**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary care and treatment for four of six sampled residents (Resident 19, 14. 61 and 39). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 8, LVN 9 and Registered Nurse (RNS) 4 assessed and monitored Resident 19 when the resident had a change in condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, and understand] behavioral, or functional status which without immediate intervention, may result in complications or death) manifested by shivering and shaking on 6/8/2025 at 11:10 p.m., and every two hours thereafter. 2. Ensure LVN 8 informed LVN 9 of Resident 19's shivering and shaking on 6/8/2025 at 11:10 p.m. during change of shift handoff. These failures resulted in Resident 19 found unresponsive on 6/9/2025, at 4:14 a.m., pronounced dead on 6/9/2025 at 5:03 a.m. after cardiopulmonary resuscitation (CPR- an emergency procedure used to restart a person's heart and breathing by giving strong, rapid pushes to the chest to keep blood moving through the body) efforts. 3. Ensure Resident 14 was provided with medications for constipation ( a condition in which stool becomes hard, dry , difficult to pass, and bowel movements become infrequent) when Resident 14 had no bowel movement ( the movement of feces through bowel and out of anus) for three days. This failure had the potential to put Resident 14 at risk for fecal impaction ( hardened stool that is stuck in the rectum) that could lead to bowl obstruction ( partial or complete blockage of small or large intestine which is life threatening). 4.a.Ensure licensed staff document a change in condition each time Resident 61's nasogastric tube (NG tube- a thin flexible tube inserted through the nose, down the throat, and into the stomach) was pulled out by Resident 61. b. Ensure an order was obtained prior to reinserting Resident 61's NG tube. Document the location of the NG tube placement for Resident 61. These failures had the potential to cause delay in provision of necessary care and treatment to Resident 61 and complications of prolonged used of NG tube. 5. Ensure Resident 39's physician was notified that Resident 39 was taking clopidogrel (a medication used to prevent blood clots with a side effect of bleeding), after the resident sustained a fall. This failure prevented the physician from being able to make informed decisions regarding the care and treatment of Resident 39. Findings: 1. During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), cardiomyopathy ( a long term condition that affects the heart muscle making it harder to pump blood), Covid -19 (highly contagious respiratory disease caused by Coronavirus which is transmitted thru coughing, talking , sneezing and touching contaminated surfaces ), and end stage renal disease (ESRD- irreversible kidney failure) with dependence on renal hemodialysis (procedure to remove waste products and excess fluids from the blood when kidneys stop working properly). The admission Record indicated the resident was discharged to a funeral home on 6/9/2025 at 10:25 a.m. During a review of Resident 19's Minimum Data Set (MDS-resident assessment tool) dated 5/15/2025, the MDS indicated Resident 19 had moderately impaired cognitive skills (ability to think, understand, learn, and remember) and was dependent on staff (helper does all the effort to complete the activity) with bathing, dressing, toilet transfer (ability to get on and off a toilet or a commode) and toileting hygiene. During a review of Resident 19's Weights and Vital Signs (VS- basic functions of the body such as temperature, blood pressure (a pressure of the blood against the artery walls when the heart beats), pulse and respiratory rate [breathing] rate), the Weights and Vital Signs Summary indicated the following: 1. On 6/8/2025, at 5:57 p.m. Resident 19's blood pressure (bp reading was 130/72 millimeters of mercury (mmHg-unit of blood pressure measure) 2. On 6/8/2025, at 10:59 a.m. Resident 19's heart rate (HR- number of times the heart beats per minute; reference range is between 60 to 100 beats per minute) was 65 beats per minute, respiratory rate (RR-number of breaths a person takes per minute; reference range is between 12 to 18 breaths per minute) was 18 RR per minute, temperature was 97.5 degrees Fahrenheit (°F- unit of measurement; reference range between 97 degrees F to 99 degrees F), and oxygen saturation (O2 Sat- concentration of oxygen in the blood; reference range between 95 percent to 100 percent) was 97 percent (%) on room air (no supplemental oxygen used). During a review of Resident 19's Transfer/Discharge summary, dated [DATE] and timed at 8:09 a.m., the Transfer/Discharge Summary indicated on 6/9/2025, at 4:30 a.m. , the charge nurse was summoned due to Resident 19 not responding and not breathing. The Transfer/Discharge Summary indicated Registered Nurse (RNS) 4 responded to the summon right away. The Transfer/Discharge Summary indicated chest compressions ( applying pressure on someone's chest in order to help blood flow through the heart in an emergency situation) were started, oxygen was delivered to Resident 19 via Ambu bag (a portable, hand held device used to provide respiratory support to patients in emergency situation), and 911( number that is called in order to contact the emergency services) was called. The Transfer /Discharge Summary indicated paramedics (highly trained healthcare professionals who provide emergency medical care) arrived on 6/9/2025 at 4:35 a.m. and continued cardiopulmonary resuscitation (CPR- an emergency procedure used to restart a person's heart and breathing by giving strong, rapid pushes to the chest to keep blood moving through the body) on Resident 19. The Transfer/Discharge Summary indicated paramedics' team leader pronounced Resident 19 expired on 6/9/2025 at 5:03 a.m. During a review of Resident 19's Emergency Medical Services (EMS-a system that respond to emergencies in need of highly skilled prehospital clinicians) Incident Information dated 6/9/2025, at 4:35 a.m., the EMS Incident Form indicated EMS team was notified on 6/9/2025 at 4:35 a.m. of Resident 19's cardiac arrest ( heart malfunctions and stops beating on its own caused by an electrical problem in the heart). The EMS Incident Information indicated a team was dispatched to the facility and arrived at 4:40 a.m. The EMS Incident Information indicated facility staff stated to the EMS team that Resident 19 was last seen on 6/9/2025, at 4:15 a.m. sleeping and breathing. The EMS Incident Form indicated Resident 19 was in asystole ( when heart's electrical system fails entirely causing the heart to stop pumping and is also known as flat line) upon assessment and throughout the entirety of the resuscitative effort provided to the resident. The EMS Incident Information indicated the time of death of Resident 19 was 5:03 a.m. on 6/9/2025. During a review of Resident 19's Medication Administration (MAR) dated 5/18/2025, the MAR indicated an order for Humulin (Insulin NPH- intermediate acting insulin to treat DM that reaches the blood stream in about 2 to 4 hours) suspension 100 unit/milliliter (ml-unit of measurement) inject 10 unit subcutaneously (applied under the skin ) in the evening for DM with food. During a review of Resident 19's Care Plan titled, Potential for hyperglycemia (condition in which the level of sugar in the blood) /hypoglycemia (low blood sugar). related to DM, initiated on 5/31/2024 and revised on 5/20/2025, the Care Plan indicated Resident 19 had an episode of hyperglycemia and hypoglycemia The Care Plan indicated the goal for Resident 19 was to be asymptomatic ( not showing symptoms) of hyperglycemia and hypoglycemia daily for three months. The Care Plan indicated the interventions included to notify the physician of the resident's change in condition and to monitor, document, and report to the physician as needed any signs and symptoms of hypoglycemia such as sweating, tremor ( shaking movements in one or more parts of the body), increased heart rate, pallor (skin paleness), nervousness, confusion, slurred speech and lack of coordination. During a telephone interview on 6/12/2025 at 10:49 a.m., with Certified Nursing Assistant (CNA) 8, CNA 8 stated on 6/8/2025, at 11:10 p.m. he noticed Resident 19 was shaking and shivering. CNA 8 stated he gave him (Resident 19) a blanket. CNA 8 stated he told Licensed Vocational Nurse (LVN) 8 about Resident 19's shaking and shivering and that Resident 19 did not look good because his upper body was shaking. CNA 8 stated LVN 8 took Resident 19's temperature and told CNA 8 that Resident 19 was okay, and that Resident 19 had been shaking and shivering because had taken a shower. CNA 8 stated on 6/9/2025, from12:00 a.m. to 12:30 a.m. Resident 19 was awake, and was no longer shaking, appeared awake but was staring at the ceiling. CNA 8 stated he asked Resident 19 at that time if he was okay, and the Resident 19 stated he was okay. CNA 8 stated on 6/8/2025, after 12:30 a.m. he got busy with other residents and did not see Resident 19 until 4:14 a.m. on 6/9/2025. CNA 8 stated on 6/9/2025, at 4:14 a.m. he entered Resident 19's room and turned on the lights upon entrance., CNA 8 stated he did not hear Resident 19 talking but he (CNA 8) did not look at Resident 19 as he was to changing Resident 19's roommate. CNA 8 stated after he almost finished changing Resident 19's roommate incontinent pad (diaper), he looked at Resident 19 and saw Resident 19 not moving, his chest did not rise or fall and looked dead. CNA 8 stated he notified LVN 9 immediately. LVN 9 called RNS 4 and called Code Blue (announcement in the facility that someone is experiencing a life-threatening medical emergency). CNA 8 stated LVN 8 and LVN 9 did not tell him to monitor or check on Resident 19 after he had an episode of shaking and shivering on 6/8/2025 at 11:10 p.m. During a concurrent interview and record review on 6/12/2025, at 7:19 a.m. and subsequent telephone interview on 6/12/2025, at 10:14 a.m. with LVN 9, Resident 19's electronic medical records (EHR) was reviewed. LVN 9 stated he did not see Resident 19 after 11:30 p.m. on 6/8/2025 when Resident 19 had episode of shaking and shivering because he was busy with another resident (unknown) who was restless, confused and was trying to get out of bed. LVN 9 stated most of his time on 6/9/2025 was spent with that resident (unknown) . LVN 9 stated he saw Resident 19 awake, resting comfortably at 11:30 p.m. on 6/8/2025 but did not talk to the resident. LVN 9 stated the last time he saw Resident 19 was on 6/8/2025 at 11:30 p.m. LVN 9 stated LVN, RN, or CNA should conduct rounding (in general) every two hours. LVN 9 stated he received report from LVN 8 from outgoing 7 p.m.