**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to implement appropriate nutritional interventions for one (#26) out of 20 sample residents to maintain acceptable parameters of nutritional status. Resident #26, age [AGE], was admitted to the facility on [DATE] with diagnoses of heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, history of falling and anxiety. Resident #26 sustained a weight loss of 10.6% (20.5 lbs) from admission on [DATE] through 1/31/23, which was considered significant. According to Resident #26's nutrition care plan, pertinent interventions initiated 3/4/23 included to monitor, record and report to the physician as needed any signs and symptoms of malnutrition such as significant weight loss and obtain and monitor lab/diagnostic work as ordered. Report results to the physician and follow up as indicated. Resident #26's labwork, dated 2/17/23, revealed his Albumin was 2.8 (ranges 3.4-5) indicating it was low. Review of the physician progress notes revealed no documentation of the resident's significant weight loss and poor nutritional status. There was no documentation on expected or unplanned weight loss, or updated care plan goals and interventions. The dental care plan was initiated on 2/22/23 (six weeks after Resident #26 admission) revealed he was edentulous and chose not to wear dentures. Pertinent interventions included to consult with the dietitian and change the resident's diet (regular diet) if chewing/swallowing problems were noted; encourage to eat meals, and observe for any difficulty with chewing and swallowing. Findings include: I. Facility policy and procedure The Weight Monitoring Policy, dated October 2022, was provided by the nursing home administrator (NHA) on 5/17/23 at 2:48 p.m. The policy read in pertinent part, Based on resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident's preferences indicate otherwise. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions b. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss c. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed d. If the interdisciplinary care team desires to explore specific meal consumption information for a resident, the Registered Dietician, Dietary Manager, or the nursing department may initiate this process. II. Resident #26 Resident #26, age [AGE], was admitted on [DATE]. According to the May 2022 clinical physician orders (CPO), the diagnoses included heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, history of falling and anxiety. The 2/26/23 minimum data set (MDS) significant change in status assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 13 out of 15. No behaviors or rejection of care were documented. He required extensive assistance of two staff with bed mobility and transfers, extensive assistance of one person with dressing, toilet use and personal hygiene and supervision with eating. He was continent. He sustained two or more falls with no injuries since admission. Section K (Swallowing/Nutrition Status) revealed the resident height was 71 inches (five foot 11 inches) and weight was 177 pounds. Loss of weight was documented as not on physician prescribed weight-loss regimen. The resident complained of difficulty with swallowing. Section L (Oral/Dental Status) documented no natural teeth. He received an antianxiety, anticoagulant, antibiotic and diuretic medications. The 1/20/23 MDS admission assessment revealed the resident's weight was 191 pounds, no weight loss and he did not complain of difficulty with swallowing. III. Resident interview and observations Resident #26 was interviewed on 5/15/23 at 2:23 p.m. He said he was not eating much because he did not have an appetite and could not chew. He said he had no teeth. Resident #26 was observed in the dining room, during the lunch meal on 5/15/23, 5/16/23 and 5/17/23. Each meal he took a few bites of food and consumed approximately 25%. Resident #26 was interviewed on 5/17/23 at 12:40 p.m. He said he was unable to chew the meat (BBQ pork rib) and had difficulty swallowing it. He said the staff did not offer him different food choices. IV. Record review A. Nutritional care plan The nutritional care plan, initiated 1/22/23, documented, Elder (resident) has unintentional weight loss. Interventions included: Invite the resident to activities that promote additional intake. Monitor/record/report to MD (physician) PRN (as needed) s/sx (signs/symptoms) of malnutrition (initiated on 3/4/23). Obtain and monitor lab/diagnostic work as ordered, report results to MD (physician) and follow up as indicated. Offer alternative meal choices as needed. Provide and serve supplements as ordered, Magic cup BID (two times a day) (initiated 3/4/23). Provide, serve diet as ordered, monitor intake and record q (every) meal. RD (registered dietitian) to evaluate and make diet change recommendation PRN (as needed). B. Dental care plan The dental care plan, initiated 2/22/23, documented, Elder is edentulous. He has dentures, but chooses not to wear them saying that he eats fine without them. Interventions included: Diet as ordered. Consult with dietitian and change if chewing/swallowing problems are noted. Encourage him to eat meals and offer snacks, observe for any difficulty with chewing and swallowing his food related to edentulous status. C. Physician orders -RCS/CC (reduced concentrated sweets/carbohydrate control) diet, regular texture; -Magic cup (nutritional ice cream supplement), two times a day for weight loss, order date 2/2/23; and, -Lasix oral tablet 80 mg (Furosemide) (diuretic), give one tablet by mouth one time a day related to heart failure. D. Resident #26's weights The Hospital Summary, dated 1/13/23, revealed the resident's weight on 1/9/23 was 94.5 kg (207.9 lbs). Resident #26 weights were documented in the medical record as follows: -On 1/13/23 the resident weighed 192 lbs (15.9 lbs difference from the hospital weight obtained the same day); -On 1/17/23 the resident weighed 182.5 lbs (9.5 lbs or 5% weight loss); -On 1/31/23 the resident weighed 171.5 lbs (20.5 lbs or 10.5% weight loss); -On 3/14/23 the resident weighed 176.7 lbs; and, -On 5/3/23 the resident weighed 176 lbs. E. Nutritional progress notes On 1/22/23 the RD documented: Attended weekly weight meeting on 1/19/23 via phone .Diet RCS/CC. Eating 56% average/day. Skin intact. Edema: none noted. No new recommendations. Continue current interventions. -The RD note did not document the weight difference from the hospital (15.9 lbs). No edema was noted with the resident being on diuretic medication. No nutritional interventions were put in place with the resident's weight loss and on average poor intake. On 