14/2024 requiring hospitalization, and another fall on 6/21/2024. The IDT assessment indicated Resident 17's medical diagnoses caused her to experience confusion and forgetfulness. The IDT assessment indicated the recommendations indicated staff would continue to educate Resident 17 to use her call light for assistance and to sit up slowly before walking. During a review of Resident 17's Fall Risk Evaluation, dated 7/30/2024, the evaluation indicated Resident 17's score was 13. During a review of Resident 17's COC assessment, dated 8/3/2024, the COC assessment indicated on 8/3/2024, Resident 17 was found on the floor, with a bleeding wound on the top of her head. The COC assessment indicated Resident 17 complained of moderate pain to her head and back. The COC assessment indicated Resident 17 was transferred to GACH 1 via emergency services. During a review of Resident 17's GACH 1 record titled Emergency Department Note, dated 8/3/2024, the record indicated Resident 17 was brought to GACH 1 by ambulance after she fell on the back of her head. The record indicated Resident 17 had a 0.5 inch laceration to the back of her head and complaints of pain to her head and lower back. During a review of Resident 17's GACH 1 computed tomography (CT) scan (a medical imaging procedure that uses X-rays and a computer to create detailed pictures of the inside of the body) report of her chest, abdomen, and pelvis, dated 8/3/2024, the report indicated Resident 17 had a compression fracture (a break in a bone that occurs when pressure causes the bone to collapse) at lumbar spine 1 (L1, the first bone of the spine in the lumbar region of the back), and broken bones to the resident's sacral region on both sides of the body. During a review of Resident 17's GACH 1 CT scan report of the head and brain, dated 8/3/2024, the report indicated Resident 17 had a moderate right parietal scalp hematoma (a collection of blood between the skin and skull bone on the side of the head). During a review of Resident 17's GACH 1 Discharge Summary Brief, dated 8/13/2024, the note indicated Resident 17 had diagnoses of bilateral (both sides of the body) sacral fractures and L1 compression fracture. The note indicated Resident 17's fractures were determined inoperable and the resident was recommended for higher level of care. During a concurrent interview and record review, on 12/3/2024 at 2:57 p.m., with Registered Nurse (RN) 1, Resident 17's COC assessments dated 6/14/2024, 6/21/2024, and 8/3/2024, and care plan titled At risk for fall related to history of fall, weakness, dementia, osteoarthritis, osteoporosis, dated 2/15/2024, were reviewed. RN 1 stated the COC assessments indicated Resident 17 had three falls after the initiation of her fall risk care plan on 2/15/2024. RN 1 stated the care plan and COC assessments did not indicate that new, resident-centered interventions to prevent further falls had been developed or implemented after Resident 17's falls on 6/14/2024 and 6/21/2024. RN 1 stated Resident 17 was confused and forgetful. RN 1 stated Resident 17 could have benefited from the implementation of staff supervision. RN 1 stated the implementation of resident-specific interventions could have prevented Resident 17 from falling and sustaining injuries on 8/3/2024. During a concurrent interview and record review on 12/4/2024 at 3:24 p.m., with the Director of Nursing (DON), Resident 17's IDT assessments dated 7/29/2024 and 10/28/2024 were reviewed. The DON stated the IDT assessment dated [DATE] indicated a fall prevention intervention of educating the resident to call for help and to sit up slowly before walking. The DON stated the IDT assessment should have been completed at the time of Resident 17's falls on 6/14/2024 and 6/21/2024. The DON stated the fall prevention intervention was not appropriate for Resident 17 because the resident was confused and forgetful. The DON stated it was not reasonable to expect Resident 17 to remember or follow staff's instructions. The DON stated the IDT should have implemented different, and/or additional, resident-specific fall prevention interventions after Resident 17's falls on 6/14/2024 and 6/21/2024. The DON stated the failure to implement new, resident-specific fall prevention measures placed Resident 17 at risk for repeated falls and injuries. 2. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 44's admitting diagnoses included history of falling and anxiety disorder (a condition that causes excessive fear, worry, and feelings of dread or uneasiness). During a review of Resident 44's H&P, dated 3/25/2024, the H&P indicated Resident 44 did not have the capacity to understand and make decisions. During a review of Resident 44's MDS, dated [DATE], the MDS indicated Resident 44 had severe cognitive impairment, and inattention and disorganized thinking. The MDS indicated Resident 44 required substantial to maximal assistance from staff to transition from a sitting to standing position, transferring from bed to chair or chair to bed, and to transfer on and off the toilet. During a review of Resident 44's Fall Risk Evaluation, dated 3/21/2024, the evaluation indicated Resident 44's score was 14. During a review of Resident 44's care plan titled High risk for falls, initiated 3/26/2024, indicated a care goal that Resident 44 would not sustain serious injury. Staff interventions indicated to follow the facility fall protocol, review information on past falls, attempt to determine the cause of falls, and