**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure two (#26 and #5) of six residents out of 16 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Resident #26 was admitted to the facility for long term care on 1/4/23 with diagnoses of dementia, hypotension (low blood pressure), hypokalemia (low potassium), hypothyroidism (low thyroid function) and depression. Upon admission on [DATE], Resident #26 weighed 152 pounds (lbs) and she reported she liked to eat eggs, coffee and sweets. Resident #26 had gradual weight gain until 4/12/24 when she weighed 190 lbs. At this time, the resident started gradually losing weight. On 9/4/24 the resident weighed 182 lbs. The resident sustained 12 lbs (6.5%) weight loss in one month, from 9/4/24 to 10/3/24, which was considered severe. The facility failed to implement effective person-centered nutrition interventions to address the resident's decreased oral intake and severe weight loss. On 9/27/24, Resident #26 weighed 174 lbs, which indicated the resident had lost eight lbs in 20 days. The registered dietitian (RD) recommended implementing a house nutrition supplement, however, the facility failed to obtain a physician's order for the house supplement and track the resident's acceptance of the intervention. Due to the facility's failures, Resident #26 continued to lose weight and weighed 168 lbs on 11/4/24, which indicated the resident lost 22 lbs (11.6%) in six months. Additionally, Resident #5 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic chronic kidney disease, anxiety, anemia (low red blood cell count) and dysphagia. Resident #5 sustained a weight loss of 12.8% (24 lbs) from admission on [DATE] through 11/4/24, which was considered severe. According to Resident #5's nutrition care plan, pertinent interventions were initiated on 8/28/24 which included a house shake once a day. The facility failed to implement additional person-centered effective nutritional interventions for Resident #5 and meet the resident's dietary preferences to prevent significant weight loss. Review of the physician progress notes revealed no documentation of Resident #5's significant weight loss and poor nutritional status. There was no documentation on expected or unplanned weight loss, or updated care plan goals and appropriate interventions to improve resident's nutritional status. Findings include: I. Facility policy and procedure The Weight Assessment and Intervention policy, revised March 2022, was provided by the nursing home administrator (NHA) on 11/7/24 at 10:00 a.m. It read in pertinent part, Any weight change of five pounds or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. The threshold for significant unplanned and undesired weight loss will be based on the following criteria one month - five % weight loss is significant; greater than five % is severe. Three months - 7.5% weight loss is significant; greater than 7.5% is severe. Six months - 10% weight loss is significant; greater than 10% is severe. II. Resident #26 A. Resident status Resident #26, over the age of 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included dementia, hypotension , hypokalemia, hypothyroidism and depression. The 10/1/24 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) was not conducted because the resident was rarely or never understood. She experienced hallucinations and wandering and required setup and clean up assistance with eating. The assessment documented the resident was 70 inches (five foot, ten inches) tall and weighed 174 lbs. It indicated the resident had weight loss and was not on a physician prescribed weight loss program. B. Observations During a continuous observation of the lunch meal service on 11/5/24, beginning at 12:01 p.m. and ending at 1:24 p.m., the following was observed: Resident #26 was served lunch consisting of the regular menu which consisted of grilled fish, parmesan noodles, sliced zucchini, wheat bread and a chilled fruit cup and ate approximately 50% of the meal. When the resident finished eating, she stood up from the table and walked to her room. -The resident was not encouraged by staff to continue eating or offered any additional snacks or food items. C. Record review The nutrition care plan, initiated on 1/18/23 and revised on 9/22/24, revealed Resident #26 had a potential nutritional problem related to hypothyroidism (low thyroid function), dementia and depression. The interventions included administering medications as ordered, (1/18/23), observing/documenting/reporting as needed any signs of dysphagia such as pocketing, chocking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals (1/18/23), providing and serving diet as ordered and recording intake (1/18/23), providing daily menu assistance with making menu choices (1/18/23), RD to evaluate and make diet change recommendations as needed (1/18/23) and weighing the resident per facility protocol (1/18/23). -Review of the resident's comprehensive care plan did not reveal the facility implemented new person centered nutritional interventions after Resident #26 had sustained significant weight loss on 10/3/24 and on 1/4/24. Resident #26's weights were documented in the resident's electronic medical record (EMR) as follows: -On 4/12/24, the resident weighed 190 lbs; -On 4/16/24, the resident weighed 188 lbs; -On 5/7/24, the resident weighed 188 lbs -On 6/4/24, the resident weighed 186 lbs; -On 7/1/24, the resident weighed 186 lbs; -On 8/5/24, the resident weighed 188 lbs; -On 9/4/24, the resident weighed 182 lbs; -On 9/24/24, the resident weighed 174 lbs; -On 10/3/24, the resident weighed 170 lbs; -On 10/15/24, the resident weighed 169 lbs; -On 10/22/24, the resident weighed 168 lbs; -On 10/28/24, the resident weighed 167 lbs; and, -On 11/4/24, the resident weighed 168 lbs. -The resident lost 22 lbs from 8/5/24 to 11/4/24, in three months, which was considered severe. -The resident lost 12 lbs from 9/4/24 to 10/3/24, in one month, which was considered severe. -The resident lost 23 lbs from 4/12/24 to 11/4/24, in six months, which was considered severe. The 5/4/24 mini nutritional assessment (MNA) documented Resident #26 had no decrease in food intake or weight loss over the past three months. -However, Resident #26 had lost two lbs during the past three months. The 7/15/24 RD assessment documented Resident #26 was eating a regular diet and more than 75% of her meals. The recommendation