1/28/23 RD documented: Attended weekly weight meeting on 1/26/23 via phone .Diet RCS/CC. Eating 54% average/day .Weight 1/24/23 182.5 lbs .Skin intact. Edema: none noted. No new recommendations. Continue current interventions. On 2/2/23 interdisciplinary team (IDT) note revealed: (Resident) is on weekly weight monitoring related to new admission with weight loss. Elder states he has difficulty swallowing at times and in the past has had his esophagus dilated. Appointments are being made regarding this. (Physician) is aware of weight loss and stools are being heme tested. His average PO (oral) intake is 46% and his average daily fluid intake is 789 ml. He accepted one snack and refused two meals. Magic cup has been ordered and elder will be offered one twice daily. Continue current interventions and weekly monitoring. On 2/4/23 RD documented: Attended weekly weight meeting on 2/2/23 via phone. Following weekly r/t (related to) new admission, weight loss. Diet RCS/CC. Eating 46% average/day . Edema: none noted. Recommendation: Magic cup BID (two times a day). Continue current interventions. -The resident had 20.5 lbs weight loss on 1/31/23 and a supplement was not offered until 2/2/23 when the resident had consistent poor intake. The resident was on diuretic medication with no edema noted in the RD documentation. On 2/23/23 IDT note revealed: (Resident) is on weekly weight monitoring related to weight loss. His average PO (oral) intake is 56% and his average daily fluid intake is 1029 ml. He accepted two snacks and did not refuse any meals .He accepted 11 out of 14 Magic Cup administrations. Continue current interventions and weekly monitoring. On 2/24/23 RD documented: Attended weekly weight meeting on 2/23/23 via phone. Following weekly weight loss. Diet: RCS/CC. Eating 56% average/day. Supplements: Magic cup BID (two times a day). Accepted 11 out of 14. Magic cup provides 260 kcal/9 gm protein per serving. Fluids: Average of 1029 ml of fluid/day from meals/supplement, plus additional water in room. Weight: 2/21/23 167 lbs. BMI: 23.3-within normal limits for height. c/o (complained of) difficulty swallowing .Edema: none noted. Recommendation: none at this time. Continue current interventions. Continue to follow weekly until weight stabilizes. -The interdisciplinary team and the RD failed to address the resident's swallowing difficulty that was noted when he was having significant weight loss. The resident was not evaluated for different food consistency, mechanical soft diet. F. Laboratory report The 2/17/23 labwork report revealed Albumin level 2.8 (low) (reference range 3.4 - 5.0) -The interdisciplinary team and the RD failed to address the resident's low Albumin level. G. Meal intakes Meal intake records/amount eaten, were reviewed for January 2023 and May 2023 revealed the documented food consumed by Resident #26 averaged approximately 50%. -However, per observations (see above) the resident ate approximately 25% for three lunch meals and per staff interviews (see below) the resident often did not eat much (25-50%) and refused at times. H. Physician notes Review of the physician notes, dated 2/16/23 and 3/21/23, revealed no documentation related to Resident #26 significant weight loss, difficulty swallowing and low Albumin level. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/17/23 at 11:27 a.m. She said she knew the resident well since his admission. She said she worked with Resident #26, usually five days per week. She said the resident did not eat well at any of his meals. She said he never finished his meals and frequently he had just a few bites. She said most of his meal intake was 26% to 50% and occasionally he refused to eat. She said the resident was on a regular diet. She said the resident's weekly weights were documented on the weights sheet and given to the nurse who would record the weights in the resident's electronic medical record. CNA #2 was interviewed on 5/17/23 at 12:43 p.m. She said she worked with the resident since his admission and knew him well. She said the resident was independent with eating however he did not eat much of his meals. She said the resident ate very little, he liked sweets. She said she was not aware the resident had difficulty swallowing his food. The NHA and the director of nursing (DON) were interviewed on 5/17/23 at 1:30 p.m. The NHA said the RD was a contractor not a full time employee and was coming to the facility every couple of weeks. She said the RD attended the weights meeting by calling on her phone. The DON said Resident #26 experienced a significant weight loss after his admission however his weight stabilized after a few weeks. She said the interdisciplinary team did not review the resident's medications during the weights meeting. She said the resident's physician was contacted after each meeting, however she was not aware the physician did not document the resident's significant weight change. She said the RD and the IDT were aware of Resident #26's difficulty chewing and swallowing, however she did not realize his diet texture change was not addressed as well as a swallow evaluation. She said the resident's low Albumin level was not addressed during the weights meeting and no other interventions and supplements were taken under consideration. She said she would provide staff training to ensure all residents' food intake was documented accurately. The RD was not available for an interview and did not return a phone call.

Based on record review and interviews, the facility failed to ensure individuals with a finding entered into the State nurse registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property for one of five sampled staff members. Specifically, the facility failed to ensure residents were free from employee negligence by employing LPN #5 with a known history of negligence entered into the State nurse registry. Cross reference: F690 (Catheters), the facility failed to follow physician's orders for catheter placement resulting in harm to Resident #4. Findings include: I. Facility policy and procedure The Background Screening policy and procedure, not dated, was provided by the nursing home administrator (NHA) on 11/21/19 at 1:10 p.m. It revealed, in pertinent part, Our campus conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees. For any licensed professional applying for a position that may involve direct contact with elders, his/her respective licensing board will be contacted to determine if any sanctions have been assessed against the applicant's license. Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual has been convicted of abuse, neglect, mistreatment of individuals, and/or theft of property further interviews and reference checks must show that it is probable that the candidate no longer exhibits this type of behavior and they do not present a risk to the elders. A. Record review Licensed practical nurse (LPN) #5 employee record was reviewed on 11/20/19 at 9:00 a.m. It revealed LPN #5 was initially hired in March 2018, left employment shortly after being hired and was hired again by the facility in September 2019. The March 2018 hire records for LPN #5 indicated the resident had a nursing license with the State of Wyoming. The Wyoming license verification, pulled on 3/8/18 at 3:16 p.m. revealed action was taken against LPN #5 for negligence, patient neglect, unprofessional conduct and substandard or inadequate care. B. Staff interviews The director of nursing (DON) was interviewed on 11/20/19 at 10:03 a.m. She said LPN #5 was hired by the facility for a short time in March 2018. She said LPN #5 left shortly after she was hired because of a family concern. She said the facility conducted a background check and license verification on 3/8/18. She confirmed LPN #5 had action taken against her license for negligence, patient neglect, unprofessional conduct and substandard or inadequate care. She said LPN #5 had applied to work at the facility in September 2019. She said she was hired, however was not put on the schedule until October 2019. She said LPN #5 had to move before she was available to work. She said the facility conducted a license check of LPN #5 for the State of Colorado. She said when the facility ran the license check, it came back clear. She said following the incident with Resident #4, the facility ran another license check. She said the license check came back suspended as of 9/28/19. She said she was informed by the board of nursing, LPN #5 had falsified her application and did not indicate any criminal charges in her history. She said she was not sure of the details surrounding the criminal charges. She said the facility background check had not indicated any criminal charges. She said when a staff member left the facility, she would indicate on their employment record whether the staff member was rehirable. She said she was unable to locate documentation to show if the staff member was rehirable from her previous employment in March 2018. She said she was not aware, when she made the decision to rehire LPN #5 of the history on her Wyoming nursing license. She confirmed the license check was present in the employee file. She said she did not read LPN #5 employee file in its entirety. The NHA was interviewed on 11/20/19 at 10:30 a.m. She confirmed the facility was aware of the action against LPN #5 State of Wyoming nursing license. She said LPN #5 had met the stipulations on her license. She confirmed the facility re-hired LPN #5 with knowledge she had action against her State of Wyoming license for negligence, patient neglect, unprofessional conduct and substandard or inadequate care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure the environment remained as free of accident hazards as possible and provide adequate supervision and assistance devices to prevent accidents for three (#18, #23, #34 and #36) of ten residents reviewed for falls out of 26 sample residents. Specifically, the facility failed to: -Implement care planned fall interventions for Resident #18 and the resident fell 25 times within a five month time frame and as a result some of the falls resulted in major injuries, such as a fracture of the clavicle, pelvis and bruising to the head. -Ensure a consent was obtained for a wanderguard for Resident #23. -Ensure interventions were put into place following falls for Residents #10, #12 and #36. Findings include: I. Facility policy and procedure The Fall Risk Assessment policy was provided by the nursing home administrator (NHA) on 11/21/19 at 1:10 p.m. It read in pertinent part, The nursing staff, attending physician and pharmacist will review medications that relate to fall risk, the attending physician and nursing staff will evaluate the signs vital signs a dhn assess the medical condition or sensory impairments that may predispose to falls, assessment will be used to identify underlying medical conditions that may increase falls the staff and attending physician will evaluate functional and psychological factors that may increase falls, the staff and attending physician will collaborate to identify and address modifiable risk factors and intervention to try to minimize the consequences of risk factors that are not modifiable. II. Resident #18's A. Resident status Resident #18, age [AGE] ,was admitted on [DATE]. According to the computerized physicians orders (CPO) diagnoses included: atrial fibrillation, hypertension, history of urinary tract infections, insomnia, chronic pain, anxiety, and mood disorder with depressive features. The 9/22/19 minimum data set (MDS) assessment the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. The resident required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. She required supervision with eating.The resident had two falls with no injuries, two falls with minor injuries and two falls with major injuries. B. Observations On 11/18/19 at approximately 12:00 p.m the resident was sitting in a recliner in front of the television in the common area. She attempted to climb over the left arm rest of the recliner. A staff member assisted her back into a sitting position. C. Record review The nurses notes, interdisciplinary team (IDT) notes, and care plan were reviewed. The nurses notes documented the resident had fallen at least 25 times between 6/6/19 and 11/14/19. Some of the falls resulted in major injuries. -On 8/25/19 at 6:55 a.m. the resident fell in her room. She complained of a headache and left arm pain. She was taken to the emergency room by her daughter and had sustained a displaced fracture to the left clavicle. The interdisciplinary note dated 8/26/19 documented the resident fell in her room. She was found on her buttocks between the wall and heater unit. She prefers to be independent with care and staff attempts to anticipate care. Staff will continue to attempt to anticipate needs.The care plan was updated on 8/30/19 to include adding self locking brakes on the wheelchair. The resident had not been documented to fall from the wheelchair on 8/25/19. The facility failed to determine the root cause and implement effective interventions. There were no other interventions added. This was the residents eighth fall. -On 9/9/19 the resident fell twice. She fell at 9:45am in the lobby. She had climbed out of a recliner. At 2:00 p.m. she fell in