- 11 pm shift but LVN 8 did not mention any change in Resident 19's condition such as shaking and shivering and reported Resident 19 was okay. LVN 9 stated he notified RNS 4 that he was busy with another resident (unknown) on 6/9/2025. LVN 9 stated RNS 4 did not come to see him (LVN 9) or see Resident 19. LVN 9 stated on 6/9/2025, at 4:30 a.m., CNA 8 notified him that Resident 19 was not breathing, and code blue was announced. LVN 9 stated they initiated CPR and EMS arrived on 6/9/2025 at 4:35 a.m. and took over the CPR During a telephone interview on 6/12/2025, at 11:39 a.m. with LVN 8, LVN 8 stated on 6/8/2025, at around 11:00 p.m., CNA 8 notified LVN 8 that Resident 19 was shivering and shaking. LVN 8 stated he provided an extra blanket and took Resident 19's temperature. LVN 8 stated he took the temperature, and it was normal but did not remember what the temperature was when Resident 19 was shivering and shaking. LVN 8 stated he did not document the temperature on Resident 19's health record. LVN 8 stated Resident 19's shivering and shaking considered a change in the resident's condition because it probably was indicating the resident had a fever or hypoglycemia (low blood sugar). LVN 8 stated he did not do a change of condition because he had done his intervention already by checking Resident 19's temperature and providing Resident 19 with a blanket. LVN 8 stated he did not inform Resident 19's physician about the shivering and shaking and did not check Resident 19's other vital signs including blood pressure, pulse rate, respiratory rate, oxygen saturation, and blood sugar. LVN 8 stated he should have checked the Resident 19's vital signs, notified the physician to address the change in condition , initiate a COC, monitor Resident 19 frequently (at least every two hours) and checked his blood sugar when Resident 19 was shivering and shaking as Resident 19 had a history of hypoglycemia (low blood sugar) and was receiving insulin (medication to treat DM). LVN 8 stated Resident 19 had a change in condition due to low blood sugar last month (May). LVN 8 stated he administered NPH Insulin (intermediate acting insulin to treat DM that reaches the blood stream in about 2 to 4 hours) on 6/8/2025 at 6:00 p.m., LVN 8 stated NPH insulin could lower the blood sugar within 4 to 5 hours of administration. LVN 8 stated failure to monitor Resident 19 after the resident was having symptoms of shaking and shivering could have contributed to Resident 19's death. LVN 8 stated he should have checked Resident 19's vital signs, notify the physician who could have ordered a transfer to the hospital for further evaluation, monitor the resident by conducting a COC to ensure Resident 19's condition would not worsen. LVN 8 stated he should have informed LVN 9 and RNS 4 regarding Resident 19's shaking and shivering to keep an eye on Resident 19 on 6/8/2025. During an interview on 6/12/2025, at 8:29 a.m., with RNS 4, RNS 4 stated on 6/8/2025, at 10:30 p.m. Resident 19 was asleep. RNS 4 stated she did not go to Resident 19's room until the resident was found pulseless and not breathing on 6/9/2025 at 4:30 a.m. RNS 4 stated on 6/9/2025, at 4:30 a.m. Resident 19 was pulseless and they were unable to check his vital signs. RNS 4 stated they initiated CPR on Resident 19 and another staff called 911. During an interview on 6/12/2025, at 3:19 p.m. with RNS 2, RNS 2 stated when Resident 19 had shaking and shivering on 6/8/2025 at 11:10 p.m., Resident 19 should have been monitored closely as it was considered a COC. RNS 2 stated a COC should be performed when the condition of a resident deviated from his baseline (an initial measurement of a condition that is taken at an early time point and used for comparison over time to look for changes in condition) . RNS 2 stated doing COC was important to ensure monitoring of the change of condition was performed, assessment and evaluation of the resident's condition done, and the physician informed to obtain physician orders for treatment. During an interview on 6/12/2025, at 4:49 p.m. with the Director of Nursing (DON), the DON stated facility staff should checked resident every two hours. The DON stated Resident 19's symptoms of shaking and shivering were considered a change of condition. The DON stated LVN 8 should have done a COC, checked the full set of vital signs, not just the temperature, including blood sugar because Resident 19 received 10 units of NPH insulin on 6/8/2025 at 4:38 p.m., and 2 units of sliding scale Regular insulin at 9:32 p.m. The DON stated LVN 8 should have informed LVN 9 and RNS 4 when Resident 19's had episode of shivering and shaking on 6/8/2025 at 11:10 p.m., during handoff. The DON stated COC was a monitoring tool and not having vital signs documented meant VS were not done. The DON stated the licensed nurse should have done a COC, took a full set of vital signs, rechecked resident's blood sugar, notified the physician, assessed and monitored Resident 19 when he had shivering and shaking. The DON stated Resident 19 should have been monitored and assessed and could have transferred to general acute care hospital (GACH) in a timely manner. The DON stated Resident 19 expired on 6/9/2025, at 5:03 a.m. 3. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including constipation, repeated falls, urinary tract infection (UTI- an infection in the bladder/urinary tract), polyp of the colon (mall clump of cells that forms in the lining of the colon), and major depressive disorder( serious mental illness characterized by persistent sadness, loss of interest in activities, and significant impairment in daily functioning). During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 had an intact cognition and required partial/moderate assistance (helper does less than half the effort) with toilet transfer( ability to get on and off a toilet commode), bed mobility, and bathing. The MDS indicated Resident 14 was always incontinent ( having no or insufficient voluntary control ) of stool. During a review of Resident 14's Activities of Daily Living (ADL- activities such as bathing, dressing and toileting a person performs daily) Task for bowel and bladder elimination, the ADL Task indicated Resident 14 did not have a bowel movement (BM-process of emptying the bowels of solid or semisolid feces) on 6/1/2025, 6/2/2025, 6/3/2025 and on 6/7/2025, 6/8/2025, 6/9/2025. During a review of Resident 14's Care Plan titled, Potential Alteration in Bowel Elimination related to Constipation, initiated on 4/26/2025. the Care Plan indicated the goal for Resident 14 to have bowel movement regularly for the next three months. The Care Plan indicated the interventions included monitoring for bowel movement, for amount, consistency and frequency, review medication that cause constipation, and administer medication as ordered. During a review of Resident 14's Physician's Order Summary Report , the Physician's Order Summary Report, dated 5/5/2025 indicated an order of Sertraline (medication used to treat depression) 25 milligrams (mg-. unit of measurement) one tablet at bedtime for depression. During a review of Resident 14's Physician's Order Summary Report, the Physician's Order Summary Report dated 5/5/2025 indicated a physician's order to monitor side effects of anti-depressant (medication used to treat depression) medication such as constipation. During a review of Resident 14's Physician's Order Summary Report, the Physician's Order Summary Report dated 5/23/2025 indicated an order of Bisacodyl ( used to treat constipation) 10 mg Suppository, to insert one suppository rectally ( given via rectum) as needed for constipation if no BM in 24 hours. During a review of Resident 14's Physician's Order Summary Report, the Physician's Order Summary Report indicated an order for 70 percent (%- quantify the amount or concentration of the medicine) Sorbitol solution (used to treat occasional episodes of constipation) 30 milliliter (ml- unit of measurement) every 6 hours as needed for constipation. During an interview on 6/9/2025, at 11:03 a.m. with Resident 14, Resident 14 complained of constipation and stated she did not have a bowel movement for a while. Resident 14 stated she kept telling the staff about her concern (constipation). During an interview on 6/10/2025, at 12:06 p.m. with Certified Nursing Assistant (CNA 5), CNA5 stated if the resident (in general) has no bowel movement for three days, the CNA notifies the charge nurse CNA 5 stated she did not check Resident 14 if the resident had BM for the past few days (6/7/2025, 6/8/2025, 6/9/2025). CNA 5 stated she should have checked if Resident 14 had a bowel movement for the past few days (6/7/2025, 6/8/2025, 6/9/2025). CNA 5 stated Resident 14 would get constipated with the risk to go to the hospital. During a concurrent interview and record review on 6/10/2025 at 3:22 p.m., with LVN 11, Resident 14's MAR and ADL Task for Bowel and Bladder Elimination were reviewed. LVN 11 stated Resident 14 had no bowel movement on 5/28/2025, 5/29/2025, 5/30/2025 and on 6/7/2025, 6/8/2025, 6/9/2025, and 6/10/2025. LVN 11 verified through MAR review that Resident 14 did not receive any as needed (prn) medications for constipation on the days Resident 14 had no BM for 3 days. LVN 11 stated the licensed nurse should have assessed Resident 14 for abdominal pain, asked the resident if she had a bowel movement monitored BM frequency, and administered prn medications for constipation. LVN 11 stated Resident 14 could be at risk for bowel obstruction (occurs when something blocks the normal passage of digested food, and fluids), sepsis ( serious condition in which the body responds improperly to an infection) or infection that could lead to death if constipation was not addressed. During an interview on 6/12/2025, at 3:08 p.m. with RN Supervisor (RNS 2), RNS 2 stated Resident 14 could be at risk for fecal impaction ( a large lump of dry, hard stool that stays stuck in the rectum), bowel obstruction, abdominal discomfort, nausea, vomiting and could increase Resident 14 risk for hospitalization if constipation was not addressed. RNS 2 stated the licensed nurse should have monitored Resident 14's BM frequency and on if there was no BM on the third day, the licensed nurse should have administered the prn medication for constipation as ordered. During an interview on 6/12/2025, at 4:43 p.m. with the DON, the DON stated the LVN (in general) should have monitored Resident 14's BM frequency, informed the physician and administered prn medication for constipation on the third day if the resident had no bowel movement. The DON stated if Resident 14's constipation was not addressed the resident appetite would be affected by the resident would have an abdominal discomfort and vomiting, and possible bowel obstruction. 4. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was admitted to the facility on [DATE] with diagnoses including dementia ( a progressive state of decline in mental abilities) and dysphagia (difficulty swallowing). During a review of Resident 61's MDS dated [DATE], the MDS indicated Resident 61's cognition was severely impaired and was dependent for toileting, showering, dressing, personal hygiene, and rolling to either side in bed. During a review of Resident 61's Order Summary Report, the Order Summary Report indicated there were a total of seven orders (5/9/2024, 8/12/2024, 10/27/2024, 11/19/2024, 1/11/2025, 4/24/2025, and 5/25/2025) placed for chest X-rays (pictures of the inside of your body) for NG tube placement. During a review of Resident 61's Order Summary Report, the Order Summary Report indicated an order was placed 1/11/2025 and 4/24/2025 for a chest X-ray for NG tube placement with no order to re-insert the NG tube. During a review of Resident 61's COC dated 1/11/2025, timed 10:30 a.m., the COC indicated Resident 61 pulled out her NG tube. No COC for 4/24/2025 for when Resident 61 pulled out her NG tube. During a review of Resident 61's Care Plan title Potential for injury related to pulling out NG tube, the Care Plan indicated there were no revisions made to the care plan after Resident 61 pulled her NG tube out on 5/9/2024, 8/12/2024, 10/27/2024, 11/19/2024, 1/11/2025, 4/24/2025 and 5/25/2025. During an interview on 6/11/2025 at 9:19 a.m., with Certified Nurse Assistant (CNA) 9, CNA 9 stated Resident 61 has mitten restraints (prevents someone from grabbing something) because she tends to pull out her NG tube. During a concurrent interview and record review on 6/12/2025 at 8:29 a.m., the Licensed Vocational Nurse (LVN) 9, LVN 9 stated Resident 61 pulls her NG tube out at least every three months. LVN 9 stated there should be an order for NG tube re-insertion, a COC documented, and documentation indicating when and which nostril the NG tube was placed. LVN 9 validated there were no orders to re-insert Resident 61's NG tube on 1/11/2025 and 4/24/2025. LVN 9 validated there were no COC documented on 4/24/2025. LVN 9 validated there were no documentation when and where the NG tube was re-inserted on 5/9/2024, 8/12/2024, 10/27/2024, 11/19/2024, 1/11/2025, 4/24/2025, and 5/25/2025. LVN 9 stated there should be a progress note indicating which nostril the NG tube was placed. During an interview on 6/12/2025 at 10:10 a.m., with the Registered Nurse Supervisor (RNS) 2, RNS 2 stated when Resident 61 pulls out her NG tube, there should be an order to re-insert the NG tube, a COC documented, and documentation of which nostril the NG tube was placed. RNS stated it was important to document which nostril the NG tube was placed to better monitor for complications of the affected nostril and to ensure they rotate sites of where the NG tube was placed. During an interview on 6/13/2025 at 9:24 a.m., with the Director of Nursing (DON), the DON stated Resident 61 had removed her NG tube several times and each time there should be an order to re-insert, a COC documented, and documentation of re-insertion and which nostril the NG tube was re-inserted and if not, this was to be considered inaccurate documentation. During a review of the facility's policy and procedure (P&P) titled Nasogastric Tube Insertion and Care, undated, the P&P indicated, Verify that there is a physician's order for insertion of the nasogastric tube. The person performing this procedure should record the following information in the resident's medical records: the date and time the procedure was performed, the size and length of the nasogastric tube, and verification of tube placement. During a review of the facility's P&P titled, Charting and Documentation, undated, the P&P indicated, The following documentation is to be documented in the resident medical record: treatments or services performed, changes in the residents condition, events, incidents, or accidents involving the resident and progress toward or changes in the care plan goals and objectives. 5. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with the diagnoses including malignant neoplasm of prostate (prostate cancer) and cerebral vascular accident (CVA - a stroke, loss of blood flow to a part of the brain). During a review of Resident 39's Medication Administration Record (MAR) for 11/ 2024, the MAR indicated Resident 39 was receiving clopidogrel 75 milligrams (mg- unit of measurement) daily to prevent a stroke During a review of Resident 39's care plan, titled Resident was at risk for bleeding/bruising/skin tear/hematuria (blood in the urine) /melena (blood in the stool) secondary to clopidogrel, the Care Plan interventions included to monitor Resident 39 for bruises or bleeding episodes. The care plan interventions also indicated the physician should be notified accordingly for unusual observation related to clopidogrel. During a review of Resident's 39's Change of Condition Evaluation (COC- a tool used by health care professionals when communicating about critical changes in residents' status) dated 11/9/2024, the COC indicated Resident 39 fell from the wheelchair to the ground. The COC did not indicate Licensed Vocational Nurse (LVN) 10 reported the resident was on clopidogrel to the on-call physician. During an interview on 6/12/2025 at 2:27 p.m., with LVN 10, LVN 10 stated they should have notified Resident 39's physician that Resident 39 was on clopidogrel because of the potential risk for bleeding. LVN 10 stated the physician would have ordered labs and an x-ray (create images of the inside of the body) immediately to see if Resident 55 was bleeding internally had they been notified. LVN 10 stated it was important to notify the doctor of antiplatelets (medications used to prevent blood clots) when a resident falls because of the risk for internal bleeding. During an interview on 6/12/2025 at 1:59 p.m., with Registered Nurse Supervisor (RNS) 3, RNS 3 stated, If a resident falls and the physician just orders to monitor the resident when they are on antiplatelet therapy, the nurse was responsible to take the initiative and notify the physician to recommend an x-ray and evaluation. This resident (Resident 39) should have at least had an x-ray done for possible internal bleeding. During an interview on 6/12/2025 at 5:13 p.m., with the Director of Nursing (DON), the DON stated that notifying the physician of a resident being on blood thinners or antiplatelets after they fall will determine the physician's course of actions and what they would order; it was part of the facility's protocol to accurately report to the doctor. During a review of facility's policy and procedure (P&P)titled, Change in a Resident's Condition, undated, the P&P indicated the facility will promptly notify resident's attending physician and representatives of changes in the resident's medical/ mental condition. The P&P indicated the Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical condition. During a review of facility's Job Description of a Charge Nurse undated, the Job Description of a Charge Nurse indicated the charge nurse will accurately assess, document, and report the resident's symptoms, reactions, progress to the attending physician ,nursing supervisor , DON, Administrator and other participating in care and treatment of the resident. The Job Description of a Charge Nurse indicated the charge nurse will promptly notify the attending physician and responsible party, family of change in resident's condition and in accordance with the facility's policies and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents, who were identified at risk for falls, did not fall and sustain injury for two of three sampled residents (Resident 50 and Resident 89). The facility failed to: 1. Ensure Resident 50's talking device (recordable voice alarm with a personalized message that plays when an alarm is triggered) was turned on as one of the interventions of fall risk prevention program for Resident 50. 2. Ensure the licensed nurses evaluated the effectiveness of interventions of Resident 50's care plan titled, At risk for falls, difficulty maintaining sitting/standing balance, history of falls/multiple falls initiated on 12/25/2024, after the resident's fall on 4/19/2025, to develop new interventions to prevent the resident's fall on 5/22/2025 with injuries. 3. Ensure staff followed the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, undated, which indicated, The care team will target interventions that will reduce individual risks related to hazards in the environment including adequate supervision and assistive devices (equipment that can help you perform tasks and activities). 4. Ensure Resident 89, who required supervision at all times, was supervised while smoking on 2/27/2025 at 1:45 p.m., in accordance with the facility's policy and procedure (P&P) titled, Smoking Policy-Residents (undated). 5. Ensure Restorative Nursing assistant (RNA) 1 did not leave Resident 89 unsupervised on 2/27/2025 at 1:45 p.m., when RNA 1 wheeled Resident 89 to designated smoking area in front of the facility. 6. Ensure staff followed Resident 89's Care Plan, titled Resident 89 is at risk for injury related to smoking, dated 9/11/2023, by not leaving Resident 89 unsupervised while smoking. 7. Ensure the spray bottle containing clear liquid was labeled to identify ingredients inside the bottle, affecting one of four medication carts (Medication Cart B2). These failures resulted in: A. Resident 50 falling from a bed to the floor on 5/22/2025 around 7:25 a.m., sustaining a right inferior (lower) pubic ramus (a bone in the pelvis, specifically a thin, flat part of the pubic bone) fracture (broken bone) right superior (above) pubic ramus (a break in the upper part of the pubic bone on the right side of the pelvis) fracture, right sacral (tail bone) fracture, and bilateral rib fractures which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. B. Resident 89 falling from a wheelchair and sustaining a nose fracture small cut on a forehead that was bleeding, bruised ( skin is not broken but is discolored) and swollen. Resident 89 sustained abrasions (superficial wound caused by scraping away of the skin's outer layer) to the forehead and left knee. Resident 89 was transferred to GACH on 2/27/2025 at 3:42 p.m., for further evaluation and treatment of swelling to both eyes. C. Had the potential to result in accidental exposure to or ingestion of isopropyl alcohol. Findings: A. During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), osteoporosis (weak and brittle bones due to a lack of calcium [mineral needed for healthy bones] and Vitamin D {nutrients needed to keep bones healthy}), fractures of left and right humerus (the long bone of the upper arm), repeated falls, and lack of coordination. During a review of Resident 50's Change in Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional condition) Form dated 12/22/2024 and timed at 2:16 p.m., the COC Form indicated Resident 50 informed the charge nurse (unknown) that she fell in the bathroom the day before (12/21/2024) after getting up unassisted. The COC Form indicated Resident 50 stated she lost her footing, fell on the ground, but was able to get up and went back to her bed on her own without calling for assistance. The COC Form indicated Resident 50 had a hematoma (a solid swelling of clotted blood within the tissues) to her right side of the head. The COC Form indicated Resident 50 was on toileting every two hours and as needed, frequent visual checks and talking device in place and working. During a review of Resident 50's Care Plan titled, At risk for falls, difficulty maintaining sitting/standing balance, history of falls/multiple falls initiated on 12/25/2024, the Care Plan goal for Resident 50 was to have decrease in significant injury as a result from falls and to minimize the risk for falls in the next three months. The Care Plan interventions included to apply and check the talking device while in bed and or wheelchair to remind and redirect Resident 50 to call for assistance and to have frequent visual checks. During a review of Resident 50's Interdisciplinary