**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents remained as free from accident hazards as possible. The facility failed to ensure interventions were implemented to prevent major injury from falls for Resident #1. Interviews during the survey revealed the facility still was not implementing interventions for toileting per the care plan. Furthermore, interviews and documentation revealed the staff did not provide transfer assistance to the resident with two person assistance as ordered. Due to the facility's failures to implement effective interventions, Resident #1 sustained a fracture of the left hip from a fall on 2/1/23. Additionally, the facility delayed assessing and monitoring Resident #1's injuries and related pain after the fall on 2/1/23, when the resident complained of having severe pain in his leg for two days after the fall (cross-reference F697). The facility failed to implement effective interventions when Resident #1 returned from the hospital on 2/6/23 which caused him to sustain additional falls. Finding include: I. Facility policy and procedure The Falls and Fall Risk Management policy, revised March 2018, was received from the director of nursing (DON) on 7/6/23 at 12:15 p.m. The policy documented in pertinent part, Based on previous evaluations and current data, the staff will identify interventions related to the resident' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that may contribute to the risk of falls, incontinence. The nurse shall assess and document/report the following when a fall has occurred: Vital signs, the condition in which the resident was found-resident found lying on the floor between bed and chair, any injury, especially fracture or head injury, subsequent first aid administered, musculoskeletal function, observing for change in normal range of motion, weight bearing, change in cognition or level of consciousness, neurological status, pain, frequency and number of falls since last physician visit, precipitating factors, details on how fall occurred, pertinent medication, especially those associated with dizziness or lethargy. Nursing staff will observe for delayed complications of a witnessed fall for 72 hours. Vital signs will be taken at the time of the fall and then every shift for the first 24 hours, then everyday on day shift for two subsequent days, Nursing staff will follow the fall, neurological record frequency for obtaining vital signs and neurological checks if a fall is unwitnessed and or head trauma is suspected. The staff, with the physician's guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out. II. Resident #1 A. Resident status Resident #1, age [AGE], admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO) diagnosis included history of left femur fracture and left hip pain, neuropathy (weakness, numbness from nerve damage) and repeat falls. The 5/15/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) with a score of nine out of 15. The resident required extensive two person assistance with transfers and toileting; and extensive one person assistance with bed mobility, dressing and personal hygiene, The resident had almost constant pain which limited daily activity. The assessment documented he had no falls since his prior assessment. -However, the resident fell on 1/18/23, 2/1/23 and 2/10/23; then again on 4/1/23 just before the above MDS assessment was completed (see below). B. Resident and resident representative interviews Two of the resident's representatives were interviewed via telephone on 7/6/23 at 10:19 a.m. The first representative said the resident called her all night in pain on 2/1/23. On 2/2/23 the representative called the facility and spoke to registered nurse (RN) #1. The representative requested the resident be sent to the hospital for an x-ray. The representative said the facility did not send Resident #1 to the hospital but had a mobile x-ray come out to the facility on 2/2/23. The representative said she had also asked the nurse about pain medication and the nurse said they were giving the resident pain medication. The representative later found out the resident had only received one Tylenol. The representative said there were no x-ray results on 2/2/23. She had called the facility multiple times as Resident #1 was in so much pain. The representative said Resident #1 called her all night again on 2/2/23 with complaints of pain to his left leg and inability to move the leg. The representative said she called the facility again 2/3/23, in the morning, to see if the x-ray results were available and was told the results were not back. The first representative said she received a call, a short time later that morning from the facility, to notify her the resident had a hip fracture and was being sent to the hospital. A second resident representative joined the telephone interview. The second resident representative said Resident #1 had called her all night on 2/1/23 and 2/2/23 with stabbing pain to his left leg. She said the resident told her his leg was displaced out to the side and he could not move the leg. The second representative was getting ready in the morning to head to the facility, while the first resident representative kept calling the facility to get the resident help. While on the way the representative said she received the information that the resident had a fracture of the left hip and was being sent to the hospital. The second representative said Resident #1 laid in bed for two days in pain, even after the first representative requested that the facility send Resident #1 to the hospital. The first representative said he continued to have a lot of pain to this day. Resident #1 was interviewed on 7/6/23 at 11:28 a.m. Resident #1 said he remembered when he fell and broke his hip. He said he had fallen in the bathroom. Resident #1 said he had a lot of pain for a few days and could not move his leg. He said anytime he tried to move it the pain was severe, but if he did not move it then it was not as bad. He said the nurses gave him Tylenol but that did not help much. He said the pain was a sharp pain and remembered he could not move his leg. He said the nurses had an x-ray done and then he went to the hospital for surgery. Resident #1 said he still had pain, and it was difficult to put any weight on his left leg. Resident #1 said the staff did not check with him throughout the day to offer assistance with toileting. He said he had to call them, and they were slow to answer the call light. C. Record review The fall care plan, initiated 8/29/22, documented potential for falls and injury related to osteoarthritis, history of falls, cognitive impairment, balance issues, unsteady gait, activity intolerance, bilateral lower extremity weakness, history of hip fracture from fall. Interventions included: physical therapy (PT) evaluation and treatment for transfer safety 8/29/22, 2/2/23 and 6/5/23, Dycem (anti slip material) in recliner 5/15/23, walker for short distance, transfers and wheelchair for long distance 5/15/23, two assist for transfers 2/14/23, urinal to be given at bedtime for night usage 2/13/23, visual aide to close footrest on recliner before getting up 11/22/22, resident forgets to lock brakes on wheelchair, anti roll backs in place 11/21/22, reacher, grabber encourage resident to use it to reach out of reach items 11/14/22, non skid strips in bathroom, gripper socks 10/3/22, toilet riser 9/26/22, education provided on proper footwear and ensuring shoes are on correctly, and how to use grabber reacher 9/21/22, bed bars to aide in bed mobility 8/31/22, orange nameplate alert placed to increase staff awareness of increase fall frequency 8/30/22, grab bars in bathroom [ROOM NUMBER]/29/22, call light in reach 8/29/22, keep personal items in reach maintain clean clutter free environment 8/29/22, observe resident and room frequently for any safety needs 8/29/22. The urinary incontinence care plan, initiated 8/29/23 documented the resident needed assistance with toileting, offer and aide in bathroom or use of urinal before and after meals, approximately every two hours while awake and as indicated. Fall history On 1/18/23 at 6:10 a.m., the nursing progress notes documented the resident was observed on the floor in the bathroom with a gash to his head and left arm. He was seen to the ER. The progress note documented the day shift would notify the physician. The resident returned to the facility in approximately two hours, with no new orders. -There were no progress notes indicating the physician was notified. The hospital transfer form documented the resident was alert and oriented and was independent with transfers, toileting and dressing. -However, the urinary care plan, dated 8/31/22, documented Resident #1 needed to be offered and assisted to the bathroom before and after meals, and every two hours while awake. The care plan documented the resident had an overactive bladder and would attempt to toilet himself. On 1/19/23 at 11:34 a.m. the nursing progress notes documented the resident sustained a skin tear to the left forehead one centimeter (cm) by 0.9 cm and a skin tear to the left arm three cm by 2.8 cm. -There were no new interventions documented in the progress notes or the care plan (see above). On 1/23/23 at 11:17 a.m. the nursing progress notes documented the resident was on a bowel and bladder program