her room. On 9/10/19 the resident complained of right hip pain. The daughter took her to the emergency room. The x-ray results confirmed a fracture of the right pubic ramus. The interdisciplinary notes were dated 9/13/19, four days after the falls. The IDT note indicated the resident was to be encouraged to be in the lobby area. However, the resident fell while in the lobby area. There were no specific instructions for when she is to be in the lobby or how often to check her. She had a recent decrease in antidepressant therapy. The care plan was updated on 9/19/19 to include, monitor residents whereabouts.There were no other specific interventions added. This was the residents 12th and 13th falls. -On 11/13/19 she fell on the floor in the dining room and obtained bruising to the right side of her face.The interdisciplinary note was requested and not received. The care plan was last updated 9/30/19. There were no new interventions related to this fall. There was no root cause determination or new effective interventions put in place. The IDT note on 11/20/19 documented to continue to anticipate needs. This was the 24th time the resident had fallen. The care plan was written on 5/17/19. In total it was only updated three times after 25 falls. The care plan interventions included: be sure the call light is within reach, encourage resident to ask for assistance, dycem (non skid pad) to recliner (9/30/19), educate resident family and caregivers about safety reminders and what to do if a fall occurs, RN to assess the resident after falls, ensure the resident is wearing appropriate footwear, fallow facility fall protocol, monitor residents whereabouts (9/16/19), review post fall and attempt to determine the cause, self locking brakes on wheelchair (8/30/19). All except three of these interventions were initiated 5/1719, before the falls with major injury. A physician's note dated 10/7/19 documented the residents daughter had asked to speak with her because the facility staff had told the daughter that her mother needed to be placed in another facility due to her increased needs. The physician note further documented she would be ordering physical therapy for the resident and if that wasn't possible she would ask the staff to start walking her. She further documented the resident had gotten worse since admission and had a fracture of the clavicle and right pubic ramus. D. Interviews Licensed practical nurse (LPN) # 3 was interviewed on 11/20/19 at 2:30 p.m. regarding fall interventions in place for Resident #18. She said we tried to keep her busy, but she was quick and would fall as soon as you looked away. Certified nurse aide (CNA) #9 was interviewed on 11/29/19 at 2:45 p.m. regarding fall interventions for Resident #18. She said the resident use to have a walker but did not use it correctly and use to drag it behind her. She doesn't walk anymore because her balance was not good. CNA # 8 was interviewed on 11/20/19 at 2:53 p.m., said we have tried to keep an eye on her and walk her if she was agitated. The director of nursing (DON), nursing home administrator (NHA) and LPN # 1 were interviewed together on 11/20/19 at 12:30 p.m. The DON said the process for falls was, the licensed nurse will do the initial evaluation of injury and notify the RN. The CNA started vital signs. Neuro checks are started to determine if the resident needed to be sent out. The nurse who was on shift at the time completed an incident report. The IDT team reviewed the incident reports every Monday, Wednesday and Friday. The IDT team includes the DON, assistant director of nursing (ADON) or nursing home administrator (NHA) dietary or social services depending on the day. There were at least three people on the committee. She said the IDT discussed interventions in place prior to fall, and they have a list of items they checked.The ADON updated the care plan after falls. The NHA said the resident has had several falls, but she was tough. She said she will stand up no matter how close we were to her. She said we do not use alarms and we do not provide one to one care She said we do not have the staffing for that. The NHA said we have asked families to come in and sit with family members. The DON said after the fall on 8/25/19 they moved her furniture around so the bed was closer to the door and decreased her celexa (antidepressant). She said the resident had returned from the emergency room with an order for an alarm, but said that the facility does use motion alarms. She did not know what interventions if any had been added for the two falls on 9/9/19. She said she did not not know what new interventions were put in place, if any after the fall, hitting her head, sustaining a black eye on 11/13/19. LPN #1 said she had recently started a fall committee in 9/2019 because the falls were a real problem and increased number of falls She said they have had 99 falls since January. She said her goal was to get the falls down to five falls per month. She said the facility had 13 falls in September but she did not know how many they had in October or as of this date in November. She said she had a performance improvement plan as of 9/2019 that includes, obtaining staff to be on the committee, weekly meeting starting 9/19/19, look at all aspects of the fall to determine cause and have the pharmacy review the medications. The committee met on Thursdays. However, the resident fell again on 11/13/19 after the start of the performance improvement plan and fall committee. She said the IDT team did not meet until 11/20/19. There were no new interventions for this resident. Staff were to continue to anticipate needs and encourage meaningful activity. The care plan was not updated (cross reference F-657 failure to revise comprehensive care plans). C. Resident #23's status Resident #23, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the November 2019 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease, dependence on supplemental oxygen, depressive episodes, cardiac pacemaker, heart failure, hearing loss, abnormalities of gait and mobility, anxiety disorder, and history of transient ischemic attack (TIA). The 10/6/19 minimum data set (MDS) assessment revealed, the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required extensive assistance from staff for most activities of daily living and she used a walker. She received oxygen therapy and had a wander guard. 