Team (IDT team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Note dated 1/9/2025 timed at 11:14 a.m., the IDT Note indicated on 12/22/2024 around 7:15 a.m., Licensed Vocational Nurse (LVN) 12 observed Resident 50 with a hematoma to the right side of her head. IDT Note indicated Resident 50 stated she fell in the bathroom on 12/21/2024. Resident 50 stated she went to the bathroom unassisted and when she was returning back to bed, she lost her footing, bumped herself ( unknown where) and ended up on the floor. Resident 50 stated she got up and went back to bed. The IDT Note indicated Resident 50 was on fall management program which consist of a talking device to remind and redirect Resident 50 to call for assistance, and a perimeter mattress (type of mattress designed with raised edges or bolsters to prevent falls and provide a safer sleep environment) for extra support. The IDT Note indicated Resident 50 was able to silence or turned off her talking device because she wanted to go to the bathroom by herself. During a review of Resident 50's COC dated 4/19/2025 and timed at 6:30 a.m., the COC indicated Resident 50 was found sitting on the bathroom floor after getting out of bed unassisted and suddenly feeling weak. During a review of Resident 50's IDT Note dated 4/28/2025 timed at 10:25 a.m., the IDT note indicated Resident 50 had an incident on 4/19/2025 around 6 a.m., when Resident 50 was observed sitting on the floor outside the bathroom. The IDT note indicated Resident 50 was assessed with no injury. The IDT note indicated Resident 50 was currently on a toileting schedule and has a talking device to remind and redirect Resident 50 to call for assistance. The IDT note indicated Resident 50 was observed by staff that she can manipulate the talking device. During a review of Resident 50's Minimum Data Set ( MDS-resident assessment tool) dated 5/22/2025, the MDS indicated Resident 50 had moderately impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making and was dependent (helper does all the effort) with toileting hygiene, showering and bathing. During a review of Resident 50's Physician's Order Summary Report, the Physician's Order Summary Report indicated an order to apply and check talking device while in bed and or wheelchair to remind and redirect the resident to call for assistance. During a review of Resident 50's COC dated 5/22/2025 and timed at 7:25 a.m., the COC indicated Resident 50 had an unwitnessed fall and was found lying on the floor. During a review of the facility's Investigation Report, (undated), the Investigation report indicated at the time of the incident (on 5/22/2025), Resident 50's talking device was noted to be disconnected. During a review of Resident 50's COC dated 5/22/2025 and timed at 2:58 p.m., the COC indicated Resident 50 had an open area to her right eyebrow. Registered Nurse Supervisor (RNS) called 911 and Resident 50 was transferred to GACH on 5/22/2025 (unknown time). During a review of Resident 50's GACH's Consultation Notes report dated 5/23/2025, the Consultation Note report indicated Per the facility, Resident 50's bed alarm (talking device) did not alarm, and she got out of bed by herself and fell. The Consultation Note report indicated Resident 50 had a computed tomography scan (CT- a medical imaging procedure that uses x-rays to create detailed, cross-sectional images of the body's internal structures) of the abdomen and pelvis on 5/22/2025. The CT scan indicated Resident 50 had a right inferior pubic ramus fracture, a right superior pubic ramus fracture, a right sacral fracture, and multiple bilateral rib fractures. During a concurrent observation and interview on 6/10/2025 at 8:22 a.m., Resident 50 was observed with a right eye bruise. Resident 50 stated she fell the other day (unable to state exact date). During an interview on 6/11/2025 at 1:46 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 50 had a fall on 5/22/2025 and sustained a fracture. CNA 1 stated Resident 50 was confused and forgot to use her call light. During a concurrent interview and record review on 6/12/2025 at 8:55 a.m., with Licensed Vocational Nurse (LVN) 9, LVN 9 stated Resident 50 was a high fall risk. LVN 9 stated Resident 50's room was close to the nurse's station. LVN 9 stated after each fall, the care plan should be revised to evaluate the effectiveness of interventions to prevent future falls from occurring. Reviewed Resident 50's Care Plan, LVN 9 stated Resident 50's care plan was not revised following her fall on 4/19/2025 and it should have been done because additional interventions could have prevented the resident's fall on 5/22/2025 which resulted in multiple fractures. LVN 9 stated Resident 50's fall was preventable if she had been monitored more closely and had a bedside commode (portable toilet) at her bedside as she gets up without assistance to use the bathroom. During a concurrent interview and record review on 6/12/2025 at 10:10 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 50's Care plan was reviewed. RNS 2 stated Resident 50 was a high risk for fall and recently had a fall on 5/22/2025. RNS 2 stated after a resident falls, the care plan should be revised to add new interventions. RNS 2 stated after Resident 50's fall on 4/19/2025, the care plan was not reviewed and revised. RNS 2 stated it was important to revise the care plan after a fall because the interventions in place were not effective, therefore, a new intervention could be added to prevent future falls. During an interview on 6/13/2025 at 9:24 a.m., with the Director of Nursing (DON), the DON stated a care plan was a guide that outlines the plan of care for the resident. The DON stated the care plan includes goals and interventions and should be revised when interventions were not effective. The DON stated Resident 50's care plan should have been revised after each fall so new interventions could be added to prevent future falls. During an interview on 6/13/2025 at 10:16 a.m., with the Quality Assurance Licensed Vocational Nurse (QA LVN), the QA LVN stated Resident 50 tends to disconnect the talking device. During a review of the facility's P&P titled, Safety and Supervision of Residents undated, the P&P indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Implementing interventions to reduce accident risks and hazards shall include the following: ensuring that interventions are implemented and documenting interventions. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered undated, the P&P indicated, Assessments of residents are ongoing, and care plans are revised as information about the residents and residents' conditions change. C.During a concurrent observation and interview on 6/10/2025 at 9:20 a.m. during medication pass with the Licensed Vocational Nurse (LVN) 1, LVN 1 used a few sprays from an unlabeled spray bottle containing clear liquid to sanitize his hands. LVN 1 stated the spray bottle contained hand sanitizer and they transferred the liquid from the original large container into the smaller spray bottle that was in use at medication cart. LVN 1 showed a large bottle labeled with 70 percent (%) isopropyl alcohol stating that the contents of the unlabeled spray bottle were the same as the large container. During an interview on 6/12/2025 at 12:51 p.m. with the Director of Nursing (DON), the DON stated it was important that the unlabeled spray bottle with clear liquid was labeled to identify its ingredients inside, which was isopropyl alcohol, to prevent any accidental ingestion by facility residents. During a concurrent observation and interview on 6/12/2025 at 12:13 p.m. with the Quality Assurance Licensed Vocational Nurse (QA LVN), observed Medication Cart B2 contained an unlabeled spray bottle. QA LVN stated the facility started receiving the large isopropyl alcohol containers recently and so they had to transfer the liquid into a smaller spray bottle to be stored on medication carts. QA LVN stated it was important to label the small spray bottle to identify that it contained 70% isopropyl alcohol, to maintain safety of facility's staff and residents. QA LVN stated it would be a risk for residents if they just grabbed it and ingested by accident. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, undated, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated, Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. B. During a review of Resident 89's admission Record, the admission Record indicated, Resident 89 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including repeated falls, nicotine (the additive drug found in tobacco products) dependency, bone density disorder (the bones are weak and more likely to break than normal), osteoarthritis (a degenerative joint disease, in which the tissues in the joint breakdown over time), and muscle wasting (the weakening, shrinking, and loss of muscle tissue). During a review of Resident 89's Care Plan, titled Resident 89 is at risk for injury related to smoking, dated 9/11/2023, the Care Plan indicated the interventions included not to leave Resident 89 alone while smoking, and provide supervision when resident is smoking. During a review of Resident 89's Physician's Order Summary, dated 11/28/2024, the Physician's Order Summary indicated Resident 89 had an order for fall precautions (measures taken to reduce the risk of falling and the likelihood of serious injury if a fall does occur). During a review of Resident 89's Smoking Safety Evaluation, dated 2/13/2025, the Smoking Safety Evaluation indicated, Resident 89 required supervision to smoke safely. During a review of Resident 89's Fall Risk Evaluation, dated 2/13/2025, the Fall Risk Evaluation indicated Resident 89 was at risk for fall. The Fall Risk Evaluation indicated Resident 89 was chairbound (confined to a chair, typically due to illness, injury, or disability) and had a balance problem while standing and walking. During a review of Resident 89's COC Evaluation dated 2/27/2025 timed at 2:27 p.m., the COC indicated that on 2/27/2025 around 2:05 p.m., Resident 89 was found on the ground in front of the facility (designated smoking area). The COC indicated Resident 89 sustained a bump on the forehead with open area. The COC indicated Resident 89 stated that she dropped her cigarettes and wanted to pick it up. The COC indicated Resident 89's physician was informed and ordered to transfer Resident 89 to GACH. During a review of Resident 89's Physician's Order Summary, dated 2/27/2025, the Physician's Order Summary indicated an order to transfer Resident 89 to GACH for further evaluation of the bump on the head after falling. During a record review of Resident 89's GACH's Emergency Department (ED) Notes, dated 2/27/2025, the ED Notes indicated Resident 89 had a bilateral nasal (nose) bone fracture with, moderate soft tissue swelling over the left periorbital (around the eye) and nasal region. The ED Noted indicated a Computerized Topography (CT -medical imaging that create detailed images of the body) of the head was done and CT scan result was bilateral (both) nasal bone fracture with moderate soft tissue swelling over the left periorbital and nasal region. The ED Notes indicated Resident 89 had an abrasion (superficial wound caused by scraping the skin) to the left forehead and mild laceration (a wound where the skin and underlying tissues are torn or cut) which was repaired with Steri-Strips (thin sticky adhesive bandages used to close small, shallow wounds or surgical incisions, often as an alternative to stiches or staples) During a review of Resident 89's Physician's Order Summary, dated 2/27/2025, the Physician's Order Summary indicated to apply Betadine (solution used to treat or prevent skin infection in minor cuts, or scrapes) to the left forehead abrasion topically (to the skin) in the morning. The Physician's Order Summary indicated the following order: 1. Monitor Resident 89's forehead bump with Steri-Strips for increase discoloration, bleeding, drainage, increase swelling, discharges, pain, and signs and symptoms of infection. 