and should be encouraged, offered and assisted to the bathroom every two hours from 2:00 p.m. to 10:00 p.m. On 2/1/23 at 4:51 p.m. the nursing progress notes documented the resident had taken himself to the bathroom and fell pulling up his pants, obtaining a skin tear to the left wrist and abrasion to the low back. No other injuries noted. The family and physician were notified. -However, the resident did develop pain by midnight and was administered Tylenol (see below). On 2/2/23 at 7:55 a.m., a restorative progress note documented restorative was held due to recent fall and the resident was in bed. The certified nursing aide (CNA) documentation for 2/1/23 to 2/3/23 was reviewed. -There was no documentation after the fall on 2/1/23 until 2/2/23. On 2/2/23 under transfers, the CNA documented that it did not occur. -There was no documentation for 2/3/23. On 2/2/21 at 1:31 p.m. the nursing notes documented PT evaluation and treatment due to fall. On 2/3/23 at 7:55 a.m. the nursing notes documented the resident's daughter called about the x-ray results. The nurse documented the facility had not received them yet. -There was no documentation in the medical record regarding why or when an x-ray had been ordered. There was no further assessment of the resident documented since the fall 2/1/23 at 4:51 p.m. There was no further assessment of his left leg or hip. On 2/2/23 at 8:29 a.m. the nursing notes documented the x-ray results were received and the physician was notified. Orders were received to transfer the resident to the hospital with a hip fracture. The x-ray report documented the x-ray was done on 2/2/23 at 3:26 p.m. -There were no records in the facility progress notes regarding an x-ray having been done. On 2/3/23 at 12:53 a.m. (after the resident is sent to the hospital) a late entry was added to the progress notes for 2/2/23. The note documented the resident had an unwitnessed fall in his restroom. The resident was in the restroom and was attempting to pull up his pants, the resident lost his balance and fell resulting in a skin tear to his left wrist and an abrasion to his low back. The resident has had two falls in the last 90 days and eight total falls since his admission. Current interventions that were in place at the time of the fall and that remain to be deemed appropriate include: visual aide in room to remind resident to put the feet of his recliner down, anti-roll backs added to w/c (wheelchair), time pattern of falls reviewed with no time pattern noted, non-skid strips placed in bathroom, gripper socks were offered and provided, orange name plate (used to identify resident as high fall risk) and bed bars to aide in independent bed mobility. New intervention, PT to eval. The hospital record dated 2/3/23, documented Resident #1 was admitted after a fall from a standing height. He was hypoxic (low oxygen levels) due to atelectasis (collapsed lung or section of lung) after laying around for two to three days post fall. The left hip was x-rayed and confirmed an acute fracture. The resident had surgery to repair the left hip on 2/3/23. -However, the investigation did not identify that the last two falls occurred in the bathroom and there were no new interventions on 1/18/23. In addition, no new interventions related to toileting the resident for the fall on 2/1/23. The February 2023 medication administration record (MAR) and treatment administration records (TAR) were reviewed there were no pain assessments for Resident #1. Resident #1 received Tylenol 325 mg one tablet as needed, on 2/2/23 at 12:33 a.m., 2/2/23 at 12:54 p.m. and 2/3/23 at 7:34 a.m. for undocumented pain levels. The Tylenol was documented as not effective 2/2/23 at 12:54 p.m. and 2/3/23 at 7:34 a.m. There was no follow up documented for the residents pain (cross-reference F697, pain management) The February 2023 TAR had an order dated 2/1/23, Monitor status for 72 hours for bruising, change in mental status or condition, pain or other injuries. However, the resident was in pain, with an externally rotated and shortened left leg as documented in the ER report. The facility nurses gave Resident #1 Tylenol and documented it was not effective. Despite initially the TAR, the licensed nurses did not follow up timely on the resident's change of condition, pain, or injury to the left hip. The July 2023 CPO documented to transfer with assistance of two persons, dated 2/14/23. The weekly summaries in the nursing progress notes were reviewed for May 2023 through 7/5/23. The progress notes revealed the following: On 5/3/23 at 1:26 a.m. the weekly summary documented the resident was ambulatory (ability to get around) with his wheelchair. -There was no documentation regarding the level of transfer assistance. There were no further weekly summaries for May 2023. On 5/23/23 at 10:47 a.m., the interdisciplinary (IDT) note documented Resident #1 required two person assistance with transfers. On 6/7/23 at 12:59 a.m., the weekly summary documented the resident requiring one person assistance with transfers. On 6/14/23 there were two weekly summaries. The one at 12:59 a.m., documented the resident was a one person assist with transfers. The weekly summary at 11:19 a.m. documented the resident was independent with a cane and wheelchair. On 6/21/23 at 12:36 a.m., the weekly summary documented the resident required two person assistance with transfers. On 6/28/23 at 1:19 a.m., the weekly summary documented the resident required two person assistance with transfers. On 7/5/23 at 12:55 a.m., the weekly summary documented the resident required two person assistance with transfers. III. Staff interviews Registered nurse (RN) #1 was interviewed on 7/5/23 at 2:07 p.m. RN #1 looked at his laptop and said there was no documentation about the resident's condition or pain after the fall; but there should have been. RN #1 said he had sent a text to the physician for an x-ray on 2/2/23. He could not remember the resident's pain level at that time or what prompted him to call for an x-ray. RN #1 said he should have documented the x-ray order and reason in the notes. RN #1 said there should have been follow up documentation on the resident's condition. He said the resident was independent with toileting and ambulation in his room at the time. RN #1 said he was not supposed to be independent, but he was. RN #1 said Resident #1 now required the assistance of one person when using the bathroom. -However, the resident's medical record documented that prior to the fall Resident #1 was a two person assist with transfers (see above). Certified nurse aide (CNA) #1 was interviewed on 7/6/23 at 9:10 a.m. CNA #1 had been working at the facility for five months and had started at the end of February 2023. CNA #1 said she was not working at the facility when the resident fell and broke his hip. CNA #1 said she was familiar with Resident #1 and was usually assigned to the hall he lived on. CNA #1 said Resident #1 would call if he needed to use the toilet. She said he did not need to be prompted or cued. She said he also had a urinal that he used. While in the resident's room she looked around for the resident's urinal but could not find it near the resident; but found the urinal in the resident's bathroom. CNA #1 said maybe the resident only used the urinal at night. CNA #1 said the resident required extensive one person assistance to transfer. She then said she thought maybe it was supposed to be two persons to assist with transfers, after looking on his wall (where his transfer status was posted) and seeing it indicated he needed two people. There were two apples on the resident's wall. The CNA said this meant he needed two person assistance. She then said he could transfer with one person's assistance. -However, the resident care plan and MDS assessment documented that the resident required two person assistance. RN #2 was interviewed on 7/6/25 at 9:20 a.m. RN #2 said he was familiar with Resident #1. RN #2 said he was not the resident's nurse when he fell and broke his hip. RN #2 said the resident required one person assistance ambulating to the bathroom. RN #2 said if a resident had a fall the process was for the RN to assess the resident, call the physician and notify the family. If the fall was unwitnessed or witnessed and the resident hit their head, the nurse would do neurological checks. He said he did not know if there was any follow up documentation that needed to be in the nursing progress notes. He said sometimes there was a place on the resident's TAR where the nurse signed off that they monitored the resident for 72 hours. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 7/6/23 at 9:34 a.m. The DON said she had been at the facility a little over a month. She said if a resident fell, there should be an assessment completed by the RN, and an event was initiated in the resident's electronic medical record (EMR). She said the nurse should notify the physician and family. The DON said neurological checks should be done for an unwitnessed fall or a fall with head injury. She said the nurses should document in the progress notes for the next 72 hours and observe for any injury or pain. She was not familiar with the fall for Resident #1 on 2/1/23. IV. Additional falls A. Record review On 2/10/23 at 2:15 a.m. the nursing progress notes documented Resident #1 had a fall from bed. The Resident's brief was wet, but not soaked. There was no injury. A urinal was provided on 2/13/23 for use at night. On 4/1/23 at 9:05 p.m. the nursing progress notes documented the resident was found on the floor near his bed. He was on his back fully dressed. He stated he had pushed the call light and was trying to get into the bed. His wheelchair was about two feet from where he was found on the floor. The nurse documented his vital signs and neurological checks were normal. On 4/1/23 at 2:51 a.m. the same nurse documented the resident had been sleeping most of the night. No further complaints of pain. Vital signs were stable at this time. Neuro (neurological) checks were within normal limits. -However, there were no vital signs or neurological checks in the record. There were no interventions implemented. There was no further documentation or update to the care plan. On 7/5/23 at 12:55 a.m. the nursing progress notes documented Resident #1 had a fall on 7/3/23, no injuries were noted. -There was no documentation before the 7/5/23 note that the resident had fallen on 7/3/23. There was no assessment, notifications or further information. B. Staff interview The DON and ADON were interviewed on 7/6/23 at 9:34 a.m. The DON said she did not know why there was no follow up from the 4/1/23 fall. She said she did not have any neurological checks or vital signs. She said there had been no new interventions added to the care plan for that fall. The DON said the resident's care plan told the staff how a resident should be transferred; gave bowel and bladder information; and information for toileting and incontinence care. Additionally, the information was put on the resident's room wall. The DON said if the resident had one apple posted on the wall in their room, the resident required a one person transfer assist, if two apples they were two person assist. The DON said she thought it had been an agency nurse who documented the 4/1/23 fall but he had not returned to the facility since that night. The DON reviewed the nursing notes dated 7/5/23 regarding a fall 7/3/23. The DON said she did not remember a fall in the past week for Resident #1. The DON thought the note might have been an error. The DON said he would investigate -No further information was provided by the end of the survey on 7/6/23. V. Facility follow-up A Performance improvement Project Guide, Reduce number of falls, dated 3/30/23, with review date set for 7/30/23, was received from medical records (MR) on 7//23 at 6:25 p.m. The form documented three items under plan, 1. Educating on orange nameplate and banner (used to identify resident as a high fall risk); Check In program for high reported to staff on floor at that time, the start date was listed as ongoing 2. Weekly rounds with Restorative RN, Director of Rehabilitation (DOR) and MDS, start date 4/6/23. 3. All staff inservice: Removing clutter/trip hazards Examples to avoid falls. Reporting decline or concerns. Day. Answering call lights, started 4/17/23, completed 4/17/23. -There was no further documentation on the plan indicating when it was reviewed for effectiveness, since it was written three months prior to the survey. A copy of a text sent 2/2/23 at 3:50 p.m. to the physician for Resident #1, was received from MR on 7/6/23 at 8:30 a.m. The text documented, Resident #1 was stating his left hip was hurting after a fall, may we get in house x-ray. The physician responded at 3:53 p.m., yes. -However, the x-ray results documented the x-ray was done at 3:26 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#1) of three residents reviewed out of three sample residents. Resident #1 fell on 2/1/23 in the bathroom. He had increased pain, at the facility, for two days until 2/3/23, when an x-ray confirmed he had a fracture of the left hip. Two resident representatives were interviewed. Both representatives said Resident #1 had called them all night long on 2/1/23 and 2/2/23 complaining of being in pain and being unable to move his left leg. The representatives said they had requested the resident be sent to the emergency room (ER) on 2/2/23 for an x-ray of the left hip. However, the facility had an x-ray at the facility, without results until 2/3/23. Resident #1 was interviewed on 7/6/23. He said he had severe stabbing pain and had been unable to move his leg for two days after falling in the bathroom on 2/1/23. He said he was then sent to the ER, from the facility, after a couple days of being in pain and had surgery related to injuries from the fall. There was no additional documentation of facility staff monitoring the resident's condition for pain or evaluation of the resident's change of condition after the initial fall evaluation on 2/1/23, between 2/1/23 to 2/3/23. Resident #1 was given only one tablet of 325mg (milligrams) of acetaminophen (Tylenol) for pain three times as needed from 2/1/23 to 2/3/23 for an undocumented (unknown) pain level. On 2/2/23 and 2/3/23 the Tylenol was documented as not effective. There was no documentation of what was done for the resident when the one tablet of Tylenol was not effective. The resident had an order for Norco pain medication as needed on admission 8/23/22; however, the facility staff said it had never been ordered from the facility pharmacy and therefore was not available to administer for the resident's unresolved pain, during the 2/1/23 to 2/3/23 time period. The 2/3/23 emergency room assessment notes documented the resident was in pain with any motion and his leg was externally rotated and shortened. The resident had surgery to repair the fracture and returned to the facility on 2/6/23. Resident #1 continued to complain of daily pain and difficulty placing weight on the left leg during the survey period. Cross-reference F689 accident hazards for the facility's failure to implement effective fall interventions that caused a fall with major injury and subsequent falls after he returned to the facility. Findings include: I. Facility policy and procedure The Pain Clinical Protocol, revised March 2018, was received from medical records (MR) on 7/5/23 at 5:50 p.m. The policy documented in pertinent part, The nursing staff will assess each individual for pain whenever there is a significant change in condition. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. II. Resident #1 A. Resident status Resident #1, age [AGE], admitted on [DATE], and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO) diagnosis included, history of left femur fracture and left hip pain, neuropathy (nerve pain), chronic low back pain and repeat falls. The 5/15/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) with a score of nine out of 15. The resident required extensive one person assistance with bed mobility, dressing and personal hygiene; and required extensive two person assistance with transfers, and toileting. The assessment documented the resident reported his worst pain level on a 0 to 10 scale (with 10 being the worst pain on the scale); was 4 out of 10. The assessment further documented that the resident said he had almost constant pain that limited his daily activity. B. Resident and resident representative interviews Two of the resident's representatives were interviewed via telephone on 7/6/23 at 10:19 a.m. The first representative said the resident called her all night complaining of being in pain on 2/1/23. On 2/2/23 the representative called the facility and spoke to registered nurse (RN) #1. The representative requested the resident be sent to the hospital for an x-ray. The representative said the facility did not send Resident #1 to the hospital but had a mobile x-ray come out to the facility on 2/2/23. The representative said she had asked the nurses on the phone about pain medication and they said they were giving the resident pain medication. The representative later found out the resident had only received one Tylenol for his pain. The representative said there were no x-ray results on 2/2/23. She had called the facility multiple times requesting alternative treatment for the resident, as Resident #1 was in so much pain. The representative said Resident #1 called her all night again on 2/2/23 with complaints of pain to his left leg and inability to move the leg. The representative said she called the facility again 2/3/23, in the morning, to see if the x-ray results were available, and was told the results were not back yet. The representative said she received a call, a short time later that morning (2/3/23) from the facility, to notify her the resident had a hip fracture and was being sent to the hospital. A second resident representative joined the telephone interview with the first resident representative. The second resident representative said Resident #1 had also called her all night on 2/1/23 and 2/2/23 complaining of stabbing pain to his left leg. She said he told her his leg was out to the side and he could not move the leg. The second representative was getting ready in the morning to head to the facility on 2/3/23, while the first resident representative kept calling the facility. The second representative said that while on the way to the facility she received the information that the resident had a fracture of the left hip and was being sent to the hospital. The second representative said Resident #1 layed in bed for two days in pain, even after being