1. Record review The elopement care plan, revised 1/4/19, documented the resident had a history of elopement attempts. The interventions included to assess for a fall risk, identify patterns of wandering, offer to walk around with her, provide structured activities and have wander guard in place. The November 2019 computerized physician orders (CPO) revealed the following pertinent orders: -Check wander guard for function every night shift for elopement risk -ordered on 8/24/18 -Change wander guard annually and as needed -ordered on 8/24/18 The resident's medical record was reviewed on 11/19/19. It did not reveal a consent for the use of a wanderguard. Staff interviews The director of nursing (DON) was interviewed on 11/20/19 at 12:30 p.m. She said consents should be obtained prior to the use of the wander guard. The nursing home administrator (NHA) was interviewed on 11/20/19 at 12:30 p.m. She said the consents should be scanned into the resident's medical record. This resident's consent was not provided. II. The facility failed to ensure an RN assessment for injury was completed prior to moving a resident who had fallen A. Resident #36 1. Resident status Resident #36, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the November 2019 computerized physician orders (CPO), the diagnoses included displaced fracture of base of neck of right femur, joint replacement surgery, dementia with behavioral disturbance and anxiety disorder. The 10/29/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. She required extensive assistance of two people with bed mobility, dressing, toileting and personal hygiene. It indicated the resident had a fracture related to a fall prior to the resident's readmission to the facility and had hip replacement surgery. 2. Record review The fall care plan, initiated on 1/17/17 and revised on 9/13/19, revealed the resident was at risk for falls related to confusion, psychoactive drug use. It indicated the resident would get down on the floor to clean. Cross reference to F657 (Care Plan Timing and Revision) because the facility failed to revise the care plan with new interventions following falls for Resident #36. The behavior care plan, initiated on 12/6/18 and revised on 1/3/19, revealed the resident had potential to be physically aggressive related to dementia with behavioral disturbance and poor impulse control. The interventions included: when the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation, and staff to walk away if the resident becomes aggressive. The 9/4/19 fall risk evaluation revealed the resident was a high risk for falls. It indicated the resident had a history of falls and overestimated or forgot limits. The 10/18/19 nursing progress note revealed the resident had a broom in one hand and a dust pan in the other hand and began chasing a certified nurse aide (CNA) wanting trash bags. The CNA asked for help from other staff, then Resident #36 lost her footing and fell to the ground, landing on her right hip. The resident asked for help up off the ground. The CNA assisted the resident off the floor to a chair prior to the registered nurse (RN) assessment for potential injury. Resident #36 sat in the chair crying and stated, they are trying to kill me and stated she could not walk when the RN entered the room. The resident continued to hold onto her right posterior hip. The physician was notified and ordered for the resident to be sent to the hospital for evaluation. Cross reference to F659 because the facility failed to ensure an RN assessment was completed timely following a fall. The 10/18/19 nursing progress note revealed the nurse received an update from the hospital. The resident was transferred to another hospital for surgery related to a right hip fracture. The 10/18/19 fall investigation revealed the resident was chasing and swinging a broom at the staff when she sustained a fall. The CNA assisted the resident off the floor and into a chair prior to the nurse arriving to assess the resident for injury. The nurse indicated the resident was very guarded to the right lower extremity, yelling and crying. The physician was notified and ordered for the resident to be sent to the hospital for an evaluation. 3. Staff interviews CNA #6 was interviewed on 11/20/19 at 2:30 p.m. She said when a resident sustained a fall, the staff should ensure the resident was ok and get the nurse to assess the resident for injury. She said if the resident was not injured, then the staff should assist the resident off the floor. She said staff should never move the resident prior to the nurse assessment because they would not know if the resident had an injury and could injure the resident even more. Licensed practical nurse (LPN) #3 was interviewed on 11/21/19 at 3:05 p.m. She said when a resident sustained a fall, the resident should be assessed for injury, assisted off the floor, and notify the physician and family. She said the resident should not be moved off the ground until an assessment has been completed of the resident to determine if an injury was sustained. The director of nursing (DON) and NHA were interviewed on 11/20/19 at 12:30 p.m. The DON said she was at the facility when Resident #36 sustained a fall on 10/18/19. She said she was called to the house by the LPN on duty to conduct an assessment of the resident. She said the resident was chasing a CNA with a broom. When the CNA yelled for help, the resident lost her footing and fell to the ground on her right side. She said the CNA assisted the resident off the floor prior to her arriving to the house to perform an assessment of the resident. She said staff should never move a resident after a fall unless the RN has completed an assessment and determined the resident did not sustain an injury. 4. Facility provided information The DON provided a document which indicated the two CNAs on shift during the resident's fall on 10/18/19 had been provided education that the nurse was required to conduct an assessment of the resident for potential injury prior to assisting the resident off the floor. The document did not have a date to indicate when the education had been provided to the CNAs. III. The facility failed to ensure consents were obtained prior to the use of a wanderguard A. Facility policy The Wandering and Elopements policy, revised March 2019, was provided by the nursing home administrator (NHA) on 11/21/19 at 1:10 p.m. It documented in pertinent part: -The facility would identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. -If identified as at risk for wandering, elopement, or other safety issues, the residents care plan would include strategies and interventions to maintain the resident's safety. B. Resident #34 status Resident #34, age [AGE], was admitted on [DATE]. According to the November 2019 CPO, the diagnoses included anoxic brain damage and aphasia. The 11/3/19 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing, eating, toileting and personal hygiene. It indicated the resident had not wandered during the assessment period. 