2. Cleanse forehead bump with Normal Saline (salt solution used for cleansing wounds), pat dry, apply Steri-Strips, and cover with gauze dressing. 3. Monitor Resident 89's right periorbital purplish discoloration for presence of increase discoloration, open area, bleeding, drainage, increase swelling, discharges, pain, signs and symptoms of infection every shift. 4. Apply Vitamin A&D external ointment (skin protectant and can aid in the healing of minor cuts, cuts, scrapes) to Resident 89's left knee abrasion daily. During a review of Resident 89's Physician's Order Summary, dated 2/28/2025, the Physician's Order Summary indicated an order to monitor Resident 89 nose discoloration and left periorbital area for increase of purplish discoloration, open area, bleeding, drainage, increase swelling, discharges, pain, signs and symptoms of infection every shift. The Physician's Order Summary indicated an order for ice compress to the forehead and facial affected area for 10 to 20 minutes to reduce swelling three times a day. During a review of Resident 89's Minimum Data Set (MDS-resident assessment tool), dated 5/15/2025, the MDS indicated, Resident 89 was dependent on nursing staff for toileting, dressing, and transferring. The MDS indicated Resident 89 needed partial to moderate assistance from nursing staff with walking, standing and sitting. During a review of Resident 89's Physician's Progress Note dated 6/4/2025, the Physician's Progress Note indicated, Resident 89 was able to express needs and make healthcare decisions. During an interview on 6/11/2025 at 2:52 p.m., with Restorative Nursing Assistant (RNA) 1, RNA 1 stated on 2/27/2025 at 1:45 p.m., RNA 1 wheeled Resident 89 to the designated smoking area in front of the facility. RNA 1 stated she stayed for 10 minutes and supervised Resident 89 while the resident was smoking. RNA 1 stated Resident 89 wanted to stay longer in the designated smoking area to get some fresh air. RNA 1 stated she left Resident 89 alone at the designated smoking area and went back inside the facility to assist another resident with RNA services. RNA 1 stated she asked the Receptionist (RCPT) to call her when Resident 89 was ready to come back inside the facility. RNA 1 stated she heard RCPT responded okay. RNA 1 stated she heard from another staff that Resident 89 fell from his wheelchair while trying to pick up a cigarette from the ground. RNA 1 stated Resident 89 was on the ground and was bleeding from the forehead. RNA 1 stated other staff helped her (RNA 1) to put Resident 89 back on the wheelchair and wheeled Resident 89 back to the facility. RNA 1 stated that she should have not left Resident 89 unsupervised while smoking in the designated smoking area for safety and prevent Resident 89 from falling. RNA 1 stated facility did not have an assigned staff to supervise the smoking area. RNA 1 stated a certified nursing assistant (CNA) assigned to the resident was responsible for supervising the resident while the resident smokes. During an interview on 6/12/2025 at 1:52 p.m., with RCPT, RCPT stated there have been instances when facility staff were supervising residents' while smoking in the designated smoking area and will step out for few minutes and return right away. RCPT stated she does not recall RNA 1 telling her to call her when Resident 89 was ready to come back inside the facility. RCPT stated she saw Resident 89 at the designated smoking area before the fall. RCPT stated she stepped away from the receptionist desk and heard about Resident 89 fall. RCPT stated she no longer supervised residents outside the designated smoking area because she was not at the receptionist's desk continuously. During an interview on 6/12/2025 at 4:04 p.m., with the Director of Nursing (DON), the DON stated if a resident requires supervision during scheduled smoking time, the facility staff should always be at the designated smoking area to supervise residents for safety and prevent fall. The DON stated Resident 89 needed supervision for safety when smoking in the designated smoking area. During a review of the facility's P&P titled, Safety and Supervision of Residents, undated, the P&P indicated the facility strives to make the environment as free from hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility's P&P titled, Smoking Policy-Residents, undated, the P&P indicated any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to prevent the resident's unplanned severe weight loss (a weight loss greater than 5 % in one month, greater that 7.5% in three months and greater than 10 % in 6 months) of nine (9) pounds ([lbs.] 9.57 percent [%] in one month for one of two sampled residents (Resident 129). The facility failed to: 1. Ensure the Registered Dietician's ([RD] a health professional who has a special training in diet and nutrition) recommendation to increase Resident 129's enteral (form of nutrition that is delivered into the digestive system as liquid) feeding from 250 milliliter ([ml] unit of measurement) four times per day to 250 ml five times per day totaling 1500 calories ([kCal] energy people get from the food and drink they consume, and the energy they use in physical activity) were followed and provided. 2.Ensure staff monitored Resident 129's weight and reported the resident's five pounds weigh loss to Resident 129's physician and RD in accordance with the care plan titled Risk for Malnutrition (lack of significant nutrients [substance used in the body to function] leading to physical decline). 3. Ensure the facility's staff informed the RD when Resident 129 had a 9.57 % weight loss from 4/29/2024 through 6/1/2024 for RD to evaluate and make necessary recommendations on Resident 129's enteral feeding formula to provide Resident 129 with a sufficient amount of calories and nutrients to prevent Resident 129's severe weight loss of 9.57 % in 34 days in accordance with the facility's policy and procedure (P&P) titled, Nutrition (Impaired/Unplanned Weight Loss-Clinical Protocol. 4. Ensure licensed staff followed facility's P&P titled, Weight Assessment and Intervention and immediately notified the Dietician in writing of Resident 129's weight loss of 5% or more since the last weight assessment on 4/29/2024. 5. Ensure the RD completed Resident 129's full nutritional assessment upon admission to the facility on 4/27/2024 and monitor Resident 129's weight and caloric intake, who was receiving tube feeding nutrition, and makes appropriate recommendations for intervention to enhance tolerance and nutritional adequacy of tube feedings per facility's P & P. These deficient practiced resulted in Resident 129's severe weight loss of 9.57 % in 34 days and placed Resident 129 at risk for malnutrition, dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake), skin break down, having feelings of depression and hopelessness. Findings: During a review of Resident 129's admission Record, indicated Resident 129 was admitted to the facility on [DATE], with diagnoses including amyotrophic lateral sclerosis ( a nervous system disease that affects nerve cells in the brain and spinal cord), dysphagia (difficulty of swallowing), gastrostomy tube ([GT] a soft tube surgically inserted directly into the stomach to administer medication, fluids and nutrition), deep tissue injury ([DTI] purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) to a sacral (tailbone) area, and muscle wasting (loss of muscle tissue). During a review of Resident 129's History and Physical (H&P), dated 4/28/2024, the H&P indicated, Resident 129 did not have decision making capacity. During a review of Resident 129's Minimum Data Set ([MDS], a standardized assessment and care screening tool]) dated 5/1/2024, the MDS indicated Resident 129 was dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and personal hygiene. The MDS indicated Resident 129 height was five feet (unit of measurement) and three inches (unit of measurement) and weighed 94 pounds ([lbs.] unit of weight). The MDS indicated Resident 129 was receiving nutrition via GT. During a review of Resident 129's Weights and Vitals Summary from 4/29/2024 to 6/1/2024, the Weights and Vitals Summary indicated the following resident's weekly weight: 1. On 4/29/2024 - 94 pounds. 2. On 5/5/2024- 93.4 pounds. 3. On 5/12/2024- 87 pounds (7.0 pounds [7.45%] weight loss). 4. On 5/19/2024- 87.4 pounds (6.6 pounds [7.02%] weight loss). 5. On 5/26/2024- 85.4 pounds (8.6 pounds [9.15 %] weight loss). 6. On 6/1/2024- 85 pounds (9.0 pounds [9.57 %] weight loss). During an interview on 6/12/2024 at 10:30 a.m., the License Vocational Nurse (LVN 5) stated when Resident 129 had a weight loss of nine (9) pounds from 4/29/2024 to 6/1/2024, a change of condition (COC) documentation should have been done, Resident 129's physician and RD should have been informed and an Interdisciplinary team ([IDT]- group of healthcare professional s working together to plan the care needed for each residents) meeting should be held immediately in order to address the resident's weight loss and recommend interventions to prevent further resident's weight loss. LVN 5 stated Resident 129 was getting weighed weekly due to a weight loss. LVN 5 stated she did not report Resident 129's severe weight loss of 9 pounds (9.57 %) to RD and the physician. LVN 5 stated severe weight loss should be reported immediately to Resident 129's physician and RD because Resident 129 could lose more weight that can lead to hospitalization due to malnutrition. During a review of Resident 129's care plan titled, Risk for Malnutrition, dated 4/28/2024 indicated a goal for Resident 129 was not to have significant weight loss of five lbs. in one month (5 % in one month, 7.5 % in 3 months, 10 % in 6 months). The care plan interventions included to monitor the resident's weight and report five lbs. weight loss to the physician and RD promptly and notify the physician of significant weight change and refer to dietician. During a review of Resident 129's Care Plan titled GT feeding, dated 4/28/2024 indicated a goal for Resident 129 was to maintain adequate nutrition and hydration (fluid intake) status and to have a stable weight with no signs and symptoms of malnutrition or dehydration. During a review of RD's Nutrition/Dietary Progress Note dated 4/28/2024 and timed at 6:55 p.m., the Nutrition/Dietary Progress Note indicated Resident 129 was receiving 250 ml of enteral feeding with