asked by the first representative that the resident be sent to the hospital. The second representative said the facility only gave the resident Tylenol which was ineffective for pain from a fractured hip. The first representative said he continued to have a lot of pain to this day. Resident #1 was interviewed on 7/6/23 at 11:28 a.m. Resident #1 said he remembered when he fell and broke his hip. He said he had fallen in the bathroom. Resident #1 said he had a lot of pain for a few days and could not move his leg. He said anytime he tried to move it the pain was severe, but if he did not move it then it was not as bad. He said the nurses gave him Tylenol but that did not help much. He said the pain was a sharp pain and remembered he could not move his leg. He said the nurses had an x-ray done and then he went to the hospital for surgery. Resident #1 said he still had pain, and it was difficult to put any weight on his left leg. Resident #1 said the staff did not check with him throughout the day to offer assistance with toileting. He said he had to call them, and they were slow to answer the call light. C. Record review The pain care plan, initiated 8/26/22, documented in pertinent part, potential for alteration in comfort related to chronic back low back pain, osteoarthritis, peripheral neuropathy, and history hip surgery which was added on 5/17/23. Interventions included: -Monitoring for side effects of Tylenol, dated 8/26/23. Monitoring for side effects of narcotic pain medications, dated 8/26/22. -Give medications as ordered, dated 8/26/22, and monitor for side effects, and effectiveness. -Notify the physician if there were side effects or if medication were consistently ineffective. -Report to nurse vocal and non verbal indication of pain. Pain assessment quarterly and as indicated. It documented the resident's acceptable level of pain was extreme. Use dementia face scale if needed. Try alternate methods of pain relief such as repositioning rest, stretching, ambulating, warmth, coolness, and distraction. On 2/1/23 at 4:51 p.m. the nursing progress notes documented the resident had taken himself to the bathroom, and fell pulling up his pants, obtaining a skin tear to the left wrist and abrasion to the low back. No other injuries noted (cross-reference F689). On 2/3/23 at 7:55 a.m. the nursing notes documented the resident's daughter called about the x-ray results. The nurse documented the facility had not received them yet. -There was no documentation in the medical record regarding why or when an x-ray had been ordered. There was no further assessment of the resident documented since the fall 2/1/23 at 4:51 p.m. On 2/2/23 at 8:29 a.m. the nursing notes documented the x-ray results were received and the physician was notified. Orders were received to transfer the resident to the hospital with a hip fracture. The hospital record dated 2/3/23, documented Resident #1 was admitted after a fall from a standing height. He was hypoxic (low oxygen levels) due to atelectasis (collapsed lung or section of lung) after laying around for two to three days post fall. The left hip was x-rayed and confirmed an acute fracture. The resident had surgery to repair the left hip on 2/3/23. The February 2023 medication administration record (MAR) and treatment administration records (TAR) were reviewed. -There were no pain assessments documented for the resident. The MAR documented the resident was on routine acetaminophen (Tylenol) 325 mg one tablet three times per day. The MAR documented the resident had an order for as needed (PRN) Tylenol 325 mg every four hours as needed for pain, dated 10/25/22. The MAR documented the resident had an order for Hydrocodone-acetaminophen (Norco) 5-325 mg by mouth every six hours as needed for pain (scale 4-10), ordered 8/23/22. On 2/1/23 the resident did not receive any PRN Tylenol. On 2/2/23 at 12:33 a.m. the resident received as needed Tylenol for pain.It documented the Tylenol was effective. -There was no pain level documented. On 2/2/23 at 12:54 p.m. the resident received PRN Tylenol. The pain medication was documented as not effective. -No pain levels were documented and here was no follow up on the resident's pain. On 2/3/23 at 7:34 a.m., the resident received Tylenol and the pain medication was documented as not effective. -The was no pain level documented. The nursing notes documented at 7:55 a.m. the physician would be called about getting the resident's Norco (hydrocodone and acetaminophen 5-325 mg, opioid narcotic analgesic) refilled. -However, the resident was admitted to the facility with the order for Norco. The interviews (see below) revealed the facility had never sent the Norco order to the pharmacy and therefore it had never been filled or available for the resident. An Interview for Pain Assessment, dated 2/13/23, after the resident's hip fracture, was reviewed. The assessment documented the resident had a history of neuropathy, chronic low back pain and pain in the left hip due to a history of fracture. The pain assessment documented Resident #1 was on schedule pain medication and had received PRN pain medication. It documented he had received non-medication interventions. The interview documented the pain was occasional and made sleeping difficult. On a scale of 1 to 10, Resident #1 rated his pain at a 10 for the worst it had been. -There was no information on what exacerbated the pain or made it better. There was no information on what an acceptable level of pain was or pain goal. There was no description of the pain, characteristics of the pain or the location of the pain. There were no listed non-medication interventions listed on the pain assessment. -The May 2023 Interview for Pain Assessment was requested from the DON and not received by the end of the survey on 7/6/23. The MDS assessment, dated 5/23/23, documented the resident had constant pain which affected his activities of daily living. Weekly nursing charting in the progress notes was reviewed for the last 90 days. There was a weekly summary twice in April 2023, once in May 2023 and four times in June 2023. -The weekly charting, when it was done weekly, did not contain documentation regarding pain. It did not document whether the resident had pain or not. The June and July 2023 medication administration records revealed the following: -Resident #1 received Tylenol 325mg (milligrams), by mouth, three times daily routinely, order date 2/6/23 for June and July 2023. -Resident #1 received gabapentin (antiseizure medication used for nerve pain) 600 mg three times per day routinely for neuropathy, order date 2/6/23, for June and July 2023. Additionally, the resident had as needed (PRN) orders started on 5/1/23 for Hydrocodone-acetaminophen (Norco) 5-325 mg by mouth every six hours as needed for pain (scale 4-10). Tylenol (acetaminophen) capsule 325 mg, one tablet by mouth every four hours as needed for pain. The June 2023 MAR documented Resident #1 received Norco 6/11/23, 6/15/23 two times, 6/23/23, 6/24/23 and 6/25/23 for pain of 8 out of 10. Pain included the lower extremities, lower back, and reddened buttocks. On 6/16/23, there was no Norco signed out as administered. However, on 6/16/23 at 11:46 p.m, the nurse documented that the Norco was documented as somewhat effective. However, there was no time documented for when it was given or what pain level. Resident #1 received PRN Tylenol for an undocumented pain level on 6/10/23 and 6/30/23. The MAR from 7/1/23 to 7/5/23, documented Resident #1 received Tylenol for pain of 4 out of 10 on 7/3/23. -However, the orders were to give Norco for pain levels of 4 to 10. On 6/12/23 at 12:14 p.m., the nursing progress notes documented the resident had pain to the buttocks on 6/12/23 at 12:14 p.m. The buttocks were documented as red, shiney and sore. -There were no pain levels and no PRN Tylenol or Norco given per the nursing notes and MAR. On 6/16/23 at 1:58 p.m., the nursing progress notes documented the resident complained of pain to his buttocks and coccyx. The area was documented as red and the resident requested to go to the hospital due to the pain. -There was no pain level documented and no PRN Tylenol or Norco documented as given. The nursing notes documented again at 6:22 p.m. that the resident complained of pain to the reddened buttocks. -It is unknown if Norco was given, or at what time and for what level of pain on 6/16/23 (see above). There was no pain level. III. Staff interviews Registered nurse (RN) #1 was interviewed on 7/5/23 at 2:07 p.m. RN #1 looked at his laptop and said there was no documentation about the resident's condition or pain level after the fall. He said there should have been. RN #1 said he had sent a text to the physician for an x-ray on 2/2/23 due to the resident being in pain. He could not remember the resident's pain level at that time or what prompted him to call for an x-ray. RN #1 said he should have documented the x-ray order and reason in the notes. RN #1 said there should have been documentation on the resident's condition. RN #1 said he did not know why the resident was given one tablet of Tylenol for pain after his fall 2/1/23, instead of the Norco ordered on admission. The controlled drug count sheet was requested for the Norco for January and February 2023. RN #1 said he did not have one. He said to check with the director of nursing (DON). RN #2 