was to continue with the current plan of care. A nutrition progress note, dated 9/20/24, documented the resident was discussed at the nutrition at risk (NAR) meeting because the resident had weight loss, however, her intake was adequate but due to her wandering during the day she needed to be encouraged to eat. Weekly weights were initiated. A nutrition progress note, dated 9/27/24, documented the resident was discussed at the NAR meeting because she had lost eight lbs. The note revealed she was sleeping more, pale and laboratory (lab) testing had been ordered. It was recommended to add house supplements to her diet once the lab results were obtained. -Review of the November 2024 CPO did not reveal a physician's order was implemented for a house supplement. The 9/28/24 progress note documented Resident #26 tested positive for COVID-19. -However, Resident #26 had already lost eight lbs prior to a COVID-19 diagnosis. The 10/4/24 RD assessment documented Resident #26 had a recent significant weight loss due to COVID-19 and poor intake while she was sick. The recommendation was for RD to monitor the resident as needed. -However, the facility failed to implement interventions to combat the residents' decreased intake while she had COVID-19. The 10/15/24 progress note documented Resident #26 was moved to the secured unit. The 10/21/24 certified dietary manager (CDM) nutritional assessment documented Resident #26's weight was trending down and that the resident liked to eat almost everything. -After the CDM identified the resident's weight was trending down, the facility failed to implement person-centered effective nutritional interventions to meet the resident's dietary preferences after the resident sustained a 11.6% (22 lbs) weight loss in six months, from 4/12/24 to 11/4/24, to address the resident's significant weight loss and decline in oral intake. D. Staff interviews NA #1 was interviewed on 11/5/24 at 1:26 p.m. NA #1 said it was difficult to get the residents on the secure unit to eat if they did not want to. She said the residents consumed more food if they were able to hold the food and walk around the unit. -However, observations did not reveal residents were given finger foods to walk around the unit with (see observations above). The NHA was interviewed on 11/6/24 at 2:27 p.m. The NHA said she had been watching over the kitchen for the past two months since the dietary manager left. She said the facility had been trying to hire someone to fill the position but it had been difficult since it was a small town. She said the RD visited the facility about twice a month. Cross reference: F801 failure to employ a full time dietitian or a qualified dietary manager. The RD was interviewed on 11/6/24 at 2:30 p.m. The RD said residents' preferences and nutrition interventions were not included in the care plan because she was directed not to include detailed information like that by another consultant. She said the nurse notified the physician and the residents' representatives of any weight loss. She said food preferences were communicated to the staff on the residents' food cards. She said she did not like the current form the facility was using to obtain the residents' preferences because it focused on the residents' dislikes and not their preferences. She said she would like to change it. The RD said when a resident was admitted to the facility, the admissions clerk collected the food preference information and if the resident was not able to identify likes and dislikes, she contacted the family for the information. She said the house supplements should only be given at meal times if the resident continued to eat the meal. She said if the resident started eating less at meal times, the supplement should be given outside of meal times. The RD said Resident #26 sustained significant weight loss since she had COVID-19. III. Resident #5 A. Resident status Resident #5, age [AGE], was admitted on [DATE]. According to the October 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic chronic kidney disease, anxiety, anemia (low red blood cell count) and dysphagia (difficulty swallowing). The 8/12/24 MDS assessment revealed the resident was cognitively intact with a BIMS score 14 out of 15. She required supervision with eating, and substantial/maximal assistance with transfers and ADLs. The MDS assessment documented the resident was 64 inches (five foot, four inches) tall and weighed 188 lbs. The resident did not have any swallowing disorders. The MDS assessment documented the resident had not had any recent significant weight loss or weight gain or nutritional approaches were documented. The MDS assessment documented Resident #5 was prescribed an anticoagulant, antibiotic, diuretic, opioid and hypoglycemic medication. B. Resident interview and observation Resident #5 was interviewed on 11/4/24 at 4:45 p.m. Resident #5 said she did not like the food that was served most of the time. She said I wish I had soup (cream of potato) every evening. She said she did not like rice. She said she liked potatoes. She said she was not aware of foods that were always available in case she did not like what was served. During the interview, the cook (CK) approached Resident #5 and said the kitchen did not have soup in the kitchen to serve to residents. C. Record review The nutrition care plan, dated 8/8/24 revealed the resident was at risk for weight loss because of poor food intake at meals which was on average 25% to 50%. Interventions included eight oz of house shake once a day (8/28/24) and her food preferences included soups. -Despite the resident's food preferences, she was not served soup (see observation above). Resident #5's weights were documented in the resident's EMR as follows: -On 8/6/24, the resident weighed 188 lbs; -On 8/12/24, the resident weighed 186 lbs; -On 9/4/24, the resident weighed 176 lbs; -On 10/9/24, the resident weighed 170 lbs; and, -On 11/4/24, the resident weighed 164 lbs. -The resident lost 12 lbs (6.4%) from 8/6/24 to 9/4/24, in one month, which was considered severe. -The resident lost 24 lbs (12.8%) from 8/6/24 to 11/4/24, in three months, which was considered severe. A review of the November 2024 CPO revealed the following physician's orders related to nutrition: House shake 8 oz in the morning, one time a day with breakfast for decreased meal intake, ordered on 8/28/24. Spironolactone oral tablet 25 