formula Fibersource 1.2 four times daily. Resident 129 body mass index ([BMI] measure body weight to height and whether a resident has a healthy weight) was 17.9 (BMI between 18.5 and 24.9 -underweight, BMI healthy range -between 25 and 29.9, and BMI between 30 and 39.9- overweight). The RD's Nutrition/Dietary Progress Note indicated RD's recommendation to change GT enteral feeding formula to 250 ml five times a day to provide Resident 129 with 1250 ml (1500 kcal) daily. The RD's Nutrition/Dietary Progress Note indicated the RD's full assessment of Resident 129 nutritional needs will follow. During a review of Resident 129's Nutritional Review Screening, dated 4/29/2024 completed by Dietary Supervisor (DS) indicated based on Resident 129's usual body weight (UBW) of 115 lbs. the resident's estimated daily need for calories were 1495-1709 kcal. The Nutritional Review Screening indicated recommendation including change enteral feeding to 250 ml five times daily to provide 1250 ml equal to 1500 kcal, 67 grams of protein, 1512 ml of free water (fluids with no salt content), and Multivitamins (dietary supplement containing all or most of the vitamins) with Minerals. During a review of Resident 129's Medication Administration Record (MAR) dated 5/2024, the MAR indicated the Enteral Feeding Order for Fibersource HN 1.2 four times a day as follows: 250 ml (Breakfast), 500 ml (Lunch), 250 ml (Dinner), 250 ml (Bedtime). During a review of Resident 129's Physician Order Summary dated 5/2024, indicated Enteral Feeding Order for Fibersource HN 1.2 four times a day as follows: 250 ml (Breakfast), 500 ml (Lunch), 250 ml (Dinner), 250 ml (Bedtime). During a review of Resident 129's MAR for the month 5/2024 indicated Resident 129 only received 250 ml of Fibersource for lunch instead of 500 ml as ordered: 1. From 5/3/2024 to 5/13/2024 (10 days) - Fibersource 250 ml. 2. On 5/14/2024- Fibersource 300 ml. 3. From 5/18/2024 to 5/20/2024 (there days)- Fibersource 250 ml. 4. On 5/27/2024- Fibersource 250 ml. During a concurrent interview and record review on 6/12/2024 at 11:05 a.m., the Director of Nursing (DON) stated residents (in general) with weight loss will trigger for weekly weight variance review (report generated to determine how much weight a resident has lost and recommendations to prevent further weight loss) and a weekly weight variance meeting to discuss the plan of care for a residents (in general). The DON stated Resident 129 was triggered for a weight variance weekly review meetings because the resident was at high risk for weight loss. The DON stated weekly weight variance meeting allows the facility to monitor Resident 129's weight and allows the facility to ensure that implemented interventions were successful. The DON stated weekly weight variance meeting also allows to evaluate if other interventions could be implemented to prevent further weight loss. The DON stated the weekly weight variance meetings were documented on the Progress Notes by nursing and the RD. After a review of Resident 129's Nurses Progress Notes and RD Progress Notes the DON stated, there was no documentation from nursing and the RD for the weekly variance meetings to address the resident's weight loss. The DON stated, if there was no documentation it means it was not done. After the DON reviewed Resident 129's Initial Nutritional Assessment, the DON confirmed the last documentation from the RD was the initial mini nutritional assessment (nutrition screening and assessment tool that can identify residents who are malnourished or at risk of malnutrition) done on 4/29/2024. The DON stated 9.57 % weight loss was considered a severe weight loss and required weekly monitoring by the facility. The DON stated the RD should have monitor Resident 129 to ensure the resident did not lose additional weight. The DON stated the staff communicates with the RD via text message regarding the weekly weight variance meetings. The DON stated it was the licensed nurses responsibility to ensure Resident 129's weight loss was communicated to the resident's physician and RD in order to prevent negative outcomes such as severe weight loss and dehydration. The DON stated when residents (in general) do not receive adequate nutrition they could have negative effects such as skin break down and malnutrition. During a concurrent interview and record review on 6/12/2024 at 1:30 p.m. with RD, the RD stated she was responsible for nutritional assessments of residents on admission and quarterly assessment which includes evaluating and addressing residents' (in general) high risk for weight loss. RD stated residents (in general) who were on GT feedings should be weighed weekly and a weekly variance meeting should be held to discuss interventions to prevent weight loss. The RD stated she does not attend the weight variance meeting; the licensed staff communicates with her via text message about any weight loss and other concerns discussed during the weight variance meeting. The RD stated she follows up with residents (in general) that have weight loss weekly. The RD stated she has done Resident 129's mini nutritional assessment on 4/29/2024 and a full assessment of Resident 129 nutritional status and needs should have been done as well. The RD confirmed that Resident 129's full assessment had not been done since the resident's admission to the facility on 4/27/2024. After RD reviewed her weekly progress notes, for Resident 129, she stated there was no weekly documentation for Resident 129's weight loss. Resident 129's Nutrition/Dietary Progress, dated 4/28/2024, indicated recommendation to change GT feeding to 250 ml five times daily to provide 1250 ml equivalent of 1500 kcal. with full assessment to follow. Reviewed Resident 129's MAR date 5/2024, the MAR indicated Enteral Feed Order four times a day Fibersource HN 1.2 250 ml (Breakfast), 500 ml (Lunch), 250 ml (Dinner), 250 ml (Bedtime). The RD stated Resident 129's enteral feeding order for 250 ml four times a day was not providing enough calories to Resident 129 and confirmed the facility's staff did not follow with her recommendation to increase the feeding to 250 ml five times a day. The RD stated Resident 129 did not receive the estimated needs of 1511 to 1727 kcal a day. The RD stated 9.57 % weight loss in 34 days was considered a severe weight loss and the facility's staff should have reported it immediately to Resident 129's physician and her. The RD stated Resident 129 could have become malnourished which would cause further skin breakdown from not receiving enough calories and protein per day. During a concurrent interview and record review on 6/12/2024 at 2:09 p.m., with LVN 1, LVN 1 stated during weekly weight variance meetings residents (in general) weight loss was discussed. LVN 1 stated any recommendations from the weekly weight variance meetings were communicated to the RD via text message and documented on the Nurses Progress Notes. LVN 1 reviewed Resident 129's Nurses Progress Notes and stated there was no documentation RD was notified about Resident 129's severe weight loss. LVN 1 confirmed that there was no documentation for Resident 129's weekly weight variance meeting and it was not held since Resident 129's admission on [DATE]. LVN 1 stated if it was not documented it means it was not done. LVN 1 stated 9.57 % weight loss in 34 days was considered a severe and had the potential to cause a negative outcome for Resident 129's health. During an interview on 6/12/2024 at 2:23 p.m., the Dietary Supervisor (DS) stated she attends the weekly weight variance meetings. The DS stated she communicates with RD on Mondays regarding the weekly weight variance meeting. The DS stated there was no weight variance meeting held for Resident 129's severe weight loss of 9.57 % in 34 days from 4/27/2024 to 6/1/2024. The DS stated it was important to monitor Resident 129's weight to ensure that the interventions were effective in order to prevent further weight loss. The DS stated Resident 129's severe weight loss put the resident at risk for dehydration, malnutrition, skin breakdown and hospitalization. The DS stated nursing staff document the weekly weight variance meetings in a resident's (in general) Progress Notes. The DS stated 9.57% of weight loss in 34 days was considered a severe weight loss. During a review of the facility's P&P titled, Weight Assessment and Intervention dated 9/2008, indicated, Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. The Dietician will review the unit weight record by the 15th of the month for follow individual weight trends over time. During a review of the facility's P&P titled, Enteral Nutrition, dated 11/2018, the P&P indicated, The dietician with input from the provider and nurses: estimate calorie, protein, nutrients, and fluid needs. Determine whether the resident's current intake is adequate to meet his or her nutritional needs. The dietician monitors residents who are receiving enteral nutrition and makes appropriate recommendations for intervention to enhance tolerance and nutritional adequacy of enteral feedings. During a review of the facility's P&P titled, Nutritional Assessment, [undated], indicated, The Dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that place the resident at risk for impaired nutrition. During a review of the facility's P&P titled, Nutrition Impaired/Unplanned Weight Loss-Clinical Protocol, [undated], indicated, The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include evaluating the care plan to determine if the interventions are being implement and whether they are effective in attaining the established nutritional and weight goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident, who had a Stage 4 pressure ulcer (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joints}, and bones caused by prolonged pressure on the skin) to sacrum (tailbone area), did not experience unnecessary pain and suffering during pressure ulcer treatment and repositioning for one of five sampled residents (Resident 73). The facility failed to: 1. Ensure the Registered Nurse (RN 6) provided Resident 73 with effective pain relieve when Resident 73 loudly screamed and moaned during the sacral pressure ulcer treatment. 2. Evaluate the pain relieve effectiveness of Tylenol (pain medication) 325 milligrams ([mg]-a unit of measurement) two tablets given to Resident 73's as ordered prior to pressure ulcer treatment before the start of pressure ulcer treatment. 3. Notify Resident 73's physician (MD 1) of Resident 73's pain management with Tylenol was unsuccessful when Resident 73 continue to moan and scream during the pressure ulcer treatment on 6/10/2024 and 6/13/2024. 