alter or remove potential causes of falls. During a review of Resident 44's COC assessment, dated 5/19/2024, the COC assessment indicated on 5/19/2024, Resident 44 had a fall. The COC did not indicate any new documented fall interventions. During a review of Resident 44's IDT Assessment, dated 6/24/2024, the IDT assessment indicated staff were required to indicate if Resident 44 had any safety issues or risks, including a history of falls in the previous 180 days. The IDT assessment did not indicate Resident 44's history of a fall on 5/19/2024. The IDT assessment did not indicate the cause of Resident 44's fall on 5/19/2024, or if staff altered or removed potential causes of falls, as indicated on Resident 44's care plan. During a review of Resident 44's Fall Risk Evaluation, dated 6/26/2024, the evaluation indicated Resident 44's score was 13. During a review of Resident 44's COC assessment, dated 8/22/2024, the COC assessment indicated on 8/22/2024, Resident 44 was found with his face down on the floor. The COC assessment indicated Resident 44 reported he fell from his bed. The COC assessment indicated Resident 44 sustained a forehead wound measuring 3.8 centimeters (cm, measurement of length) by 3.8 cm, with surrounding redness to the skin. The COC assessment did not indicate any new documented fall interventions. During a review of Resident 44's COC assessment, dated 9/14/2024, the COC assessment indicated on 9/14/2024, Resident 44 was found with his face down on the floor. The COC assessment indicated Resident 44 reported he fell from his bed. The COC assessment indicated Resident 44 complained of moderate pain to his head. The COC assessment did not indicate any new documented fall interventions. During a concurrent interview and record review, on 12/3/2024 at 2:57 p.m., with RN 1, Resident 44's COC assessments dated 5/19/2024, 8/22/2024, and 9/14/2024, care plan titled High risk for falls, initiated 3/26/2024, and IDT assessment, dated 6/24/24, were reviewed. RN 1 stated the COC assessments indicated Resident 44 had three falls following the initiation of his fall risk care plan on 3/26/2024. RN 1 stated the care plan did not indicate new fall prevention interventions were created after Resident 44 fell on 5/19/2024. RN 1 stated Resident 44's IDT assessment, was inaccurate because it did not address Resident 44's fall from 5/19/2024. RN 1 stated the IDT indicated Resident 44 was at risk for falls. RN 1 stated Resident 44's fall and IDT assessment were two opportunities for the IDT to assess Resident 44 and develop resident-centered interventions to prevent additional falls. RN 1 stated no interventions were developed based on Resident 44's needs. RN 1 stated Resident 44's falls on 8/22/2024 and 9/14/2024 could have been prevented. During a review of the facility's policy and procedure (P&P) titled Fall Risk and Prevention Assessment, updated 3/2018, the P&P indicated facility staff were to assess and identify residents who were at risk for falls and develop appropriate plans of care to prevent resident falls and/or further falls. The P&P indicated residents identified as high risk for falls were supposed to be referred to the IDT for further assessment, proper intervention, and care planning to prevent falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide visual monitoring and prevent accident hazards, as indicated in the resident ' s care plan, for one of seven sampled residents (Resident 1), who had a high risk for fall. This deficient practice resulted in Resident 1 falling, sustaining facial trauma and a right arm fracture (broken bone) which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 1 ' s admission record (face sheet), dated 1/22/2024, the face sheet indicated Resident 1, was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included parkinsonism (a brain condition that causes slow movement, stiffness, and tremors), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and osteoarthritis (a wearing down of the protective tissue at the ends of bones, causing pain and stiffness). During a review of Resident 1 ' s History and Physical (H&P) dated 1/14/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 11/1/2023, the MDS indicated Resident 1 sometimes understood others and was usually understood. The MDS indicated Resident 1 required moderate assistance from staff for activities of daily living (ADL) such as eating, oral hygiene, and personal hygiene. The MDS indicated Resident 1 required maximum assistance from staff for lower body dressing. The MDS indicated Resident 1 was dependent on staff for toileting, and showering. The MDS indicated Resident 1 was dependent on staff for transferring from a chair to a bed, and to the toilet. The MDS indicated Resident 1 required staff ' s assistance in wheeling her wheelchair for 50 feet with two turns and wheeling 150 feet. During a review of Resident 1 ' s fall risk assessment dated [DATE], the fall risk assessment indicated Resident 1 was a high risk for falls. During a review of Resident 1 ' s fall risk evaluation, dated 11/6/2023, the fall risk evaluation indicated Resident 1 was at high risk for falls. During a review of Resident 1 ' s care plan titled, At risk for fall/injury, dated 11/2023, the intervention indicated staff will assist Resident 1 with transfer and ambulation as needed (PRN), and visual monitoring every hour. During a review of Resident 1 ' s care plan titled, The resident has impaired cognitive function, impaired