mg (diuretic medication), give 25 milligrams (mg) by mouth in the morning for edema, ordered on 9/5/24. Torsemide oral tablet 20 mg (diuretic medication), give one tablet by mouth two times a day related to unspecified diastolic (congestive) heart failure, ordered on 8/27/24. On 8/8/24, the RD documented the resident was new to the facility. The RD would monitor the resident's weights while she adjusted to the facility. The resident had one plus (1+) edema to her bilateral lower extremities. The resident's weight may fluctuate. The resident's current weight was 188 lbs. The resident was at increased nutritional risk related to COPD, chronic kidney disease, diabetes and gastro esophageal reflux disease (GERD). On 8/27/24 the RD documented, the resident was at increased nutritional risk for weight loss as evidence by poor meal intake. She had recently gained weight related to edema. The RD documented the resident's weights may fluctuate related to diuretic use. The resident was recently started on a house shake eight oz one time a day. The RD documented the resident's recent weight gain was related to edema to her lower extremities. The RD tried to contact the physician several times. The RD documented she would continue to monitor. -However, the resident had lost two lbs from 8/6/24 to 8/12/24. On 9/5/24 the RD documented, the resident had lost weight. The resident had edema and was on diuretics. She was not eating well. The resident was at increased nutritional risk related to COPD, dementia, chronic kidney disease, diabetes and GERD. The resident's meal intake was poor. -However, review of the resident's EMR did not indicate changes in the resident's 1+ edema to her bilateral lower extremities. On 11/5/24 the RD documented, Resident #5 had 1+ edema to her bilateral lower extremities. The resident was on diuretics. She has been losing weight since admission, which could be related to fluid loss. The resident was receiving a house supplement with breakfast. The resident was at risk for weight loss as evidenced by poor intake at meals. The resident was consuming an average of 25% to 50% of her meals. The resident's weight had been trending down related to edema and diuretic use. The resident liked soup. The resident was encouraged to ask for an alternate meal option if she did not like what was being served. The RD documented she would continue to monitor as needed. -A review of Resident #5's EMR did not reveal physician notes related to the resident's nutritional status and weight loss. D. Staff interviews The RD was interviewed on 11/6/24 at 3:45 p.m. The RD said she did not observe Resident #5 eating her meals as she was not in the facility often. She said she participated in the NAR meetings remotely. E. Facility follow-up The facility provided documentation on 11/8/24 indicating Resident #5 was on two diuretics, she was reviewed weekly in the NAR meeting and interventions were in place. -However, review of Resident #5's EMR did not reveal documentation indicating the resident's edema had worsened or improved from 1+ on her bilateral lower extremities and did not include efficient supplementation to improve nutritional status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents were kept free from abuse for three (#1, #2 and #3) of six residents reviewed for abuse out of six sample residents. Resident #1, who had a diagnosis of Alzheimer's disease and a tendency to wander, had a plan of care which documented the resident had impaired safety awareness and wandered aimlessly. The interventions were to offer Resident #1 pleasant diversions, structured activities, food, conversation, television and card games. On 2/28/24 Resident #1 wandered into Resident #2's room. Resident #2 told Resident #1 he was in the wrong room and told him to leave. Resident #1 refused to leave the room which caused Resident #2 to push Resident #1 to the floor. A staff member, who was informed that Resident #1 went to the wrong room, rushed to the room but she was unable to open the door. Resident #1 was on the floor in front of the door and was moaning in pain. The staff member eventually opened the door. Resident #1 and Resident #2's roommate informed the staff member that Resident #2 pushed Resident #1. Resident #1 was sent to the hospital and was diagnosed with a fracture to his right femoral neck (the thigh bone below the hip joint). Resident #1 was admitted to the hospital and required surgical repair to heal the fracture. On 3/8/24 Resident #1 re-admitted to the facility. The resident was placed on 15-minute checks for supervision related to Resident #1 being non-weight bearing when he returned to the facility. On 7/9/24 Resident #1, who remained on 15-minute safety checks, went into Resident #3's room. Resident #3 and his roommate asked Resident #1 to leave the room. Resident #1 refused and Resident #3 attempted to push Resident #1's wheelchair out of the room. Resident #1 hit Resident #3 in the face and pulled Resident #3's hair. A staff member intervened and removed Resident #1 from the room after the altercation occurred. Due to the facility's failure to prevent Resident #1 from wandering into another resident's room, Resident #1 was involved in a resident to resident altercation with Resident #2, which resulted in Resident #1 sustaining a right hip fracture and being sent to the hospital for surgical repair of his hip. Additionally, after the resident to resident altercation with Resident #2, the facility again failed to implement person-centered interventions to prevent Resident #1 from wandering into other resident's rooms, which resulted in a resident to resident altercation between Resident #1 and Resident #3. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 8/6/24 at 3:00 p.m. It read in pertinent part, Residents have the right to be free from abuse. The resident abuse prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: -Identify and investigate all possible incident of abuse; -Investigate and report any allegations within timeframes required by federal requirements; -Protect residents from any further harm during investigations; -Establish and implement a quality assurance and performance improvement (QAPI) review and analysis of reports, allegations or findings of abuse; and, -Involved the resident council in monitoring and evaluating the facility's abuse prevention program. The Abuse and Neglect Clinical protocol, revised March 2018, was provided by the NHA on 8/6/24 at 3:00 p.m. It read in pertinent part, The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The physician and staff will order measures required to address the consequence of an abuse situation. The physician and staff will address appropriately causes of problematic resident behavior where possible. The staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood and function. The medical director will advise facility management and staff about ways to ensure that basic medical, functional and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately. The physician will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process. II. Incident of physical abuse between Resident #1 and Resident #2 on 2/28/24 The facility abuse investigation documented that on 2/28/24 at 7:08 p.m. a resident informed the nurse that Resident #1 wandered into Resident #2's room. Resident #2 and his roommate asked Resident #1 to leave the room. Resident #1 refused to leave the room. Resident #2 got out of his recliner, walked over to Resident #1 and pushed Resident #1 to the floor. When staff arrived to the room, Resident #1 was on the floor in front of the room door moaning in pain. Resident #2 said Resident #1 fell. Resident #2's roommate and Resident #1 motioned that Resident #2 pushed Resident #1. The summary of the incident documented Resident #1 had a history of wandering and wandered into Resident #2's room and refused to leave. Resident #1 was sent to the hospital via an emergency ambulance. Resident #1 sustained a right femur fracture and required surgery to repair the injury. Upon Resident #1's return to the facility on 3/8/24, 15-minute safety checks were implemented for Resident #1. The facility substantiated the incident. III. Incident of physical abuse between Resident #1 and Resident #3 on 7/9/24 The 7/29/24 facility abuse investigation documented Resident #1 ambulated via his wheelchair into Resident #3's room. Resident #3 and his roommate told Resident #1 he was in the wrong room, but Resident #1 refused to leave. Resident #3 attempted to push Resident #1's wheelchair backwards out the door. Resident #1 swung at Resident #3 with his hands and hit Resident #3 in the face. Resident #1 then pulled Resident #3's hair. Resident #3 yelled out and staff entered Resident #3's room. Resident #1 was sitting in his wheelchair with his head down and Resident #3 was standing next to Resident #1. Both residents were assessed and no injuries were noted. Resident #1 did not answer questions about the incident. Resident #3 and his roommate were interviewed on 7/29/24 and said Resident #1 wandered into their room and refused to leave. Resident #3 and his roommate said Resident #1 hit Resident #3 and pulled Resident #3's hair before staff entered the room. The investigation documented the previous interventions included Resident #1 was on 15-minute safety checks. The investigation documented no new recommendations or interventions were implemented. -The facility failed to implement a new effective person-centered intervention to prevent Resident #1 from wandering into other resident's rooms in order to prevent an additional resident to resident altercation. The facility did not substantiate this allegation because it was not identified as abuse. -However, physical abuse occurred due to Resident #1 willfully hitting and pulling Resident #3's hair. IV. Observations During a continuous observation on 8/7/24, beginning at 10:50 a.m. and ending at 11:15 a.m. The following was observed: At 10:50 a.m., Resident #1 was laying on his bed with his head under a blanket. At 10:52 a.m., licensed practical nurse (LPN) #1 walked down one of the two hallways and completed 15-minute checks on other residents. LPN #1 failed to go down the hallway where Resident #1's room was located to complete a 15-minute check for the resident. At 11:00 a.m., Resident #1 was laying on his bed with his head under a blanket. At 11:05 a.m. LPN #1 assisted a resident and passed by Resident #1's room but did not look in Resident #1's room. At 11:15 a.m., Resident #1 was laying on his bed with his head under a blanket. Staff did not complete a 15-minute check. -The facility failed to complete a 15-minute check on Resident #1 from 10:50 a.m. to 11:15 a.m. V. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnosis included Alzheimer's disease. The 6/19/24 minimum data set (MDS) assessment revealed Resident #1 was unable to complete a brief interview for mental status (BIMS). A staff assessment for mental status revealed the resident was rarely understood, had moderate cognitive impairments, and was unable to identify the current season, the location of his room and staff names or faces. B. Resident #1's representative interview Resident #1's representative was interviewed on 8/7/24 at 11:58 a.m. The resident's representative said he understood the facility was not able to provide one on one attention to each resident but he felt Resident #1 needed a little more supervision. He said Resident #1 worked his entire life and did not like to sit still. The resident's representative said Resident #1 needed fulfilling activities such as being helpful instead of arts, crafts or games. The resident's representative said when he visited Resident #1 he took the resident outside on walks and it helped with limiting the resident from attempting to self-transfer. The resident's representative said he felt the supervision the facility provided for the resident could have been better. He said he was not sure what the facility did for Resident #1 when he was not at the facility visiting regarding care, activities and supervision. The resident's representative said he did not see staff complete 15- minute checks when he visited the facility. He said he felt Resident #1 did not get enough activities that he enjoyed or to keep him busy. C. Record review The elopement care plan, revised 2/5/24, revealed Resident #1 was an elopement risk and wandered. The intervention included Resident #1 had a wander guard for safety. -The facility failed to update Resident #1's care plan to include an intervention to keep Resident #1 from wandering into other residents' rooms after the resident to resident altercations on 2/28/24 and 7/29/24. The behavior care plan, revised 7/25/24, revealed the resident had behavioral issues that were due to his diagnosis