1. Observations The resident was observed on 11/18/19 at 10:34 a.m. A wanderguard bracelet was observed on the resident's left wrist. 2. Record review The November 2019 CPO revealed the following physician orders: - may use wanderguard for safety - ordered 6/27/17 - test the wanderguard functioning daily for functioning every night shift for wanderguard - ordered 7/26/17 - change the wanderguard bracelet annually and as needed every day shift every 12 months starting on the 8th for one day for monitoring of the device and as needed for safety - ordered 11/8/19. The 10/30/19 wandering assessment revealed the resident was ambulatory and had a history of wandering. It indicated the resident wandered around the house daily and had a wanderguard in place. The elopement care plan, initiated on 6/27/17 and revised on 1/3/19, revealed the resident was an elopement risk due to anoxic brain damage. The 9/13/19 nursing progress note revealed the resident exited the patio and just made it past the threshold when the staff were able to reach the resident and provide redirection. It indicated the alarms and pagers alerted staff the resident was attempting to elope from the patio. The resident's medical record was reviewed on 11/19/19 at 12:38 p.m. It did not reveal a consent for the use of a wanderguard. 2. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 11/21/19 at 3:05 p.m. She said the facility used a wanderguard for resident's who posed a risk of elopement from the facility. She said a physician's order would be obtained prior to use of the wanderguard. She said a consent should be signed prior to use of the wanderguard. She said each consent was scanned into the resident's electronic medical record. The director of nursing (DON), nursing home administrator (NHA) and LPN #3 were interviewed on 11/20/19 at 1:28 p.m. The DON said the facility used a wanderguard for resident's who wandered and attempted to elope from the facility. She said a consent from the resident's responsible party should be obtained prior to use of the wanderguard. She said the consent should be scanned into the resident's electronic medical record. The NHA said the facility was unable to locate documentation to show the resident's responsible party provided consent prior to the use of the wanderguard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policies, it was determined the facility failed to provide the appropriate care and services for one resident (#4) of one with a suprapubic catheter with a total sample of 26 residents. Specifically, the facility failed to: -Insert the indwelling catheter into the superpubic area, for Resident #4. The indwelling catheter was wrongly inserted into the penis meatus which resulted in bleeding, bruising and pain (Cross Reference F 606 failure to not employ staff with a history of negligence). Findings include: I. Professional reference According to [NAME], P., [NAME], A., Stockert, P., & Hall, A. (2017) Fundamentals of Nursing (9th ed.), p.1112, .A suprapubic catheter is a urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis. The catheter may be sutured to the skin, secured with an adhesive material, or retained in the bladder with a fluid-filled balloon similar to an indwelling catheter. Suprapubic catheters are placed when there is blockage of the urethra (e.g., enlarged prostate, urethral stricture, after urological surgery) and in situations when a long-term urethral catheter causes irritation or discomfort or interferes with sexual functioning . II. Facility policy and procedure The undated policy titled, Suprapubic Catheter Replacement was received from the nursing home administrator (NHA) on 11/21/19 at 1:10 p.m. The policy documented the first step .verify that there was a physician's order for this procedure III. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physicians orders (CPO) diagnoses included, neuromuscular dysfunction of the bladder, urethral stricture, retention of urine and dementia. The 11/10/19 minimum data set assessment (MDS) documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. He required extensive assistance with bed mobility, transfers, toileting, personal hygiene, dressing, bathing and eating. He was coded as having an indwelling catheter. B. Record Review The November 2019 CPO showed an order dated 9/27/19 to change the suprapubic catheter one time per day every 21 days related to urinary tract infections. In addition, he had an order dated 5/22/19 to change supra pubic catheter as needed. On 10/7/19 at 7:04 a.m., licensed practical nurse (LPN) # 5 documented in the nurse ' s note the catheter had come out and was replaced using an 18 french catheter and the balloon inflated with 20 milliliters of normal saline. The note further documented there was some blood on return of the urine. At 8:11 a.m. the nurse ' s note documented the physician was notified because the catheter had been inserted into the penis and not into the suprapubic site. On 10/8/19 at 10:36 a.m., the nurse ' s note documented the resident continued to have bleeding from the meatus and the, penis shaft was bruised and scrotum was purple, black with swelling. On 10/9/19 at 11:11 p.m., the nurse ' s note documented the resident had blood in his brief at the head of the penis, dark red in color. He continued to have dark purple bruising to his penis and testicles. On 10/10/19 at 11:16 p.m., the nurse ' s note documented the resident continued to bleed in brief dark red color. He continued to have bruising, .dark purple in color to penis and scrotum and along lower buttocks near scrotum. Swelling continues to area of penis and scrotum. On 10/11/19 at 11:24 a.m., the nurse note documented the, ,,,bruising to penis and scrotum has increased .entire penile shaft and scrotal sack are dark purple black in color and bruising extends to perineal floor nearly to rectum .continues to ooze bright red blood from meatus with scant amount of bleeding in brief bright red. On 10/14/19 at 8:06 a.m., the nurse ' s note documented the resident continued to have bruising and blood drainage from meatus .area cleansed which causes facial grimacing the resident said the area was tender. The nurses notes continued to document bruising, swelling and bleeding from the penis through 10/28/19. On 10/29/19 at 5:31 p.m., the nurse notes documented the daughter requested a urinary analysis because the resident ' s urine was dark and cloudy. On 10/30/19 at 12:20 a.m. The nurse notes documented the resident went to the emergency room on [DATE] per