thought process related to dementia, dated 12/10/2023, the care plan intervention indicated staff will supervise Resident 1 as needed. During a review of Resident 1 ' s visual check monitoring sheet dated 8/2022, the monitoring sheet did not indicate Resident 1 was monitored every hour in 2024, as indicated in Resident 1 ' s care plan intervention. During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR) Fall report, dated 1/7/2024, the SBAR indicated on 1/7/2024, Resident 1 was in the hallway outside her room, waiting to be transferred to bed. The SBAR indicated Resident 1 was found on the floor, face down, in front of the wheelchair. The SBAR indicated Resident 1 had a pain level of 6/10 (moderate pain) and swelling to her left elbow and forehead. The SBAR indicated Resident 1 ' s Physician ordered the resident to be transferred to an emergency room (ER) for further evaluation. During an interview with Registered Nurse (RN 1) on 1/22/2024 at 3:30 p.m., RN 1 stated on 1/7/2024, while at the nurses ' station, a Certified Nurse Assistant (CNA) notified him, Resident 1 fell. RN 1 stated it was an unwitnessed fall which occurred after a CNA (name unknown) left Resident 1 on his wheelchair, outside the resident ' s room, unattended. RN 1 stated the CNA should not have left Resident 1 in the hallway and unattended. RN 1 stated the CNA should have notified another staff to monitor Resident 1 for safety. During an interview with Licensed Vocational Nurse (LVN 1) on 1/23/2024 at 2:45 p.m., LVN 1 stated on 1/7/2024, she observed Resident 1 outside her room on her wheelchair when she fell. LVN 1 stated she was not sure who brought Resident 1 back outside her room since the residents had just finished eating lunch. LVN 1 stated Resident 1 was at risk for falls and should not have been left unsupervised. During a concurrent interview and record review with the Director of Nursing (DON) on 1/23/2024 at 3:55 p.m., Resident 1 ' s fall risk assessment was reviewed. The DON stated Resident 1 was at risk for falls. The DON stated Resident 1 ' s interventions included visual checks and monitoring. The DON stated, Resident 1 fell after a CNA left the resident in the wheelchair, unsupervised in the hallway. The DON stated there was no staff monitoring or supervising Resident at the time of the fall. During a phone interview with CNA 1 on 2/1/2024 at 12:19 p.m., CNA 1 stated she saw Resident 1 on the floor face down, when she was walking down the hall. CNA 1 stated there were no other CNAs around when Resident 1 fell because it happened after lunch time. CNA 1 stated CNAs were busy taking residents back to their rooms. CNA 1 stated staff were not supposed to leave any residents in the hallway. During an interview with LVN 1 on 2/1/2024 at 3:42 p.m., LVN 1 stated Resident 1 was in the hallway in front of her room when Resident 1 fell. LVN 1 stated it was hard to see the resident in the hallway if the staff were inside the nurse ' s station. LVN 1 stated if staff could not see Resident 1 in the hallway, the resident was not supervised and could fall. LVN 1 stated Resident 1 ' s fall could have been prevented if the resident was supervised and monitored. During a concurrent interview and record review on 2/1/2024 at 4:11 p.m., with RN 2, Resident 1 ' s fall risk care plan was reviewed. RN 2 stated interventions for the fall risk care plan included visual (seeing) monitoring every hour. RN 2 stated visual monitoring meant making rounds every hour and seeing where the residents were. RN 2 stated the facility had just switched from paper to electronic charting and she was not sure where the visual monitoring for Resident 1 was documented. During a concurrent interview and record review on 2/1/2024 at 4:40 p.m., of Resident 1 ' s Visual Checks Monitoring Sheet dated 8/2022, with the medical records (MR), the MR stated the last visual check monitoring sheet for Resident 1 was from 8/2022 and was unable to find documentation visual monitoring being done every hour on the electronic records. During a phone interview with LVN 1 on 2/2/2024 at 9:35 a.m., LVN 1 stated she saw a CNA push Resident 1 in her wheelchair while she was gathering resident supplies. LVN 1 stated, then she saw Resident 1 sitting in the hallway outside her room but did not see any staff with Resident 1. LVN 1 stated when Resident 1 fell in the hallway, and no one saw Resident 1 fell, no one must have been keeping an eye on Resident 1. LVN 1 stated she did not tell any other staff to keep an eye on Resident 1. LVN 1 stated if anyone was at the nurses ' station, it would have been difficult to see Resident 1. During a review of Resident 1 ' s physician ' s order dated 1/7/2024 at 1:32 p.m., the order indicated to transfer Resident 1 to the GACH ER. During a review of Resident 1 ' s GACH radiology (process of taking pictures to diagnose and treat diseases) report dated 1/7/2024, the report indicated multiple right rib fractures, most likely old, maxillofacial (jaw and face) with soft tissue swelling, left supracondylar (a round part at the end of a bone) fracture and dislocation (separation of bones). During a review of Resident 1 ' s GACH ' s, H &P, dated 1/8/2024, the H &P indicated Resident 1 fell from a wheelchair and sustained a left forehead, periorbital (surrounding the eye), left elbow bruising with deformity (abnormal shape). During a review of Resident 1 ' s GACH Discharge summary, dated [DATE], the discharge summary indicated Resident 1 ' s admitting diagnosis