of dementia, aggression and exit seeking behaviors. Interventions included the following: administering medications as ordered (7/26/21), anticipating and meeting the resident's needs (7/26/24), being aware of the resident's triggers and which of his behaviors triggered other residents (5/9/22), providing the opportunity for positive interactions and attention (8/18/22), explaining all procedures to the resident before starting cares and allowing him a few minutes to adjust to changes (7/26/21), intervening as necessary to protect the rights and safety of others (7/26/21), monitoring behavior episodes and attempting to determine an underlying cause (7/26/21) and providing an activities program that was of interest and accommodated the resident's status. -However, the facility failed to implement new interventions following the resident to resident altercations on 2/28/24 and 7/9/24. The care plan last had new interventions implemented on 6/18/22. The intervention documented on 7/25/24 had was already been implemented on 6/18/22. The 2/28/24 progress note documented the NHA was notified of an incident and arrived at the facility to start an investigation. The 2/29/24 progress note documented the staff were directed to a resident's room that Resident #1 had entered. Resident #1 was on the floor in front of the room door and was yelling out in pain. The staff opened the door and Resident #2's roommate pointed at Resident #2 and motioned that the resident pushed Resident #1. Resident #1 said Resident #2 pushed him to the floor. Resident #2 denied pushing Resident #1. The staff called 911 and Resident #1 was transferred to the emergency room for medical treatment. The 2/29/24 progress note documented the hospital notified the facility that Resident #1 had fractured his right hip and the resident was being admitted to the hospital. The 3/8/24 progress note documented the resident was admitted back to the facility. VI. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE] and discharged to a hospital on 4/14/24. According to the April 2024 CPO, diagnoses included heart failure and dementia. The 4/15/24 MDS assessment documented, based on staff assessment, the resident had a memory problem, experienced inattention and disorganized thinking. The assessment documented Resident #2 had physical behaviors directed towards others and verbal behaviors directed at others. B. Record review Resident #2's cognitive care plan, revised 3/5/24, revealed he was at risk for impaired thought process due to dementia. Interventions included asking yes or no questions to determine the resident's needs, communicating with the resident and his family regarding his capabilities and needs and monitoring for changes in his cognitive function. Resident #2's behavioral care plan, revised 3/5/24, revealed the resident displayed conflictual and difficult behaviors with other residents due to adjusting to his living situation and his diagnosis of dementia. Interventions included intervening when the resident demonstrated inappropriate behaviors, helping the resident identify his stressors which led to behaviors and referring to counseling as needed. -The facility failed to update Resident #2's care plan after the resident to resident incident occurred on 2/28/24 and failed to inform staff the resident had a problem with other residents wandering into his room. A review of Resident #2's electronic medical record (EMR) did not reveal documentation regarding the resident to resident altercation with Resident #1 on 2/28/24. VII. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included Huntington's disease (neurological disorder that causes nerve cells in the brain to break down), muscle weakness and abnormalities of gait and mobility. According to the 7/18/24 MDS assessment, Resident #3 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. B. Record review Resident #3's communication care plan, revised 7/12/19, documented he had a communication problem due to Huntington's disease and was slow to find his words. Interventions included anticipating and meeting the resident's needs, being conscious of the resident's position when in groups to promote proper communication with others, discussing the resident's concerns or feelings regarding his communication difficulty and validating Resident #3's message by repeating what he said out loud. Resident #3's cognitive care plan, revised 7/12/19, documented he had an impaired thought process due to Huntington's disease. Interventions included administering medications as ordered, asking yes or no questions in order to determine the resident's needs and presenting just one thought at a time. Resident #3's neurological care plan, revised 7/16/19, documented he had an alteration in his neurological status due to Huntington's disease. Interventions included completing assessments for side effects of psychotropic medications, cueing and reorienting the resident as needed, giving medications as ordered and obtaining and monitoring lab or diagnostic work as ordered. -A review of Resident #3's EMR did not reveal documentation regarding the resident to resident altercation with Resident #1 on 7/9/24. VIII. Staff interviews The NHA was interviewed on 8/7/24 at 10:00 a.m. The NHA said Resident #1 constantly wandered. She said Resident #1 wandered into the storage closet in the NHA's office when Resident #1 had to use the restroom. The NHA said she wondered if Resident #1 wandered into other rooms when he needed to use the restroom. The NHA said Resident #1 was placed on 15-minute checks when he returned from the hospital on 3/8/24. She said the facility felt 15-minute checks were a good intervention for Resident #1's wandering and because he was a high fall risk because it provided increased rounding and supervision for the resident. The activity director (AD) was interviewed on 8/7/24 at 1:43 p.m. The AD said she updated the activity calendar for each month and scheduled four to five group activities each day. She said she updated the activity care plans but she was pretty far behind. The AD said she reviewed the residents' diagnoses and cognitive levels to determine if a resident was independent or dependent upon staff of activities. The AD said Resident #1 was dependent upon staff to meet his emotional, intellectual, physical and social needs. The AD said she had not updated Resident #1's care plan. The AD said she