the daughters request because he just did not seem right. On 10/10/19 at 1:25 p.m. an interdisciplinary note was written by the director of nurses (DON), the note documented LPN #5inserted the catheter in the penis and urine and blood were noted. The Medical director was notified assessed the resident. The medical director instructed the staff to monitor the bleeding and she would call the urologist for further orders. There was documentation for further orders. The medical directors note on 10/7/19 documented the resident has a history of urethral stricture, adn prostate cancer so I suspect when the Foley (catheter) was placed it caused significant irritation and therefore bleeding. On 10/11/19 at 7:49 p.m. health status note documented the urologist said to notify him if the bleeding increased. Urology notes after the incident were requested from the DON on 11/20/19 but not received. The only urology note provided was on 9/23/19 before the incident. IV. Interviews Certified nurse aide (CNA) #3 was interviewed on 11/10/19 at 3:02 p.m. CNA #3 said she was working the morning of 10/7/19 and was assigned to Resident #4. She said LPN #5 had gone in to replace the resident ' s indwelling catheter that had come out. She said she could hear the resident outside his door while the nurse was in the room replacing the catheter. She said he was screaming, stop it hurts. She said she went in to see the resident after the nurse had left. She said she observed a large amount of blood in his catheter bag and went to tell the nurse. LPN #5 told her that was normal. CNA #3 said she went back to the resident ' s room and observed the catheter was in the penis and not in the lower stomach where it normally was. She said she went back and told the nurse that she had put the catheter in the wrong spot. She said the LPN #5 looked surprised and said she would fix it. CNA #3 said the resident bled for several days in his catheter bag and from his penis. She said he was in so much pain for the first three days they could hardly clean his penis or peri area without him crying out. She said his penis and scrotum swelled bigger than a baseball and there were blood clots coming from his penis for several days afterwards. CNA # 1 was interviewed on 11/20/19 at 2:05 p.m. CNA #1 said she was assigned to the resident ' s area that day but had been moved to a new resident area and was not there when the nurse inserted the catheter, she said to speak to CNA # 3 who was assigned to Resident #4 that day, CNA #4 told her she heard Resident #4 crying and yelling in distress when the catheter had been inserted on 10/7/19. She said she was assigned to Resident #4 the next day and observed his penis and scrotum were swollen and he had dark purple bruising, almost black, over his entire peri area up the right side of his abdomen and around to his anus. She said it did not start to fade for several weeks. The assistant director of nursing (ADON) was interviewed on 11/19/19 at 1:18 p.m. The ADON said she was aware of LPN #5 inserting the the catheter in the penis rather than the suprapubic site on 10/7/19. She said the LPN #5 failed to check the physician order for a suprapubic. She said he bled a lot, and had bruising over his entire front groin area, testicles, penis and clear around to his anus. She further said the nurse was new, but clearly had not checked his physician's orders before inserting the catheter. The ADON orders always needed to be checked before a catheter was inserted. The order would direct the cather type, size, and balloon size. She said the director of nursing (DON) had investigated the situation. The DON and NHA were interviewed together on 11/19/19 at 10:23 a.m. The DON said when she arrived that day the catheter had already been removed from the penis and was in the suprapubic (opening in abdominal wall into the bladder for catheter insertion) site. She said there were clots by the tip of the penis. The DON said she called the physician who instructed her to monitor the area and the physician would come in. The DON said the resident had deep purple bruising from the entire groin to anus with penial and scrotal swelling. She said she interviewed LPN #5 who said she had not checked the physician order. She saw the catheter tubing lying on the bed next to his penis and assumed that was where the tubing came from. The DON said she educated LPN #5 on catheter care that day which included checking the physician's order. She said she expected nurses to follow the five rights of administration and check the orders. The DON said catheter care education was not provided to any of the other licensed nurses. She said the nurse was oriented to the facility and to this specific resident during her floor orientation when she was hired. She said this did not include competencies for catheter care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews; the facility failed to maintain acceptable parameters of nutritional status for one (#23) of two residents reviewed for nutrition out of 26 sample residents. Specifically, Resident #23, diagnosed with hypokalemia, anemia, hypocalcemia, gastro-esophageal reflux disease, and hyperlipidemia. On 5/3/19 the resident's weight was recorded at 143.0 lbs (pounds) and six months later on 10/16/19 the resident weighed 125.0 lbs. This was a 17.5 lbs significant weight loss, which was 12.24% over six months. On 9/3/19 the resident weighed 141.3 lbs and 18 days later on 9/21/19 the resident weighed 129.5 lbs. This was an 11.8 lbs significant weight loss, which was 7.8%. On 9/21/19 the resident weighed 129.5 lbs and 26 days later on 10/16/19 the resident weighed 125.0 lbs. This was a 4.5 lbs and 3.8% weight loss. Review of the resident's medical records revealed the facility continued to review and document the resident's weight loss from 1/4/19 to 11/20/19, but failed to implement nutritional interventions to prevent further weight loss. Findings include: I. Facility's policy and procedure The Weight Monitoring policy, revised November 2017, was provided by the nursing home administrator (NHA) on 11/21/19 at 1:10 p.m. It documented in pertinent part, -The facility would ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight, unless the resident's clinical condition demonstrates that it was not possible or resident preferences indicate otherwise. -Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) may indicate a nutritional problem. -The physician should be informed of a significant change in weight and may order nutritional interventions. -The Registered Dietitian (RD) should be consulted to assist with interventions and actions recorded in the nutritional progress notes. A. Resident status Resident #23, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the November 2019 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease, hypokalemia, anemia, hypocalcemia, gastro-esophageal reflux disease, hyperlipidemia, anxiety disorder, and history of transient ischemic attack (TIA). The 10/6/19 minimum data set (MDS) assessment revealed, the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required extensive assistance from staff for most activities of daily living. She had a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months and was not on a physician prescribed weight loss regimen. She had a mechanically altered diet and was edentulous. She needed supervision, encouragement, cueing and set up when eating. 