included a fall with facial trauma and bilateral orbital ecchymosis (bruises), left elbow fracture and multiple rib fractures (possibly old findings). The discharge summary indicated Resident 1 had a left shoulder brace in place and due to her age, the resident was not a candidate for surgery because the risks outweighed the benefits. During a review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated the facility ' s priority was to ensure resident safety, supervision, and assistance to prevent accidents. The P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated implementing interventions to reduce accident risks and hazards shall include communicating specific interventions to relevant staff and assigning responsibility for carrying out interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services for four of 24 sampled residents (Resident 70, 9, 49, and 68) by failing to: 1a. Ensure the correct dose of Methadone (a powerful drug used for pain relief and treatment of drug addiction) 50 milligrams ([mg]- a unit of measurement) twice a day was transcribed (copy from one place to another) per physician order. 1b. Follow up on the delivery of the Methadone with the pharmacy on 11/8/2023 when ordered by the Physician. 1c. Ensure accurate and complete documentation of the medications administered on the Electronic Medication Administration Record (EMAR, an electronic record of medications administered to a resident) and the Controlled Drug Administration Record. 1d. Notify the physician that Resident 70 had been receiving the wrong dosage of Methadone 5mg twice a day for six days (9/8/2023-9/13/2023). 2. Ensure Resident 9's diaper change was performed in a timely manner. 3. Ensure Resident 49's antibiotic (medication that treat an infection) treatment was completed and was administered at the time the medication was scheduled. 4. Ensure Resident 68 was fed in a timely manner. These failures resulted in Resident 70 verbalizing symptoms of pain, inability to sleep, and anxiety (a feeling of fear, dread, and uneasiness) as evidenced by reporting a level of eight out of ten (severe) pain on a pain scale throughout his entire body, shortness of breath, and feelings of anger, and had the potential not to meet Resident 9, 49, and 68's physical, mental, psychosocial needs, and resident's well-being. Findings: 1. During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 70 was admitted with diagnoses that included but not limited to fibroblastic disorders (tumors that affect connective tissue of the body), heart failure (condition in which the heart cannot pump enough oxygen-rich blood to meet the body's needs), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems) and anxiety. During a review of Resident 70's Minimum Data Set ([MDS]- a comprehensive resident assessment and care-screening tool), dated 9/14/2023, the MDS indicated Resident 70's cognition (ability to think and reason) was intact and Resident 70 required extensive assistance for bed mobility, transfers, getting dressed, toileting and performing personal hygiene. During a review of Resident 70's Care Plan, titled, At risk for pain or discomfort related to diagnosis of necrotizing fasciitis (aggressive skin and soft tissue infections that cause death of the muscle and tissues of the body), osteomyelitis (inflammation or swelling that occurs in the bone), and polyneuropathy (simultaneous [at the same time] malfunction [not working] of the nerves throughout the body), dated 9/2/2023, and revised on 9/14/2023, the staff's interventions indicated to administer pain medications as ordered, observe for pain and provide comfort. During a review of Resident 70's History and Physical (H&P), dated 10/24/2023, the H&P indicated Resident 70 had a diagnosis of polysubstance abuse (the consumption of one or more illicit substances over a defined period or simultaneously) and on methadone. During a review of Resident 70's Physician's Orders, dated 11/8/2023, the Physician's Orders indicated Resident 70 was to receive Methadone 5mg ([mg]- unit of measurement) twice a day, for a total of 10 mg a day, for chronic pain; Hydrocodone- Acetaminophen (narcotic pain medicine) oral tablet 10-325 mg, every 6 hours, for severe pain; and Hydroxyzine (medication used to help control anxiety and tension caused by nervous and emotional conditions) oral tablet 25 mg by mouth, every six hours, as needed for anxiety manifested by inability to sleep. During a review of the Pharmacy Delivery Receipt, dated 11/14/2023 and timed 12:01 p.m., the Pharmacy Delivery Receipt indicated the facility received 14 tablets of Methadone 5mg. During an interview, on 11/14/2023, at 8:25 a.m., with Resident 70, Resident 70 stated, I feel anxious, and I did not sleep well. They (staff) gave me a pill. It did not work. If I don't have my Methadone, I will feel terrible. Makes me feel angry. During an interview, 11/15/2023, at 7:36 a.m., with Resident 70, Resident 70 stated he was experiencing an eight out of ten (severe) pain, on a pain scale of 1 to 10, all over his body, felt short of breath, could not sleep well, and felt anxious. During an interview on, 11/15/2023, at 9:28 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 70's dose of Methadone was not available on 11/15/2023 and 11/14/2023. During an interview, on 11/15/2023, at 9:55 a.m., with the Pharmacist in Charge (PIC), the PIC stated the last dose of Methadone 5 mg, was delivered 11/14/2023 at 6:22 p.m. and stated was the first