was not aware Resident #1 enjoyed working. She said she planned to update his preferred activities to job-like activities. She said Resident #1 enjoyed participating in the ball toss groups but other activities did not interest him. The director of nursing (DON) and the NHA were interviewed together on 8/7/24 at 1:59 p.m. The DON said if a resident sustained several falls the facility implemented 15-minute safety checks. The DON said Resident #1 was a high fall risk and wandered which was why he was placed on an enhanced supervision level. The DON said the nurses and the CNAs completed the 15-minute checks. She said all of the staff were aware of the supervision levels for each resident and which residents were on 15-minute safety checks. The DON said the staff included Resident #1 in as many activities as possible and Resident #1 enjoyed walking. She said the staff were told if Resident #1 started walking then staff needed to follow behind him with his wheelchair. The DON said she was not aware Resident #1's care plan was not updated. The NHA said Resident #1 understood English but preferred speaking Spanish. The NHA said the facility had quite a few staff members who were fluent in Spanish and it helped when communicating with Resident #1. She said Resident #1 did not respond well to female staff whether the female staff spoke Spanish or not. She said Resident #1 usually only spoke to male staff who spoke Spanish. The NHA said she was not aware the staff who did not speak Spanish did not attempt to communicate with Resident #1 at all and just asked the male staff to translate for them. She said all staff needed to attempt to communicate with the resident. The NHA said she did not think to add the resident's preferred communication and staff to the resident's care plan. The DON said she was not aware the staff signed off on the 15-minute checks without looking at the residents each time. The NHA said she was not aware the staff signed off on the15-minute checks without looking at the residents each time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#11) of two residents reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 25 sample residents. Resident #11 was at nutritional risk with diagnoses of gastroesophageal reflux disease, muscle weakness and dementia. The registered dietitian (RD) implemented measures for the resident's nutrition risk and weight. Observations during the survey revealed the resident was not provided finger foods or fortified foods at meals, a brightly colored plate and alternatives offered when Resident #11's intake was poor. The facility failed to implement nutritional recommendations at mealtimes. Furthermore, the nutritional recommendations were for the interdisciplinary (IDT) team to follow up with the physician regarding her weight loss on multiple occasions and a reweight when Resident #11 lost weight and those recommendations were not followed up on. Due to the facility's failure to implement the nutritional recommendations, Resident #11 sustained a weight loss of eight pounds between 11/3/23 and 11/17/23, 6.8% which was considered significant weight loss. In addition, the resident continued to lose weight in total of 14 pounds in two months, 11.9% which was considered significant weight loss. Findings include: I. Facility policies The Weight Assessment and Intervention policy, revised March 2022, was provided by the nursing home administrator (NHA) on 2/8/24 at 8:57 a.m. It documented in pertinent part, Any weight change of 5% or more since the last weight assessed is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. The Nutrition/unplanned Weight Loss policy, revised September 2017, was provided by the NHA on 2/8/24 at 8:57 a.m. It documented in pertinent part, The staff will report to the physician significant weight losses or any abrupt or persistent change from baseline appetite or food. The physician will review medical causes of anorexia and weight loss before ordering interventions. The staff and physician will identify pertinent interventions based on identified causes and resident conditions. The physician and staff will monitor nutritional status and response to interventions. II. Resident #11 A. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the February 2024 computerized physician orders, diagnoses included glaucoma (eyesight problem), gastro-esophageal reflux disease (backflow of stomach acid into to the esophagus), muscle weakness, vascular dementia (impaired blood flow to brain causing problems with memory, reasoning, judgment and planning) and psychotic and mood disturbances. The minimum data set (MDS) from 1/10/24 documented Resident #11 was rarely/never understood. The MDS showed the resident required substantial/maximal assistance with activities of daily living (ADLs), which included eating, dressing, toileting and mobility. The resident was 68 inches tall (five foot eight inches) and weighed 108 pounds. B. Observation Resident #11 was observed continuously on 2/5/24 from 4:40 p.m. to 6:30 p.m. The observations were as follows: -At 4:55 p.m. the resident was assisted to the dining room table. -At 5:30 p.m. the resident received her meal. The food was served on white plates and not on bright colored plates (see care plan below). The meal consisted of a vegetable soup, cottage cheese with fruit and dessert. There was no supplement or cranberry juice served with the meal. There were no finger foods or fortified foods that she was supposed to be served (see record review below). -At 5:40 p.m. an unidentified certified nurse aide (CNA) assisted the resident with her meal. She took two bites of her dinner. She then took two bites of her dessert. -There were no other food choices offered to the resident for having eaten less than 50% of her meal. Resident #11 was observed continuously on 2/6/24 from 11:30 a.m. to 1:15 p.m. The observations were as follows: -At 12:24 p.m. the resident received her meal. The food was served on white plates and there was no cranberry juice served with the meal. The meal consisted of mashed potatoes, broccoli, a pork chop and slice of cake. There were no finger foods or fortified foods served to her. -At 12:30 p.m. an unidentified CNA assisted Resident #11 with her eating her meal. -The resident ate one bite of food and pushed the plate away from her. -There was no other food offered to this resident. -The interventions