4. Ensure RN 6 identified frequency, location, quality, onset, and manner of pain when Resident 73's experienced pain, in accordance with the resident's Care Plan titled, Potential for altered comfort which maybe evidenced by grimacing or moaning related to a Stage 4 pressure ulcer to the sacral area, bilateral knee osteoarthritis (degenerative joint disease) and pancreatic mass (tumor that forms in the cells of pancreas) dated 4/20/2023. These failures resulted in Resident 73's to experience severe, unrelieved, and uncontrolled pain manifested by loud screaming and moaning during pressure ulcer treatment and personal care on 6/10/2024 and 6/13/2024. Findings: During an observation and concurrent interview on 6/10/2024, at 10:09 a.m., Resident 73 was observed screaming, groaning, and moaning with facial grimaces (facial expression usually suggesting pain or disgust). Concurrently, during an interview, Resident 73 nodded the head Yes and grimaced when asked if she was having pain. During an interview on 6/10/2024, at 10:09 a.m. with Resident 62 (Resident 73's roommate) Resident 62 stated Resident 73 was constantly groaning and moaning especially when staff was cleaning or doing personal care. Resident 62 stated staff members were aware of Resident 73's moaning and screaming. During an observation of RN 6 preparation for Resident 73's sacral pressure ulcer treatment on 6/10/2024, at 10:30 a.m., in Resident 73's room, Resident 73's physician (MD 1) entered the resident 's room and informed RN 6 he (MD 1) will put an order for Norco (narcotic [used to treat moderate to severe pain] pain medication) to administer prior to pressure ulcer treatment as Resident 73 was observed moaning and screaming. RN 6 replied to MD 1 that Resident 73 does not need Norco as Resident 73 will receive Lidocaine spray (anesthetic topical [applied to the skin] spray) prior to the pressure ulcer treatment. During an observation Resident 73's pressure ulcer treatment on 6/10/2024, at 10:32 a.m., Resident 73 was observed screaming and moaning when RN 6 positioned Resident 73 on her back with head of the bed in a flat position. RN 6 left Resident 73's room and ask another staff member to assist during pressure ulcer treatment. RN 6 came back with the Director of Staff Development (DSD). RN 6 and DSD turned Resident 73 to her right side. Resident 73 continuously moaned and screamed. RN 6 was observed to spray Resident 73's sacral Stage 4 pressure ulcer surrounding area with Lidocaine spray before the start of treatment. Resident 73 screamed and moaned louder when RN 6 cleaned the reddened surrounding area of Stage 4 sacral pressure ulcer with Hibiclens (liquid antibacterial cleanser) and applied Collagen powder (wound dressing that is applied topically) to the pressure ulcer. RN 6 completed the pressure ulcer treatment despite Resident 73's moaning and screaming. During a review of Resident 73's admission Record, the admission Record indicated Resident 73 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified dementia (loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), osteoarthritis of both knee (degenerative joint disease), a Stage 4 pressure ulcer to the sacral region, and attention/ concentration deficit. During a review of Resident 73's History and Physical (H& P) dated 5/9/2024, indicated Resident 73 was not able to express needs, communicate, not to follow commands and talked in full sentences. Resident 73 had no decisions making capacity. During a review of Resident 73's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 5/1/2024, indicated Resident 73 was dependent on staff for bed mobility, moving from sitting on side of bed to lying flat on bed, toileting hygiene, bathing, dressing, personal hygiene, and oral hygiene. The MDS indicated Resident 73 had a Stage 4 pressure ulcer on the sacrum (sacral area). During a review of Resident 73's Physician's Order dated 6/10/2024, the Physician's Order indicated the order for Lidocaine spray to apply to the resident's sacral area topically every day for pain management during sacral pressure ulcer treatment. During a review of Resident 73's Physician Order dated 4/20/2024, the Physician order indicated to cleanse sacral wound with Hibiclens, pat dry, apply Collagen powder to the pressure ulcer base then apply Hydrofera Blue (special dressing type) then cover with Allevyn (dressing) every day (7 a.m.to 3 p.m.) Monday, Wednesday, and Friday. During an interview on 6/10/2024, at 10:45 a.m., and subsequent interview on 6/10/2024, at 11:22 am., with RN 6, RN 6 stated the Lidocaine spray was the only medicine he used to help with Resident 73's pain during pressure ulcer treatment. During a concurrent interview and record review on 6/12/2024 at 9:36 a.m., with DSD, the DSD stated for residents, who are not able to verbalize pain, the facility was using the facial pain scale tool (a picture with of different facial expressions referencing different pain level to help a resident effectively communicate the severity of their physical pain) to assess pain level. The DSD stated Resident 73 screamed loudly when RN 6 cleansed Resident 73's pressure ulcer with Hibiclens and when the Collagen powder was applied to the resident's Stage 4 sacral pressure ulcer. The DSD stated when Resident 73 screamed loudly during the pressure ulcer treatment, RN 6 should have stopped the treatment, assessed Resident 73 pain level, including the non-verbal cues like facial grimacing, notified the physician, and provide Resident 73 pain medication. The DSD reviewed Resident 73's Medication Administration Record (MAR) and stated Resident 73 received Tylenol 325 mg two tablets on 6/10/2024, at 10:07 a.m., prior to pressure ulcer treatment for pain level 3 out of 10 on a pain scale rating from zero to ten (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). The DSD stated based on Resident 73 screaming and moaning during sacral pressure ulcer treatment Tylenol given at 10:07 a.m. was not effective to alleviate Resident 73's pain. The DSD stated Resident 73 experienced excruciating (extremely painful, causing intense suffering) pain and discomfort during the pressure ulcer treatment which was unnecessary pain. The DSD stated RN 6 should have asked the physician for a stronger pain medication after the resident screamed during sacral pressure ulcer treatment on 6/10/2024. During an interview on 6/12/2024, at 3:31 p.m., with Treatment Nurse (TN 1), the TN 1 stated she coordinated Resident 73's pressure ulcer treatment with the charge nurse in order to give pain medication to the resident before pressure ulcer treatment. TN 1 stated for residents, who could not verbalize pain and its severity, the staff used non-verbal indication of pain like screaming, moaning, or crying, and facial grimace. TN 1 stated Resident 73 screamed and moaned during pressure ulcer treatment, and it was an indication the resident was in excruciating pain. TN 1 stated Lidocaine spray was used topically and only applied on the skin and would not be enough to help with the pain during treatment. TN 1 stated if the resident screamed and moaned during pressure ulcer treatment RN 6 should have stopped the treatment, call the physician because the Lidocaine spray was not effective in managing Resident 73's pain. TN 1 stated Resident 73 should be assessed for pain before and during pressure ulcer treatment. TN 1 stated Resident 73's unrelieved pain could affect her health and comfort if her pain was not managed effectively. During an interview and record review on 6/12/2024 at 4:08 p.m., RN 6 stated when Resident 73 screamed from pain during the pressure ulcer treatment, he should stopped the treatment and notified the Resident 73's MD 1. RN 6 stated on 6/10/2024, MD 1 came to the resident's room and told him (RN 6) about ordering Norco for pain because of the moaning and crying, and confirmed he told MD 1 Resident 73 did not need Norco because the Lidocaine spray was being applied to the pressure ulcer. RN 6 stated Resident 73's family did not want the resident to have any strong pain medication. RN 6 confirmed thru record review of Interdisciplinary Team Meeting ([IDT]-a healthcare team members and resident / family representative collaborate, solve problems, plan, and coordinate care of the resident) Notes and Care Plan there was no documentation of Resident 73's family not wanting strong pain medication to be given to Resident 73 during pressure ulcer treatment. RN 6 stated Resident 73 was suffering from pain during a sacral pressure ulcer treatment manifested by the resident's screaming and moaning. RN 6 stated Resident 73 continued to suffer from pain because her pain was not addressed and managed during the pressure ulcer treatment on 6/10/2024. RN 6 stated Tylenol's pain relieve effectiveness was not evaluated prior to begin the treatment. During an observation on 6/13/2024, at 10:54 a.m., with TN 1 and Certified Nursing Assistant (CNA 5) in Resident 73's room, Resident 73 was observed starting moaning during repositioning. Resident 73 observed moaned louder as the TN 1 started to clean the surrounding skin area of the sacral pressure ulcer and applying the Collagen powder on the pressure ulcer. TN 1 observed to pause the pressure ulcer treatment and started reassuring the resident and massaging the resident's skin. TN 1 was observed to resume the treatment when Resident 73 stopped moaning. During an interview on 6/13/2024, at 12:45 p.m. the TN 1 stated Resident 73 moaned during pressure ulcer treatment due to pain. TN 1 stated the resident had dementia and it was hard to tell when the resident was in pain, but the presence of pain should still be addressed by staff by using the resident's facial clues, grimacing, moaning and jerky movement during treatment. During an interview on 6/13/2024, 2:04 p.m., CNA 5 stated every time she would clean and change Resident 73 after a bowel movement, the resident would moan and cry. CNA 5 stated Resident 73 would also moan during pressure ulcer treatment. During a review of Resident 73's Care Plan titled Potential for altered comfort evidenced by grimacing or moaning related to a Stage 4 pressure ulcer to the sacrum, bilateral knee osteoarthritis and pancreatic mass (tumor that forms in the cells of pancreas), dated 4/20/2023, the goal for Resident 73 was to be comfortable. The Care Plan's interventions included to identify frequency, location, quality, onset, and manner of expressed pain and administer medication as ordered. During a review of Resident 73's Care Plan titled, Resident has a Stage 4 sacral pressure ulcer on admission, initiated on 10/30/2023 indicated one of the interventions was to assess pain and discomfort at site of the altered skin area. During a concurrent interview and record review of Resident 73's Physician Order on 6/13/2024, at 3:31 p.m. with Director of Nursing (DON), the DON confirmed the physician order for Tylenol 325 mg two tablets for pain relief did not include the pain parameters, however, Resident 73 had an order to monitor the intensity of pain using numerical pain rating scale. The DON stated pain level was not assessed properly and Resident 73's pain was not managed effectively during pressure ulcer treatment. The DON stated Resident 73 should be assessed for pain during and after pressure ulcer treatment. The DON stated if the resident was experiencing pain by screaming and moaning, the pressure ulcer treatment should be stop, the staff should have assessed the resident for pain, addressed the pain if pain was present, called Resident 73's physician to notify about the presence of pain. The DON stated Resident 73 had experienced undue suffering which could have been prevented if the resident was assessed properly for pain management. During a review of facility's policy and procedure (P&P) titled Pain Assessment and Management, undated, the P&P indicated to observe the resident during rest and movement for physiologic and behavioral (non-verbal) signs of pain. The P& P indicated possible behavioral signs of pain are verbal expressions such as groaning, crying, screaming, facial expressions such as grimacing, frowning, behavior such as resisting care, irritability, or depression. The P&P indicated to review resident's treatment record to identify any situations or interventions where an increase in the resident's pain may be anticipated such as treatment like wound care or dressing changes. During a review of facility's P&P titled Pressure Ulcer Treatment, undated, the P&P indicated to review the resident's care plan to assess for any special needs of the resident. The P&P indicated for residents who had a Stage 4 Pressure Injury one of the guidelines was to manage pain during wound care. According to a review the article titled The Symptoms of Pain with Pressure Ulcer: A Review of the Literature, dated 5/2008 on website for Wound Care Leading Management and Prevention, pain is an issue in persons with pressure ulcers, measuring and managing pain will become more important for effective care with an aging population at risk for pressure ulcer development. https://www.hmpgloballearningnetwork.com/site/wmp/content/the-symptom-pain-with-pressure-ulcers-a-review-literature

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a resident was placed securely in the sling (part of a lift system placed under and around patients who have mobility issues to assist them to be lifted and transferred safely from a bed, wheelchair, toilet, or shower) for a mechanical lift (a device used to ensure the safe transfer of patients from one location to another), prior to being transferred from a bed to a wheelchair, for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 falling from the mechanical lift onto his bed and sustaining a fracture (partial or complete break in the bone) of his clavicle (the collar bone) and his rib (chest bone). Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation, treatment, and a Computed Tomography scan ([CT scan] a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body) of his head. Findings: During a review of Resident 1's admission Record (Face sheet), the Face Sheet indicated, Resident 1 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. The Face Sheet indicated, Resident 1 had diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move on one side of the body) following a cerebral infarction (a stroke) affecting the left dominant side of Resident 1's body, epileptic seizures (a disorder of the brain causing uncontrolled electrical activity in the brain, which may produce a physical convulsion, thought disturbances, or a combination of symptoms and a nontraumatic intracranial hemorrhage (bleeding into the brain in the absence of trauma or surgery). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/29/2023, the MDS indicated, Resident 1's cognition (thinking, attention, language, learning, memory, and perception) was intact. The MDS indicated, Resident 1 required extensive one-person physical assist for bed mobility. Resident 1 was totally dependent and required a two-person physical assist for transfers and toilet use. During a review of Resident 1's Care Plan, dated 4/5/2022, the Care Plan indicated Resident 1 had an activity of daily living ([ADL] activities related to personal care) self-care performance deficit related to hemiplegia and hemiparesis. The goals indicated, Resident 1 would improve his functional abilities with less support from staff while maintaining comfort and safety. The Care Plan interventions indicated, Resident 1 required assistance and may use a mechanical lift for transfers. During a review of Resident 1's Nursing Progress Notes, dated 6/13/2023, timed at 5:15 p.m., the Progress Notes indicated, at approximately 12:30 p.m., Resident 1 was found on the floor with his head on the lap of Certified Nurse Assistant (CNA) 1. The Progress Notes indicated CNA 1 reported that Resident 1 had an assisted fall while being transferred from his bed to his wheelchair using a mechanical lift. The Progress Notes indicated Resident 1 had a bump on his left forehead and Resident 1 reported he hit his head but stated he did not remember where he hit his head. The Progress Notes indicated Resident 1's physician was called, and an order was obtained to transfer Resident 1 to a GACH for further evaluation and a CT scan of Resident 1's head. During a review of Resident 1's Situation, Background, Assessment, & Recommendation ([SBAR] a form of communication between members of a health care team) dated 6/13/2023 and timed at 1:14 p.m., the SBAR indicated, Resident 1's left upper extremity was sensitive to touch, he was unable to move, and he had a left forehead bump with discoloration and slight bleeding at the site that was sensitive to touch. During a review of Resident 1's Physician Orders, dated 6/13/2023, the Physician's Orders indicated, to transfer Resident 1 to a GACH emergency room (ER) for further evaluation after Resident 1 fell and sustained a head injury. During a review of Resident 1's Nursing Progress notes, dated 6/13/2023, at 6:29 p.m., the Nursing Progress notes indicated, Resident 1was picked up by an ambulance and transported to the GACH. During a review of the GACH's CT report of Resident 1's chest dated 6/13/2023, and timed at 8:01 p.m., the CT indicated, Resident 1 had a nondisplaced (a fracture in which the bone cracks or breaks but retains its proper alignment) left sixth posterior (direction toward the back of the body) rib fracture. During a review of the GACH's X-ray of Resident 1's left shoulder, dated 6/13/2023, and timed at 9:56 p.m., the X-ray indicated, Resident 1 had an anterior (front) subluxation (dislocation) of the left humeral head (shoulder) and a nondisplaced fracture of the distal (away from the trunk of the body) left clavicle (collar bone). During a review of the GACH's Emergency Department (ED) Physician Notes, dated 6/13/2023 and timed at 10:36 p.m., the ED notes indicated, Resident 1 had a shoulder reduction (the process of returning the shoulder to its normal position following a shoulder dislocation) and Resident 1's left shoulder was placed in a sling (a device that keeps the arm against the body and prevents too much movement). During an observation on 10/24/2023, at 12:38 p.m., CNA 1 prepared to transfer Resident 2 using a mechanical lift. CNA 1 quickly attached each hook on the mechanical lift to the sling that was under Resident 2. CNA 1 got assistance from another CNA (CNA 2) but CNA 1 nor CNA 2 did not check to ensure all hooks were safely connected and secured to the mechanical lift prior to transferring Resident 2 from his bed. During an interview on 10/24/2023, at 1:09 p.m., CNA 1 stated, there should be two people assisting while using a mechanical lift at all times. CNA 1 stated, regarding the fall incident on 6/13/2023, she looked for assistance to transfer Resident 1, but everyone was busy, and Resident 1 told her to hurry up because his family was visiting so she transferred Resident 1 using the mechanical lift alone without assistance from another staff member. CNA 1 stated, she put the sling under Resident 1's body and placed the hooks from the mechanical lift into the sling's openings. Resident 1 held onto the bar on the mechanical lift with his right hand while she lifted him using the mechanical lift. CNA 1 stated, one of the hooks on the upper left side of the sling came off and Resident 1 fell on top of the upper left side of his bed. CNA 1 stated Resident 1's legs were still in the sling and hanging from the mechanical lift and he was at an angle diagonally across his bed. CNA 1 stated she lowered the mechanical lift and Resident 1 fell onto the bed with his body slightly raised in the air while still attached to the sling that was still attached to the mechanical lift. Resident 1's right foot was hanging off the bed touching the ground and his left leg was on the bed. CNA 1 stated Resident 1 was holding onto her and would not let her go. Resident 1 was too heavy, and she had to lower Resident 1 onto the floor. CNA 1 stated she used the mechanical lift alone, because everyone was busy, and she felt confident enough to transfer Resident 1 on her own. CNA 1 stated it was important to use two people to assist when using the mechanical lift to keep the resident safe. CNA 1 stated she was instructed during in-services that two people were to always be present and assist when using a mechanical lift. During an interview on 10/24/2023, at 2:50 p.m., LVN 1 stated, CNA 1 reported to her that Resident 1 fell, she (LVN 1) went to Resident 1's room where she saw Resident 1 on the floor next to his bed. LVN 1 stated she assessed Resident 1 and noted a bump on the left side of Resident 1's head. During an interview on 10/24/2023, at 3:01 p.m., Registered Nurse Supervisor (RNS) 1 stated, two people were needed to transfer a patient using a mechanical lift. RNS 1 stated, CNA 1 reported that she was transferring Resident 1 from his bed to his wheelchair when Resident 1 slipped from the mechanical lift. RNS 1 stated when she entered Resident 1's room, CNA 1 was holding Resident 1's head in her lap and CNA 1 told her that she (CNA 1) caught Resident 1 when Resident 1 slipped from the mechanical lift. RNS 1 stated she assessed Resident 1 and found a bump on Resident 1's left forehead During an interview on 10/24/2023, at 3:37 p.m., the Director of Staff Development (DSD) stated, if a resident could only use one side of his body, then two people should assist when using a mechanical lift. The DSD stated Resident 1 required two people to transfer him using a mechanical lift because Resident 1 had left sided weakness and Resident 1's right side might not be strong enough to hold onto the mechanical lift. The DSD stated this injury was avoidable if the policy and procedure had been followed. The DSD stated, staff should make sure the sling is safely secured on the hooks of the mechanical lift, the second person provides a second check for safety and supports the upper back of the resident during the transfer. The DSD stated if everyone was busy, CNA 1 should have waited until someone came to assist before transferring Resident 1 by herself. During an interview on 10/25/2023, at 4:39 p.m., Director of Nursing (DON) 2 stated, it was reported to her that Resident 1 slipped from a mechanical lift, complained of chest pain, and was transferred to a GACH for a CT scan. DON 2 stated the hooks of the mechanical lift that go into the sling should have been checked to make sure the hooks were secured properly, and CNA 1 must have missed a step when using the mechanical lift. DON 2 stated the importance of using two people and checking that the hooks were secured properly was to prevent an accident such as a fall from the mechanical lift. During a review of the facility's Policy and Procedure (P/P), Lifting Machine, using a Portable revised 4/2007, the P/P indicated the portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two nursing assistants will be required to perform the procedure.