dose of the Methadone 5 mg delivered to the facility in November 2023. The PIC stated Resident 70 had previously been on Methadone 50 mg twice a day. The PIC stated 70 tablets of Methadone 10mg was delivered on 10/31/2023 to the facility and there had been no doses taken from the facility's emergency medication kit. During a concurrent interview and record review, on 11/16/2023, at 11:30 a.m., with LVN 1, Resident 70's eMAR, dated, 11/2023, was reviewed. The eMAR indicated the facility had administered Methadone 5 mg twice a day, per physician's order, from 11/9/2023 to 11/13/2023 at 9:00 a.m. and 5 p.m. each day. The eMAR indicated LVN 1 administered the Methadone 5 mg dose on 11/9/2023 at 9:00 a.m. and 11/13/2023 at 9:00 a.m. LVN 1 stated the Methadone 5 mg was unavailable until 11/14/23 at 12:01 p.m. and she had documented the administration of Methadone 5 mg on 11/9/23 at 9:00 a.m. and 11/13/23 at 9:00 a.m. in error. LVN 1 stated she (LVN 1) should have followed up on the reason as to why the Methadone 5 mg dose was not delivered by the pharmacy and unavailable in the facility. LVN 1 stated the lack of follow up led to the unavailability of Methadone 5 mg for six days (11/8/2023- 11/13/2023) and the inaccuracy of the eMAR documentation led to the uncontrolled pain and discomfort for Resident 70 from 11/8/2023 through 11/13/2023. LVN 1 stated this was considered a medication error. During a concurrent interview and record review, on 11/16/2023, at 12:50 p.m., with LVN 2, Resident 70's eMAR, dated 11/10/2023, was reviewed. The eMAR indicated LVN 2 administered the 5 mg dose of Methadone on the morning of 11/10/2023. LVN 2 stated the Methadone dose was not available and she inaccurately documented the administration of Methadone 5 mg. LVN 2 stated she was assigned a lot of residents that day (11/10/2023). LVN 2 stated, if the eMAR was not accurate, and Resident 70 had not received his dose of Methadone, then the resident would be subjected to pain and the resident's quality of care would be affected. During an interview, on 11/16/2023, at 1:51 p.m. with Registered Nurse (RN) 1, RN 1 stated she made a mistake when transcribing the physician order for Methadone on 11/8/2023. RN 1 stated the physician ordered Methadone 50 mg twice a day and RN 1 transcribed the order as Methadone 5 mg twice a day in the eMAR. RN 1 stated RN 1 had another admission within the same hour of Resident 70's admission, felt rushed, and did not check if the eMAR had the correct order. RN 1 stated she did not notice the transcription error until 11/14/2023, six days after Resident 70 had been admitted to the facility on [DATE]. RN 1 stated due to this mistake, Resident 70 had the potential to exhibit symptoms of pain and withdrawal during the six days of the Methadone 5mg order. During a concurrent interview and record review, on 11/16/2023, at 2:54 p.m., with the Director of Nursing (DON), the Controlled Drug Administration Record, dated 11/2023, Resident 70's eMAR, dated 11/2023, and the Nursing Progress Notes, dated 11/2023 were reviewed. The Controlled Drug Administration Record indicated the facility withdrawn from the controlled rug supply 5 tablets of Methadone 10mg, for a total of 50 mg, on 11/8/2023 at 8:41 a.m. and on 11/9/2023 at 4:17 p.m. The Controlled Drug Administration Record indicated there was no preparation documented on 11/8/2023 for the 5 p.m. dose, and on 11/9/2023 for the 9 a.m. dose. There was no documentation indicating the 9 a.m. and 5 p.m. doses were withdrawn from the drug supply on 11/10/2023, 11/11/2023, 11/12/2023, and 11/13/2023 for the 9 a.m. and 5 p.m. doses. The eMAR indicated the following administrations of Methadone 5mg, 1 tablet, to Resident 70 on following dates/times: 11/8/2023, no administration at 9 a.m. 11/8/2023, 1 tablet at 5 p.m. 11/9/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/10/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/11/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/12/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/13/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/14/2023, no administration at 9 a.m. and 5 p.m. The Nursing Progress Notes lacked documentation to explain the reason as to why the Methadone 5 mg was not given on 11/14/2023. The Nursing Progress Notes, dated 11/8/2023, indicated Resident 70 was admitted to the facility around 11:00 a.m. The Nursing Progress Notes, dated 11/8/2023, indicated Resident 70 was admitted to the facility around 11:00 a.m. The eMAR indicated Resident 70 received three doses of Hydrocodone- Acetaminophen oral tablet 10-325 mg on 11/14/2023 at the following times: At 1:10 a.m., for severe pain At 7:43 a.m., for severe pain At 16:46 (4:46 p.m.), for severe pain The eMAR indicated Resident 70 received 1 dose of Hydroxyzine (medication used to help control anxiety and tension caused by nervous and emotional conditions) 25 mg on the following dates/ times: 11/12/2023, 1 tablet at 1:38 a.m. 11/13/2023, 1 tablet at 9:59 p.m. 11/15/2023, 1 tablet at 6 a.m. The DON stated several LVN's (LVN 1, 3, and 5) had possibly administered Methadone 10 mg tablets from Resident 70's previous supply prior to the resident's readmission on [DATE]. The DON stated RN 1 had transcribed Methadone 5 mg twice a day instead of Methadone 50 mg twice a day when Resident 70 was readmitted to the facility on [DATE]. The DON stated the licensed nurses administered the wrong dose of Methadone, the facility failed to provide Resident 70 Methadone 