from the care plan were not followed based on these observations (see below). B. Facility assessment of resident's nutritional status on admission The care plan, updated on 11/21/23, identified that this resident had a nutritional problem related to dementia. Pertinent interventions included encouraging the resident to have snacks in the dining room, provide fortified foods, drinks and desserts, bright colored plates used to encourage intake and cranberry juice served at meals. The RD assessed this resident on 12/20/24. She assessed the resident's weight was trending downwards. She documented the resident's low intake of meals at 55%. C. Resident's weight record Resident #11's weight record showed the resident lost eight pounds which occurred between 11/3/23 and 11/17/23, 6.8% which was considered significant. The resident's weight on 11/3/23 was 118 pounds and the weight recorded on 11/17/23 was 110 pounds. The wheelchair scale was used in each weight. -There was no reweigh documented for confirmation of a loss the following day (as indicated by the RD assessment). The next weight entered was 108 pounds on 11/30/23. The resident's current weight was 104 pounds on 1/30/24. The resident lost 14 pounds over a two month period, 11.9% which was considered sginficant weight loss. D. Registered dietitian recommendations The registered dietitian (RD) recommended the resident was offered fortified foods and desserts, offered a supplement twice daily, had meals served on brightly colored plates, had meal assistance from nursing staff, was offered a sweet snack between meals (ice cream, cookies), was offered cranberry juice at meals and was brought out of her room for snacks and activities. This RD note was documented on 11/17/23. The progress note from nutrition/dietary services dated 11/17/23 documented this resident had a 12 pound weight loss in two weeks and meal intake was low at 52%. A reweigh was requested. The nursing team was going to discuss it with the physician. The nursing team was to continue with the recommendations (see above) from the RD. -However, the reweigh was not documented. -There was no documentation that the nursing staff had this discussion with the physician in the medical record. The nutrition/dietary services progress note dated on 12/15/23 showed nursing staff was to inform the physician of additional weight loss and to discuss appetite-stimulating medications. The nutrition/dietary services progress note on 12/22/23 documented nursing staff was to follow up with the physician on appetite stimulants. The nutrition/dietary services progress note on 1/5/24 documented the nursing staff was to discuss the resident with the physician. -There was no documentation in the medical record the nursing staff had discussions with the physician. III. Staff interviews The cook was interviewed on 2/6/24 at 12:30 p.m. The cook said that the tray line did not have any food which contained fortified food (powder protein). -An observation of the puree vegetable during the interview revealed there was no protein added to the pureed vegetables when they were supposed to be fortified. The dietary manager (DM) was interviewed on 2/6/24 at 12:40 p.m. The DM said the whey protein powder was added to the resident's meal (who consumed fortified foods) after the meal was served. The corporate registered dietitian (CRD) was interviewed on 2/8/24 at 9:50 a.m. She said residents with weight loss were reviewed weekly in nutrition risk meetings by a registered dietitian (RD). She said the RD was onsite typically for one day each month. She said she did not know Resident #11's nutrition plan of care. The director of nursing (DON) was interviewed on 2/8/24 at 11:18 a.m. The DON said there was an offsite dietitian who completed the weekly nutrition assessment report (NAR) for at-risk residents. She said it was the dietary manager's responsibility to follow up and ensure the fortified foods were in place for the appropriate residents. She said every resident should always be offered an alternative to their meal if they ate less than 50%. She said nurses were to enter progress notes of when and what they have communicated with physicians about.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure adequate supervision and provide assistance devices to prevent falls for one (#20) of six residents reviewed for falls out of 24 sample residents. The facility failed to ensure Resident #20, who had nine falls within six months, had effective interventions, supervision and assistance in place to prevent further falls. Resident #20 suffered multiple falls with injuries including lacerations to his face and his head, including an emergency room visit where he received six stitches and he continued to fall. Findings include: I. Facility policy The Nursing Services Policy and Procedure Manual for Long-Term Care, revised April 2018, was provided on 6/15/23 at 3:07 p.m. by the nursing home administrator (NHA). It read in pertinent part, The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. II. Resident #20 A. Resident status Resident #20, age [AGE], was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, chronic pain, muscle weakness, lack of coordination, unspecified abnormalities of gait and mobility, dementia and other abnormalities of gait and mobility. The 6/6/23 minimum data set (MDS) assessment showed that Resident #20 had severe cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The MDS assessment indicated Resident #20 required extensive assistance with transfers and toilet use and limited assistance from caregivers for walking around his room. His balance was unsteady and he needed assistance to balance himself. He used a walker or wheelchair for ambulation. Resident #20 was listed as having one fall since admission or most recent assessment. -However, Resident #20 had nine falls within a six-month period (see record review below). B. Resident interview Resident #20 was interviewed on 6/14/23 at 2:52 p.m. He stated he was supposed to use his call light when he wanted to get up. Resident #20 said the caregivers did not respond in a timely manner to call lights, especially when he had to use the restroom. I got to do what I got to do, so I would walk to the bathroom alone and fall. Resident #20 had signage around his room that documented, Please remember to use your wheelchair or walker at all times. He explained how previous falls