was interviewed on 7/6/25 at 9:20 a.m. He said he knew Resident #1. RN #2 said Resident #1 was on Trazadone (antidepressant) for pain. -However, the resident was not on Trazodone for pain, but for depression. RN #2 said the Resident #1 had an order for Norco which he said the resident received for pain. RN #2 said the licensed nurses did not currently document a routine pain level. He said a pain level was only assessed and documented if the resident or someone else came and reported pain. He said he heard the facility was going to start doing pain assessments routinely, but he did not know when that was to start, and could not remember who told him this. The DON and assistant director of nursing (ADON) were interviewed on 7/6/23 at 9:34 a.m. The DON said she had been at the facility a little over a month. She said if a resident fell, there should be an assessment completed by the RN, and an event was initiated in the electronic medical record (EMR). She said the nurses should document in the progress notes for the next 72 hours, and observe for any injury or pain. She was not familiar with the fall for Resident #1 on 2/1/23. The DON said pain was assessed quarterly and as needed. She said pain was documented in the resident's weekly summary in the progress notes. -However, the weekly summaries reviewed for the last 90 days, when done weekly, did not contain information about pain. The ADON said pain should be assessed every shift and documented on the resident's MAR and when any pain medication was given. The DON said there was no count sheet for the Resident #1's Norco during the time prior to the resident's transfer to the hospital on 2/3/23. The DON said she had spoken to the pharmacy and the Norco had not been ordered. The ADON said the Norco was ordered and administered as needed after the resident returned form the hospital on 2/6/23. The ADON said she had started a performance improvement plan (PIP) for pain management yesterday (7/5/23) and would provide a copy. IV. Facility follow-up A document titled Performance Improvement Plan, Project Name: Pain Assessment and Management, initiated 7/5/23, was received from medical records on 7/6/23 at 5:58 p.m The plan documented the goal was to have a complete record of the resident's pain levels with a start date of 7/5/23. Action items initiated were, add pain question to daily Grand Rounds 7/7/23, no responsible person was listed, electronic health record will prompt nurses for basic pain assessment every shift as well as during administration of medications and treatments start 8/1/23, no responsible person was listed. Educate nurses on regular pain documentation every shift especially 72 hours after a fall or when new orders obtained with diagnosis of pain example, new order for tylenol or x-ray, no date or responsible person was listed, all medications for pain will have associated pain scales initiated on approved by medical director no date or responsible person was listed, policy update to reflect changes 7/6/23, final approval with medical director and interdisciplinary team 7/24/23, no responsible person listed. Indicators and Measures documented there would be electronic medical record documentation audits, it was unclear what would be audited, there was no start date, frequency, or responsible person identified. The PIP documented incidents would be audited for complete documentation by ADON weekly, and quarterly comprehensive pain assessments by the MDS coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews; the facility failed to maintain acceptable parameters of nutritional status for one (#52) of three residents reviewed for nutrition out of 22 total sample residents. Resident #52 with diagnosis of severe weight loss and unspecified dementia, was at risk for weight loss. The facility failed to document, track and monitor weight records consistently. The facility failed to provide the appropriate level of assistance with eating. The facility failed to update the resident's care plan with nutritional risks and interventions. Due to the facility failures, Resident #52 sustained a 13 pound avoidable weight loss considered significant in six months. Findings include: I. Facility policy and procedures The Nutrition policy, revised October 2017, was received from the health information manager (HIM) on 5/19/21 at 10:50 a.m. It read in pertinent part: As part of the resident assessment, a nutritional assessment should be conducted including nutritional status and risks for impaired nutritional status for each resident upon admission. The registered dietician along with the nursing staff and other administration staff shall conduct the nutrition assessment. The assessment team shall identify risk factors for impaired nutritional status such as cognitive decline, pain and increased need for calories or protein. Once conditions and risk factors are identified, individualized care plans will be developed to help minimize those risk factors such as to identify the causes of impaired nutritional status along with the residents' personal preferences and benchmarks for improvement. II Resident #52 A. Resident status Resident #52, age [AGE],was admitted on [DATE]. According to the May 2021 computerized physician orders (CPO) diagnosis included unspecified dementia, pressure ulcer of the right heel and severe weight loss. The 4/7/21 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) revealed the resident was severely cognitively impaired with non-traumatic brain dysfunction.The MDS indicated the resident had a five percent or more weight loss in the last 30 days. According to the MDS the resident was not on a physician prescribed weight loss program. Her weight and height were not indicated on the MDS. She required maximal two-person assistance with dressing, bathing and transferring, and one person assistance with eating. B. Observations of meals On 5/5/21 at 11:20 a.m. Resident #52 was seated in her wheelchair at a table in the dining room. An unidentified certified nurse aide (CNA) accompanied her. -At 11:25 a.m. the resident received her meal. The meal was chili dogs and potato salad. The food was chopped up in small pieces. -At 11:27 a.m. the CNA proceeded to give Resident #52 a bite of food. The resident chewed the food and swallowed it. -At 11:28 a.m. the CNA gave the resident a drink of juice through a straw. She swallowed the juice. -At 11:30 a.m. the CNA gave the resident another bite of food. She would not open her mouth to take the bite. No alternative was offered to the resident. One bite of the food was eaten which left 99% of the food on the plate. -At 11:32 a.m. the CNA tried again to give the resident a bite of food. She again did not open her mouth to take the food. -At 11:34 a.m.the CNA offered the resident a drink of the health shake which she drank. The resident took six more drinks of the shake and then refused to take anymore. -At 11:36 a.m. the CNA offered the resident another drink of the health shake. The resident did not open her mouth to take a drink. On 5/6/21 at 9:00 a.m CNA #2 sat with Resident # 52 at the nurses station. -At 9:05 a.m. to 9:30 a.m. CNA #2 assisted Resident #52 to eat oatmeal and drink her health shake. The CNA took a health shake from the fridge in the nurses station. She offered the shake in between bites of oatmeal. The resident consumed approximately 25% of the oatmeal. She was not offered an alternative. She drank 50% of the health shake. She refused to take any more after that. On 5/10/21 at 11:00 a.m Resident #52 sat at the table at the nurses station in her wheelchair. Registered nurse (RN) #2 was sitting at the table with her. This was thirty minutes before lunch started. -At 11:05 a.m. the RN gave the resident a drink of her health shake. -At 11:07 a.m. the resident took a drink of the shake assisted by RN#2. -At 11:09 a.m. the RN offered the resident a drink of the shake and she did not open her mouth. -At 11:12 a.m. the resident fell asleep in her chair. The nurse got up from the table and went to the medication cart.The cup of shake was half empty. The RN#2 threw the cup away. -At 11:16 a.m. the assistant director of nursing (ADON) came to the nurses station and assisted the resident to her room. C. Record Review The nutrition care plan initiated upon admission on [DATE] indicated Resident #52 had potential for weight loss due to dementia and major depressive disorder. The interventions included in the care plan on admission were to monitor the resident for change in nutritional status, intake, and her ability to feed herself. The care plan was updated on 2/11/21 to include the physician order of the Ensure clear. -There was no other nutrition care plan for the resident.The care plan failed to show any update on new interventions until 2/10/21 after the resident had lost weight (see below). Review of the resident's documented weights from January 2021 through May 2021 were as follows: 1/12/21= 112 pounds (lbs) 2/3/21= 106 lbs, 6 lbs weight loss in one month, 5.4% considered significant; 3/4/21= 104 lbs 4/7/21= 100.5 lbs 5/6/21= 99lbs, 13 lbs weight loss in six months, 11.6% considered significant. The resident experienced significant weight loss at 11.6% with a 13 lbs weight loss. -The medical record failed to show the registered dietitian (RD) did a complete and thorough assessment which included calorie needs