50 mg twice a day as ordered by the physician, and these failures led to significant medication errors for Resident 70. The DON stated, These practices have led to the resident (Resident 70) to exhibit pain, withdrawal, and anxiety as we (DON and facility's staff) have seen today. More training needs to be done for the nurses, the RNs, and some nurses are so new. All of this [these practices] can affect the quality of care for our residents During an interview on 11/16/2023, at 3:13 p.m., with the PIC, the PIC stated the pharmacy had not delivered the dose of Methadone 5 mg because the pharmacy was questioning the dose, made multiple attempts to reach the prescribing physician, and waited until a signature authorization was sent to them. The PIC stated the pharmacy finally received the authorization and proceeded to deliver the dose on 11/14/2023. During an interview on 11/16/2023, at 4:25 p.m., with the PIC, the PIC stated, the pharmacy questioned the medication order and held the medication because the dose was significantly lowered. The PIC stated with a medication like methadone, the dose was usually gradually lowered by the prescriber. The PIC stated that if a resident had been on a high dose of a narcotic for a length of time and had been given a significantly lowered dose of the medication, then that could possibly cause withdrawal symptoms for the resident. The PIC stated, If the resident received subtherapeutic doses of methadone, especially if it was prescribed for chronic pain, then the resident may have endured pain. During an in interview on 11/17/2023, at 11:24 a.m., with Resident 70's Physician's Assistant (PA) 1, PA 1 stated Resident 70 had the potential to experience withdrawal, agitation, night sweats, inability to sleep, and anxiety due to the subtherapeutic (less than the amount needed to be effective) doses of Methadone that was wrongfully prescribed. PA 1 stated he was not made aware that Resident 70 was given a lower dose of Methadone. PA 1 stated he was not made aware Resident 70 was experiencing, pain and anxiety. PA 1 stated Methadone 10 mg a day was a significantly lower dose compared to Resident 70's usual dose of Methadone 100 mg a day. PA 1 stated it was important that he (PA 1) knew about the dosage change and the symptoms Resident 70 had been experiencing so that he could further evaluate the resident. During a review of the facility's P&P titled, Physician Orders (undated), the P&P indicated the facility was to provide care and services to the resident in accordance with physician orders. During a review of the facility's P&P titled, Controlled Substances, dated 4/2019, the P&P indicated the facility was to ensure medication administration included the name, strength, and dose of the medication and the time of administration. During a review of the facility's P&P titled, Documentation Principles (undated), the P&P indicated the facility was to ensure the staff adhered to maintain clinical records in a manner that would comply with licensing and certification governmental agency requirements and professional standards. The P&P indicated clinical entries must be accurate, legible clear and timely (recorded within the required time period). 2. During a review of Resident 9's admission Record, the admission record indicated Resident 9 was originally admitted to the facility on [DATE] with diagnosis that included pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (tailbone) and chronic pain (long standing pain that persists beyond the usual recovery period or occurs along with a chronic health condition). During a review of Resident 9's Care Plan titled, Activity of daily living (ADL, self-care activities performed daily such as bathing, grooming, and dressing), dated 10/11/2023, the care plan indicated the goal was for all ADLs needs to be met. The staff's interventions indicated to provide assistance as needed. During a review of Resident 9's Care Plan titled, Skin Integrity, dated 10/11/2023, the care plan indicated the goal was for Resident 9 not to have skin complications. The staff's interventions to provide incontinent care as needed and to keep the resident's skin clean and dry. During a review of Resident 9's H&P dated 10/12/2023, H&P indicated Resident 9 had the capacity to understand and make decisions. The H&P indicated Resident 9 had a history of hypertension (high blood pressure). During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decision making was intact. The MDS indicated Resident 9 was totally dependent on staff for toileting, hygiene, and shower/bathing. The MDS indicated Resident 9 had a diagnosis of pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid). During a concurrent observation and interview with Resident 9 on 11/14/2023 at 8:27 a.m., in Resident 9's room, Resident 9 stated she put her call light on and told CNA 3 to change her diaper at 7:30 a.m. Resident 9 stated CNA 3 told her she was busy and would return when she (CNA 9) was done. Resident 9 stated it she felt uncomfortable sitting on a soiled diaper for almost an hour. Observed CNA 3 enter resident 9's room at 8:25 a.m., then left and returned with linens. During a concurrent observation and interview with CNA 3, in Resident 9's room, CNA 3 stated she entered Resident 9's room to change the resident's diaper. Observed CNA 3 provide a diaper change to Resident 9. CNA 3 stated she did not change Resident 9's diaper earlier because she was busy with returning food trays and then