1. Record review The nutritional care plan, revised 1/30/18, documented the resident had a potential nutritional problem related to refusal of food/fluids at times. Pertinent interventions were to monitor fluid intake/edema. Monitor weight. Monitor/record/report to physician as needed for signs and symptoms of malnutrition such as emaciation, muscle wasting, significant weight loss: three lbs in a week, 5% in one month, 7.5% in three months or 10% in six months. Offer alternates/choices/favorite foods. Offer alternative meal choice. RD to evaluate and make diet change recommendations as needed. The November 2019 CPO included an order, dated 10/17/19, to weigh the resident weekly, every Tuesday. The CPO did not include orders for additional nutrition interventions. The weight records revealed she had a 12.24% weight loss in six months: -On 5/3/19 the resident's weight was recorded at 143.0 lbs (pounds) -6/3/19 at 141.0 lbs -7/3/19 at 138.0 lbs -8/3/19 at 141.0 lbs -9/3/19 at 141.3 lbs -9/21/19 at 129.5 lbs -10/16/19 at 125.0 lbs -11/19/19 at 125.5 lbs, which was a 17.5 lbs weight loss at 12.24%, indicating a significant weight loss greater than 10% over six months. Cross reference to F580 (Notify of Changes) because the facility failed to ensure the physician was notified of Resident #23's weight loss. Review of nutrition progress notes from 1/4/19 to 11/20/19 revealed: -The 1/4/19 dietary manager (DM) note documented the resident was on a regular mechanical soft diet and that her average intake was between 26% to 50% of meals. Current weight was 142.0 lbs and she had edema. She made her own meal choices and fed herself in her room. She often chose not to eat full meals at meal time but would eat small meals and snacks throughout the day. No supplements or devices needed. No recommendations at this time. -The 4/11/19 RD note documented no concerns were voiced. Continue with current interventions and provide food requests as menu permits. -The 7/5/19 DM note documented the residents average intake was between 51% to 75% of meals. No supplements or devices needed. No recommendations at this time. -The 11/20/19 RD note documented the resident was sleeping and did not awaken for the interview. Weight was 125.5 lbs, stable for the month. Continue with current interventions. Review of the physician progress notes from 7/18/19 to 11/20/19 revealed they did not address the weight loss. Review of the weekly weight interdisciplinary team (IDT) meeting notes revealed: -The 10/17/19 weight review note documented the assistant director of nursing (ADON), the director of nursing (DON) and the DM were in attendance. It revealed the resident was started on weekly weights related to weight loss following a hospitalization from 9/19/19 to 9/21/19. -The 10/28/19 weight review note documented resident was on weekly weight monitoring related to weight loss after hospitalization. The resident's intake varied and she was noted to have specific food preferences and often ate small meals throughout the day and night. Continue to monitor weekly. Staff interviews Certified nurse aide (CNA) # 4 was interviewed on 11/21/19 at 9:33 a.m. CNA #4 said the nurse or the CNA were responsible for weighing the resident monthly or weekly depending on the resident's need. If the weight was off by four pounds the resident would be reweighed for accuracy. She said We fill out the weight sheet given to us. We report weight changes and turn in the weight sheet to the nurse. Licensed practical nurse (LPN) #2 was interviewed on 11/21/19 at 9:45 a.m. She said the CNA or the nurse weighed the residents and the nurse inputted the weights into the resident's medical record. She said if there was a five pound difference in weight, they put the resident on weekly weights. She said the nurse then reported it to the DM or DON. She said she believed the DM notified the RD. She confirmed that the physician and RD were not notified of Resident #23's weight loss. The DM was interviewed on 11/21/19 at 9:51 a.m. She said the CNA was responsible for obtaining the weights. She said she gave them the weight sheets at the beginning of the month and they had three days to complete them. She said if there was a five pound discrepancy they were to reweigh the resident for accuracy. She said if the weight loss was accurate they would start the resident on weekly weights and give weekly weight notes to the physician. She said the RD was notified on her monthly visit when she was given a list of residents with weight loss or nutritional issues. She said they had just found out last month that the resident was losing weight and started her on weekly weights and to continue to monitor. The ADON was interviewed on 11/21/19 at 9:55 a.m. She said herself, the DM and a nurse have a weekly weight meeting to discuss weight loss. She said they did not add any new interventions for Resident #23 except to check weekly weights. She said she sent copies of weekly weights to the physician. She said they did not follow up with the physician or the RD for Resident #23's weight loss. The RD was interviewed on 11/22/19 at 3:31 p.m. She said when a resident had a significant weight loss, the DM sent her a text message and she would review the resident's medical record from home. She said when she needed to communicate with staff, she wrote a progress note with interventions or new orders. She said interventions would include supplements, snacks or special meals. She said she did not take part in the weight committee because she only visited the facility monthly. She said the DM gave her a list of residents who had a change of condition, weight loss, new admission or skin issues. She said the DM did not tell her that Resident #23 had a significant weight loss. She said Resident#23 was not put on her list of residents to see. She said nursing staff was responsible for communicating with the physician.