and assessments of the current interventions, as the resident had experienced a significant weight loss and was not completed until 5/11/21 (see below, five days after the weight was recorded on 5/6/21). Review of the May 2021 CPO revealed the following physician orders -Regular diet, texture solids and thin liquids with a start date of 6/20/2020; -House supplement shake eight ounces to be administered with meals for continued weight loss. Give her as many shakes as she wants with a start date of 7/30/2020; -Ensure clear eight ounces twice daily with a start date of 2/10/21. -The Ensure clear was not implemented until 2/10/21 which was seven days after the resident had a recorded weight loss on 2/3/21 (see above). Review of the medication administration records (MAR) for 4/28/21 to 5/11/21 revealed the resident drank Ensure clear 100% on three of the days. The record indicates that the resident drank 50% to 75 % on the rest of the days. The intake record for the house shake dated 4/28/21 to 5/11/21 indicates that the resident drank 50% to 100% on six of those days. The record indicates the resident consumed 0% to 50% on eight of those days. Review of the resident's food and fluid intakes beginning 3/1/21 to 5/6/21 showed the resident consistently ate on an average of up to 25% per meal. The average fluid intake varied from 180 ml to 300ml per day. Snacks were taken on 10% of the days. A nutrition note dated 4/8/21 the RD documented, the resident did not feed herself and she ate her meals at the assisted medical dining room (MDR). The 5/11/21 registered dietitian (RD) note indicated that Resident #52 was prescribed a maximum of 1920 calories per day along with 76 grams of protein with nutritional supplements. She indicated Resident #52 needed a minimum of 1350 calories per day to maintain her current weight of 99 pounds.She said the intervention would be for staff to notify her if the resident did not meet the minimum requirements of 1350 calories per day. She included she would then notify the doctor and the family. -However, based on observations and record review (see above) the resident was not meeting the minimum calories per day. No additional interventions were added after the resident sustained a 13 lbs weight loss (see above). D. Interviews Certified nurse aide (CNA) #8 was interviewed on 5/10/21 at 10:31 a.m. She said Resident #52 sometimes ate 80% of her breakfast. She indicated that the resident's intake fluctuated on a daily basis. She said the resident experienced no weight loss lately. She indicated that the resident was a total assist with feeding. CNA #8 said the resident would not open her mouth if she did not want to eat. She indicated that there were foods Resident #52 liked in the nursing refrigerator like pudding, applesauce and yogurt to offer if she refused to eat her meal. She said she did not document anywhere if the resident ate those foods. She indicated that the resident would sometimes eat her meals in bed. The registered dietitian (RD) was interviewed on 5/10/21 at 11:00 a.m. The RD said she was aware Resident #52 had experienced a severe weight loss. The RD said she was aware of the resident's daily intake of food. A meal alternative was not suggested if the resident had not eaten the meal. She included the resident was prescribed meal shakes and Ensure clear as a supplement if she did not eat. She stated that the CNAs weighed the resident on a weekly basis. -However, the vital record above indicated the resident was weighed monthly (see above). CNA #2 was interviewed on 5/11/21 at 9:11 a.m. She said Resident #52 food intake was documented in the resident's medical record. She said the CNAs did not document what food was offered to the resident. She indicated the staff assisted the resident with what they could get her to eat. She included Resident #52 liked cottage cheese, yogurt and pudding. She said the resident's intake was hit or miss meaning that some days she would eat and some days she would not. CNA #2 said the resident would close her mouth when she did not want to eat. She included Resident #52 refused snacks most of the time. The director of rehab (DOR) was interviewed on 5/11/21 at 9:15 a.m. She said Resident#52 did not have swallowing issues. She said the restorative aides assisted the resident with eating three times per week. She said the aides did not document what the resident ate. She included that the resident would shut down sometimes when staff tried to help her eat.The DOR acknowledged the incidents of the resident declining to eat should be recorded and reported to the IDT. The RD was interviewed again on 5/11/21 at 10:30 a.m. She said the staff were to notify her and the nursing staff if Resident #52 did not meet the minimum daily intake requirements of 1350 calories per day. She stated that she would then alert the resident's physician and the family to inform them of the decline in the resident's intake. The RD acknowledged she did not provide any interventions for the resident when she did not meet the minimum intake requirements of 1350 calories per day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to provide appropriate treatment and services to a resident with depression to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one (#16) of four out of 22 sampled residents. Resident #16, with a diagnosis of major depressive disorder and anxiety disorder, often expressed feelings of wanting to die and about going to heaven. On several occasions, it was documented and staff interviews revealed the resident was persistently depressed and had feelings of anxiety. The facility failed to provide the appropriate treatment and services to the resident to attain the highest practical mental and psychosocial well-being. Cross-reference F745 provision of social services. Findings include: I. Facility policy and procedure The Behavior Assessment, Intervention, and Monitoring policy, updated in December 2016, was provided by the health information manager (HIM) on 5/10/21 at 3:00 p.m. It read in pertinent part Residents who do not display symptoms of or have not been diagnosed with, a mental, psychiatric psychosocial adjustment or post-traumatic stress disorder will not develop a pattern of decreased social interaction or increased withdrawn, angry or depressive behaviors from baseline or historical status of, that cannot be explained or attributed to a specific clinical condition that makes the pattern unavoidable. Residents will have minimal complications associated with the management of altered or impaired behavior. Appropriate assessment and treatment of behavioral symptoms require differentiating between behavioral symptoms that can be managed by treating underlying factors, and those that cannot. II. Resident #16 Resident #16, aged 78, was admitted to the facility on [DATE]. The May 2021 computerized physician orders revealed a diagnosis of major depressive disorder, anxiety disorder, and congestive heart failure. The 2/19/21 minimum data set (MDS) revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident's depression assessment, patient health questionnaire-9 (PHQ-9, depression questionnaire), revealed the resident had moderately severe depression with a score of 15 of 27. The resident required extensive two-person assistance with bed mobility, extensive one-person assistance with dressing, toileting, and hygiene, supervision and one-person assistance with eating, and one-person physical assistance while bathing. III. Resident interview and observation The resident was interviewed on 5/5/21 at 9:45 a.m. She said she hates this whole thing. She said she could not walk, could barely hold her head up, or feed herself. She said her tremors (shakes) were so bad it interfered with her ability to feed herself. She said she prayed all the time (visible tears began running down the resident's face). She said she wished there was something the facility could do to help her feel better about her situation that did not have so many side effects (medication). She said she was on some funny pills that gave her hallucinations and nightmares. The resident was interviewed on 5/6/21 at 10:45 a.m. She said she was ready to go to heaven and be with Jesus. She said she did not wish to be a burden to her children and was ready to leave this world. The resident was interviewed again at 3:40 p.m. She said God needed her in heaven and it was her time to go. The resident was interviewed on 5/10/21 at 10:44 a.m. She said she still felt like she needed to go to heaven. She said she had talked with multiple facility staff about her feelings of wanting to go to heaven. She said a priest came to visit her on Sunday and they discussed her feelings of wanting to die and if it would be a sin to choose to die. She said she was not sure if she wanted to try other medications for her depression or anxiety. She said the certified nurse aides (CNA) and nurses talked with her, held her hand, and validated her feelings when she talked about going to heaven. She said if she was not all crippled up she would be trying harder. She said she knew she was not going to get better so she did not feel like trying. She said she preferred to stay in her room and enjoyed independent activities. She did not like using the mechanical lift for transfers because of the pain she experienced. IV. Record review A PASRR (Preadmission Screening and Resident Review) note, dated 2/16/21, documented the resident was receiving scheduled Zoloft 25 mg for depression and as needed (PRN) Ativan (anti-anxiety medication). The medications were to be tracked and monitored for two weeks to determine effectiveness. Staff reported on several occasions that the resident expressed being miserable and not caring about anything. While the nurse was completing a blood draw the resident had a flat affect and expressed little joy. A nursing note, dated 2/18/21, documented the resident reported not feeling well and wished to see her family. Staff informed her that while she was in isolation she could not receive visitors. The resident stated that she did not think she would be alive at the end of her isolation. Staff tried to reassure the resident but she seemed pretty down. Social services were notified and were in the room talking with the resident. The care plan, dated 2/23/21, documented psychosocial well-being related to (R/T) recent hospital stay and recent nursing home admission. The resident was not oriented to the facility, the resident's BIMS was completed 2/15/21 with a score of 8/15, and PHQ9 (depression scale) was 15/27. Her strengths included strong family support. Documented interventions included allowing the resident to voice concerns and validate, encourage meals in the main dining room and join out of room activities of choice to encourage socialization, encourage participation in activities of daily living (ADL) to the best of her ability and assist as needed, encourage family visits often for support, explain procedures to the resident and allow time to process and respond, reassure the resident that she is safe and her needs are being met, and social service (SS) visits one-to-one (1:1) as needed. A 2/23/21 PASRR note documented the physician recommendations for a gradual dose reduction to the residents PRN Ativan medication from 0.5 milligrams (mg) to 0.25 mg and was to continue for the remainder of the two weeks. The physician increased the resident's Zoloft from 25 mg to 50 mg each day. The medication changes were made due to the resident's change in overall condition, the resident's power of attorney (POA) was notified and gave verbal consent. A 2/24/21 nursing note documented the resident received her first increased dose of Zoloft this morning. Monitoring for effectiveness and side effects initiated. No side effects were noted and the resident was cooperative and pleasant. Will continue to monitor. A nursing note, dated 2/25/21, documented the resident was crying and refusing care from CNAs. The resident stated that she did not want to do this anymore. Staff provided reassurance and support to the resident. Monitoring for an increase in Zoloft medication in progress. A 2/26/21 PASRR note documented the facility being out of 0.25 mg Ativan. The PRN 0.5 mg Ativan order was reactivated due to the resident being in great mental distress related to changes in her routine. A nursing note, dated 2/26/21, documented the resident was teary-eyed and refusing a bath before her transfer out of isolation. The resident stated that she did not want to be there and that she just wanted to die. A 2/27/21 nursing note documented the resident requested her PRN Ativan related to her room change. She said she was feeling anxious and needed to get some sleep. The resident slept through the night following the medication. The resident did not appear in distress or discomfort. The resident was being monitored for the increase in Zoloft with no apparent side effects. A 2/27/21 activity note documented the resident did not feel up to having a visit from activity staff that day. A 3/1/21 nursing note documented the resident experienced one episode of anxiety and reported feeling like the walls were closing in on her. The writer spoke with the resident and reassured her she was safe and upon exiting the room, left the door open so the resident could see into the hallway. PRN medication was given and no other behaviors noted. A nursing note, dated 3/2/21, documented the resident expressed she felt the walls were coming in on her around 12:45 p.m. Staff talked with the resident and reassured her safety, and offered her as needed (PRN) antianxiety medication. She accepted and rested well the rest of the night. A 3/5/21 nursing note documented the resident was on behavioral charting for an increase in Zoloft medication. No signs or symptoms of an adverse reaction and no unusual behaviors displayed or reported. The resident was compliant with medications and provided care. The resident reported a low appetite this evening and declined to eat dinner. A 3/11/21 nursing note documented the resident continued on behavior monitoring for an increase in Zoloft. No adverse effects noted. The resident requested PRN Ativan last night while experiencing a panic attack. Medication was effective and the resident rested peacefully after receiving medication. A 3/12/21 nursing note documented the discontinuation of the resident PRN Ativan. The resident continues on an increased dose of Zoloft at the hour of sleep for depression and anxiety. The resident's generalized anxiety disorder scale evaluation, dated 3/25/21, revealed the resident had moderate anxiety with a score of 10 out of 21. The evaluation indicated the resident's anxiety made it somewhat difficult to work, take care of things at home, or get along with other people. A nursing note dated 4/12/21 documented a one-week hold of the resident's antidepressant (Zoloft) medication was completed and the resident was to resume the medication that day. The resident was teary-eyed and expressing she did not want to be home, she did not want to be at the facility, and that she just wanted to go to heaven. The resident complied with getting out of bed for the breakfast meal but requested to go immediately back to bed after she finished. A 4/17/21 nursing note documented the resident refused her Zoloft during medication pass. The resident asked the nurse if she was still receiving those funny pills and the nurse said yes. The resident stated she did not ever want those pills again. This nurse assured the resident that she would not receive any medications she did not want and provided education about why she was taking Zoloft. When asked why the resident did not want to take the medication she said she thought they made her see things that were not there. The physician was notified and approved the discontinuation of the medication until further notice. The care plan, updated 4/23/21, documented the resident was taking antidepressant medication for depression and an as-needed antianxiety medication for anxiety. Target behaviors included expressions of sadness and apathy. The care plan documented an increase in antidepressant medication on 2/23/21 and the discontinuation of the antidepressant medication on 4/17/21. Documented interventions included give medication as ordered and monitor effectiveness, monitor and report side effects of sleepiness or fatigue, dizziness, dry mouth, nausea, tremors, headaches, and constipation, monitor need for continued use or potential for an alternate approach, non-pharmacological interventions included refocus on functional progress and encourage spirituality, and to report changes in mood and behavior to the nurse. A dietary note dated 5/6/21 documented that while the registered dietitian (RD) was visiting with the resident, the resident expressed that she did not wish to get up for meals, only for family visits. The resident voiced that she wanted to go to heaven and did not have an appetite. A nursing note dated 5/11/21 documented that while the activity assistant was visiting with the resident, the resident asked that if she stopped taking her meds (medication) would she still go to heaven. The activity assistant explained to her the only God decides how long we live. The activity assistant also discussed with her the benefit of medication and how they affect her wellbeing while she was alive. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/10/21 at 11:46 a.m. She said person-centered care to her was getting to know the resident's preferences, encouraging residence independence, encouraging residents to do their best, and reassuring the safety and security of the residents. She said some residents did express a wish to die, and she struggled with this. She said when residents expressed this to her she reassured the resident that they were not alone and she was here to help them and make their day better. She said when residents express a desire to die she notified the nurse. She said she informed the nurse if the resident appeared depressed or was displaying behaviors of any kind. She said she had not received behavior training regarding depression or anxiety from the facility but had from other facilities she worked at. She said some residents with depression will not eat much or at all, they want to stay in their room in bed or brought up going to heaven. She said the staff did use the resident care plans for care preferences and programs the resident was involved in. She said she was not sure if behaviors or emotional problems were included in the care plan. She said the nurse knew and told her most of the behavioral information she needed to know about residents. She said it could be hard to help new residents acclimate to the facility. She said she tried to get to know the residents and their needs and helped them acclimate by meeting those needs and orienting them to their environment. She said she worked with Resident #16 when she first arrived at the facility and after she moved out of isolation. She said they would talk and pray together. She said Resident #16 told her often that she wanted to go to heaven. She said when the resident expressed this she would reassure the resident that she was safe and would pray with her. She said the last time the resident told her she wanted to go to heaven was five days ago (5/5/21) on her last shift. She said she tried to advocate for the residents when they expressed wishes to die. Licensed practical nurse (LPN) #1 was interviewed on 5/10/21 at 12:08 p.m. She said person-centered care to her was meeting the resident's medical needs, talking with them about their families, and listening to them so they felt heard. She said when a resident expressed a wish to die she discussed with them why they felt that way, encouraged them to talk about their families, and focused on the good things in their life. She said if it was a serious expression and talking with them does not help she reports their feelings to the charge nurse and their physician. She said the behavior was tracked after the physician was informed and medication changes were made. She said new medications or medication changes were tracked daily for two weeks and the resident was monitored for side effects, improvements, and behavior changes. She said she received in-service training from the facility about depression and anxiety. She said signs and symptoms of depression and anxiety included isolating in their room, not wanting to get out of bed, and expressing concern for family members. She said signs and symptoms of depression and anxiety were resident-specific. She said non-pharmacological interventions for depression and anxiety included family phone calls and visits, offering preferred activities, staff visits, putting on their favorite movie or television show, offering favorite snacks or beverages, and encouraging safe socialization. She said she did use the resident's care plans and included routine preferences, favored activities, and interventions. She said Resident #16 frequently expressed wanting to go to heaven. She said Resident #16 expressed to her yesterday (5/9/21) that she wished to go to heaven, had no will to live, and a desire to unburden her family. She said the resident had been on antidepressant medications and refused them. She said the facility had been working medically and spiritually to meet her needs and it was not effective. She said social services (SS) notified the family of the residents ' expressions and maintained the families ' involvement in care. She said both of the social workers (SW) from the facility go in and talk with her about her feelings. The activity director (AD) was interviewed on 5/10/21 at 12:56 p.m. She said resident activity preferences were discovered through the initial activity preference interview and through reports from staff members. She said activity staff provided one-to-one sessions with residents who prefer to stay in their rooms. She said residents who had depression received one-to-one visits regularly from activity staff. She said if residents expressed a desire to die, the activity staff talked with them and informed the nurse and the social workers. She said Resident #16 received three one-to-one visits a week from activity staff. She said the resident expressed wanting to be out of bed only for family visits which she received often. The social service director (SSD) and the social service assistant (SSA) were interviewed on 5/10/21 at 1:34 p.m. They said they completed training with staff members about redirection and intervention for resident behaviors but did not keep in-service records or log-in sheets of the staff who attended. The SSD said when residents express feelings of wanting to die to staff, they often come to social services for tips and advice about how to discuss this with the residents. He said he or the SSA would also go talk with the resident about their feelings. He said they should be documenting these encounters with residents. He said he conducted annual training with staff about emotional issues the residents could face. He said when he was on the floor he would provide on-the-spot training to staff if he saw something that warranted it. He said staff informed himself or the SSA if resident behavior was out of the normal. He said non-pharmacological interventions for residents could be found in the care plan and progress notes. The SSA said he checked in with Resident #16 often to make sure she was doing alright. He said he felt she was having a hard time adjusting to life at the facility. He said she chooses to stay in her room except when she has visitors. He said a big part of acclimating to the facility was communal dining and socialization, which she declined. He said he met with the resident frequently to help her adjust to the facility. He said he should have documented his one-to-one sessions with the resident and what he assisted her with during the session. He said she frequently expressed her desire to die and go to heaven to him. He said she had no plan and did not express suicidal ideation. He said these expressions did not evoke concern because he had experienced this with other residents. He said when she expressed these feelings he would sit and talk with her about her family and the good times she had in her life and that usually helped her feel better. He said she mentioned going to heaven and dying twice to him that week. He said he should have documented these expressions, and had been asked to document his sessions with residents. He said he should have included her feelings and expressions of wanting to die in her care plan with intervention options for staff to use. He said a resident with a PHQ9 (depression scale) score of six or more, should be referred to senior counseling services. He said Resident #16 had a score of 15/27 and should have been referred to counseling, but he did not follow up on the recommendation. He said he should have offered her senior counseling services and that they could benefit her wellbeing. He said he had not offered or discussed senior counseling services with the resident. The DON and assistant director of nursing (ADON) were interviewed on 5/10/21 at 2:37 p.m. They said staff should offer reassurance and validate the resident's feelings when a resident expressed feelings of wanting to die. They said if the expression was odd or unusual for the resident the CNAs should tell the nurse who should inform social services (SS). They said a mood care plan should be included for residents who experience depression or anxiety and that is completed and updated by SS. They said SS conducts behavior, trauma-informed care (TIC), and dementia training annually with all floor staff members, and the annual training was scheduled for 7/26/21. The activity assistant (AA) was interviewed on 5/11/21 at 9:11 a.m. She said the facility and activities department specifically provided depression and anxiety training all the time. She said the training covered the general signs and symptoms of depression and anxiety, and how to maintain and establish the well-being of the residents. She said she learns more about the residents ' specific presentation of depression and anxiety by spending time and talking with them. She said she visited with Resident #16 three times a week. She said they typically pray, read scripture and sing during their visits. She said the resident asked her if she stopped taking her medications if God would be ok with that and she would still go to heaven. She said she reassured the resident that medications made her time on earth more comfortable and God would take her when he was ready for her. She said Resident #16 expresses her desire to go to heaven every time she meets with her. She said she informs the nurse for the hall when the resident expresses this. The registered dietitian (RD) was interviewed on 5/11/21 at 1:34 p.m. She said if a resident expressed a desire to go to heaven while she was talking with them she informs the SW. She said the emotional state of residents can have an impact on appetite. She said when Resident #16 told her she wanted to go to heaven, she was concerned and informed social services on 5/6/21. She said she called the family and informed them of the resident's lack of appetite. She said the family informed her that the resident did not have an appetite and had issues eating before being admitted to the facility. She said she continued to offer preferred food choices and the resident was not interested. She said the family brought her food often when they came to visit. VI. Follow-up A social service note dated 5/11/21 documented the resident's depression scale, PHQ9, results were forwarded to the psychiatric nurse for a referral to senior counseling services. The physician signed and approved the referral. A new order for Cymbalta 30 mg once a day was requested and approved by the resident physician on 5/11/21 for the resident's depression. The resident agreed to the medication and the POA was notified and gave verbal consent.