went on her break. CNA 3 stated the time Resident 9 waited to get her diaper changed was acceptable. CNA 3 stated for a resident with a decubitus ulcer (skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin) on her buttocks, sitting on a soiled diaper for almost one hour could cause further skin problems. Observed CNA 3 provide a wet washcloth to Resident 9 to wipe the resident's face. CNA 3 grabbed the wet washcloth and placed it in a wet basin and used that same washcloth to clean resident's perianal area (genital region). CNA 3 stated she used the same washcloth for Resident 9's face and perianal area because she did not grab more washcloths. CNA 3 stated she should have grabbed more washcloths because using one was not hygienic. CNA 3 stated that using one washcloth could possibly cause an infection in the resident's perianal area. Resident 9 had complaints of pain when was asked to move side to side during the diaper change. CNA 3 did not offer Resident 9 a break or question where the pain was located. CNA 3 stated Resident 9 had something wrong with her hip and that was why the resident was in pain. CNA 3 stated Resident 9 was usually in pain. CNA 3 stated she did not know she had to inform her charge nurse that Resident 9 was in pain. During an interview with the Director of Staff Development (DSD) on 11/15/2023 at 3:41 p.m., the DSD stated that she expects all staff to answer call light and assist the residents right away. The DSD stated a resident should not wait more than 10 to 15 minutes for care. The DSD stated it was unacceptable to have a resident wait for almost one (1) hour to change their diaper. The DSD stated for a resident that waited for almost an hour to get a diaper change, it was negligent and CNA 3 did not meet Resident 18's needs. The DSD stated for a resident that sat on a soiled diaper, it could increase the risk for skin breakdown. The DSD stated CNA 3 should have attended to Resident 18's needs first before taking a break and CNA 3 should have communicated to someone that she was busy and Resident 18 needed a diaper change. During a review of facility's P&P titled, Call Light, dated 4/4/2017, the P&P indicated staff must answer the call light, ask the resident what they need and to attend to resident's needs promptly. 3. During a review of Resident 49's admission Record (Face Sheet), the admission Record indicated Resident 49 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included urinary tract infection (UTI, infection in any part of the urinary system that includes the kidneys and bladder), extended spectrum beta lactamase resistance (ESBL, enzyme that makes bacteria difficult to treat with antibiotics), type 2 diabetes mellitus (high blood sugar), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49's cognition was moderately impaired. The MDS indicated Resident 49 was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. During a review of Resident 49's Order Summary Report, dated 11/8/2023, the Order Summary Report indicated to administer Piperacillin Sod-Tazobactam So Solution Reconstituted (also known as Zosyn, name of antibiotic) 3-0.375 gram (g, unit of measurement) intravenously (IV, into the vein), every 8 hours, at 7 a.m., 3 p.m., and 11 p.m. for UTI and ESBL in the urine for five days until 11/13/2023. During an interview on 11/1/5/2023 at 11:21 a.m., with RN 1, RN 1 stated the RNs were responsible for administering IV antibiotics. RN 1 stated when she administered antibiotics, she looked at the order from the physician and did not look back at the previous shift to see what time the antibiotics were last given. During a concurrent interview and record review on 11/15/2023 at 11:40 a.m., with the IPN, Resident 49's Medication Administration Record (MAR), dated 11/2023, was reviewed. The MAR indicated Resident 49 did not receive Zosyn on 11/9/2023 at 11 p.m., 11/10/2023 at 3 p.m., 11/10/2023 at 11 p.m., and 11/11/2023 at 11 p.m. The MAR indicated the scheduled time and the administered time for the dose of Zosyn were as follows: 1. Scheduled dose on 11/10/2023 at 7 a.m. was administered at 10:24 a.m. 2. Scheduled dose on 11/11/2023 at 7 a.m. was administered at 8:53 a.m. 3. Scheduled dose on 11/12/2023 at 7 a.m. was administered at 11:44 a.m. 4. Scheduled dose on 11/12/2023 at 3 p.m. was administered at 6:22 p.m. The IPN stated Resident 49 did not receive 4 doses of Zosyn. The IPN stated completing the full course of antibiotics was important to ensure the resident would be rid of the initial infection and to prevent the infection from reoccurring and making the resident sick again. The IPN stated if a dose of antibiotics was missed, the physician must be notified to see if an additional dose was to be administered. The IPN stated antibiotics were the most effective when given at the scheduled time. The IPN stated giving the antibiotics too late could cause the medication to not be as effective. The IPN stated administering the medication too close together could result in adverse (harmful) reactions such as an upset stomach or damage to other organs. The IPN stated since Resident 49 did not complete his course of antibiotics, there was the potential the resident still had the infection, and another course of antibiotics would be necessary. The IPN stated Resident 49's infection could become worse, or the infection would become even more resistant to antibiotics. During an interview on 11/15/2023 at 3:07 p.m., with the DON, the DON stated when a resident missed a dose of antibiotics, the nurse was responsible for notifying the physician to see if the physician wanted to extend the course of the antibiotics. The DON stated if the antibiotic course was not completed, there was the potential that the infection did not go away and if the infection were to worsen, the resident could become septic (life-threatening emergency where the body has an extreme response to an infection). During a review of the facility's P&P titled, Physician Orders, undated, the P&P indicated, It shall be this facility's policy to provide care and services to the resident in accordance with physician orders. During a review of the facility's P&P titled, Administering Medications, revised 4/2019, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame . Medications are administered within one hour of their prescribed time, unless otherwise specified. 4. During a review of Resident 68's admission Record, the admission record indicated Resident 68 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included aphasia (language disorder that affects a person's ability to communicate) and dysphagia (difficulty or discomfort in swallowing). During a review of Resident 68's H&P dated 8/12/2023, the H&P indicated Resident 68 did not have the capacity to understand and make decisions due to history of dementia. The H&P indicated Resident 68 had a history of cerebrovascular accident (CVA, a loss of blood flow to part of the brain, which damages brain tissue). During a review of Resident 68's Minimum MDS, dated [DATE], the MDS indicated Resident 68's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 68 sometimes made herself understood and sometimes understood others. The MDS indicated Resident 68 was totally dependent on staff for all ADLs. The MDS indicated Resident 68 required extensive assistance for eating. The MDS indicated Resident 68 had a diagnosis of hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness, and lack of control in one side of the body). During a review of Resident 68's Care Plan titled, Swallowing, dated 8/24/2023, the care plan indicated the goal was for Resident 68 not to have an injury related to aspiration, and Resident 68 would not have choking episodes when eating. The staff's interventions indicated for Resident 68 to be on 1:1 feeding assistance. During a review of Resident 68's Order Summary Report dated 9/23/2023, the order summary report indicated Resident 68's enteral feeding was to start at 6:00 p.m., and to end at 6:00 a.m. The order summary report dated 10/17/2023 indicated Resident 68 required 1:1 feeding assistance. During an observation on 11/14/2023 at 12:45 p.m., in Resident 68's room, observed Resident 68's lunch tray on the bedside table. The food was uncovered, the utensils were clean, and the food was not touched. During an interview with CNA 2 on 11/14/2023 at 1:00 p.m., in the hallway, CNA 2 stated she was assigned to Resident 68 but did not know who was assigned to feed the resident. CNA 2 stated Resident 68 ate a little but needed to be fed by staff. CNA 2 stated she could not feed Resident 68 because she was busy answering call lights and had another resident in the restroom. During an interview with the Director of Staff Development (DSD) on 11/14/2023 at 1:16 p.m., in Resident 68's room, the DSD stated after staff passed out food trays, staff have to return to feed their residents. The DSD stated CNA 3 was supposed to feed Resident 68 but did not know why the resident was not fed. During an interview with CNA 3 on 11/14/2023 at 1:22 p.m., in Resident 68 room, CNA 3 stated she did not feed Resident 68 because she was busy passing out trays and feeding another resident. CNA 3 stated she did not inform anyone she was running behind and did not request for help. CNA 3 stated she had come to Resident 68's room to start feeding the resident now. CNA 3 stated she was not aware Resident 68's food had been uncovered and was sitting on the bedside table for 35 minutes. CNA 3 stated it was her practice to feed Resident 68 when she got a chance. CNA 3 stated staff uncovered the resident's food and left it at the bedside. CNA 3 stated a resident should not be eating cold food. During a concurrent observation and interview with the DSD and CNA 4 on 11/14/2023 at 1:25 p.m., in Resident 68's room, CNA 4 entered the room to remove Resident 68's food tray and return it to the food tray cart. CNA 4 saw the food was untouched and did not ask if Resident 68 was done eating. CNA 4 stated she took the tray because she thought Resident 68 was done eating. The DSD asked CNA 4 if she had asked anyone if Resident 68 was done eating and CNA 4 stated she did not. CNA 4 stated she was supposed to ask if Resident 68 was done eating before removing the food tray. During a review of the facility's policy and procedure (P&P) titled, Feeding the Resident, undated, the P&P indicated the food lid is to be removed prior to food preparation. The P&P indicated the nursing assistant will document the food intake percentage on the appropriate form. During a review of the facility's P&P titled, Activities of Daily Living, supporting, dated 2001, the P&P indicated residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal care and oral hygiene. The P&P indicated that staff would provide assistance with elimination (toileting) and dining (meals and snacks). The P&P indicated that care and services to prevent and/or minimize functional decline will include appropriate pain management.