led to his placement at the facility and he kept falling during his stay. He said staff kept his wheelchair out of reach so he would not use it without calling for assistance but he still got up anyway when he could not wait any longer to use the restroom. Resident #20 stated he used to have a walker but the facility did not want him to use it anymore due to falling a lot and removed it from his room. -The use of a wheelchair and no walker and keeping the wheelchair out of the resident's reach so he would ask for assistance was not included in the care plan (see below). C. Observations On 6/12/23 at 2:00 p.m., Resident #20 was observed walking out of his room into the hallway. A staff person approached and asked him why he was walking, then helped him back into his room and closed the door. During the resident interview on 6/14/23 at 2:52 p.m. (above), no walker was observed in his room. He was in bed and his wheelchair was at the foot of his bed facing away from him toward the wall. Resident #20 was observed throughout the survey, from 12:00 p.m. to 6:00 p.m. on 6/12/23 and from 8:30 a.m. to 6:00 p.m. on 6/13, 6/14 and 6/15/23. He spent most of his time in his room with his door closed, except for meals and going outside to smoke. He ambulated in his wheelchair independently wheeling himself through the facility to the back door and received assistance from staff to exit the back door to the smoking area. D. Record review According to the fall risk care plan, initiated on 9/15/21 and most recently revised on 4/18/23, Resident #20 was listed as weight-bearing and he needed assistance from one staff member to ambulate. Resident #20 also needed limited assistance from one staff for when he walked around and as needed (PRN) in his wheelchair. Resident #20 was listed as a high fall risk due to a diagnosis of Parkinson's disease which would affect his coordination and gait. Interventions were the following: -Anticipate and meet the resident's needs (9/15/21). -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance (9/15/21). -Resident #20 forgets to use his walker or wheelchair and needs reminders to use his call light and allow staff to assist with transfers (undated). -Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (10/12/21). -Ensure proper positioning when in wheelchair (4/18/23). -Ensure the resident is wearing appropriate footwear when ambulating or mobilizing in a wheelchair (9/15/21). -Follow facility fall protocol (9/15/21). - 'I like to get myself up and into my wheelchair, please make sure my wheelchair is within easy reach' (6/13/23, during the survey). -Offer frequent assistance to the bathroom, assist in keeping clean, dry, and comfortable (10/1/21 and 6/13/23). -Signage placed in room to remind resident to use his wheelchair and walker when ambulating (9/21/22). -Place signage around my room to remind me to use my call light and wait for assistance (11/15/22). -Place wheelchair wedge with support to help with falling (4/17/23). -Push wheelchair when outside (4/18/22). -The resident's actual falls with injury were not documented in his care plan. -There was no evidence of tracking and trending the times of day or night the resident had fallen, in order to develop more effective fall prevention measures. -The care plan did not define how frequently the resident should be offered assistance to the bathroom. -New interventions following each fall were not added to the care plan. -No wedge cushion was observed in the resident's wheelchair during the survey. -No signage was observed in the resident's room to remind him to use his call light for assistance. -The resident's wheelchair was not within his reach in keeping with the care plan, per observation and resident interview. Review of nursing progress notes and fall investigations for the previous six months revealed: 1. Unwitnessed fall on 1/17/23 Resident #20 had an unwitnessed fall on 1/17/23 at 1:49 a.m. He was found on the bed on his hands and knees, cursed at staff, and said he had fallen to the floor. No injuries were noted. -No fall investigation was provided. 2. Witnessed fall on 2/9/23 Resident #20 had a witnessed fall on 2/9/23 at 4:45 p.m., with an injury that led to an emergency room visit. He had a laceration to the right eyebrow and received six stitches in the hospital. He had been ambulating in the hall behind his wheelchair, tripped and fell, hitting the right side of his face. -The facility failed to correct how Resident #20 was utilizing his wheelchair which resulted in an injury. The facility failed to provide limited assistance with walking due to the resident being unsteady and supervision to ensure timely assistance to prevent falls with injury. 3. Unwitnessed fall on 2/17/23 Resident #20 had an unwitnessed fall on 2/17/23 at 5:15 p.m. (late entry documented at 9:28 p.m.) He came out of his room and told staff he fell while he was walking across the room. He had a laceration to the right side of his forehead, no bleeding or swelling and no other injuries. Witnessed fall, staff involved, on 3/16/23 Resident #20 had a witnessed fall on 3/16/23 at 6:57 p.m. Staff were pushing him in after smoking, his wheelchair caught on the door threshold, pitching him from the wheelchair to his knees. He had abrasions on both knees. 4. Unwitnessed fall on 3/27/23 Resident #20 had an unwitnessed fall on 3/27/23 at 9:33 p.m. according to nursing notes which documented no further details other than that neurological checks were initiated. No injuries were noted. 5. Witnessed fall on 4/13/23 Resident #20 had a witnessed fall on 4/13/23 at 9:35 p.m. He was outside in his wheelchair, hit a groove in the concrete causing him to fall. He hit his head and suffered a laceration above his right eye. The nurse cleaned, steri-stripped, provided an ice pack and initiated neurological checks. The resident later had swelling to the right side of his face. Review of the facility investigation revealed the interdisciplinary team (IDT) recommendation for a new intervention was education. The facility documented in the report they updated the care plan to reflect the recommendation. -However, the care plan was not updated regarding education. -The type of education to be provided and to whom was not documented in the investigation. -The care plan intervention to supervise the resident for safety when he was outside was not updated until 4/18/23, five days later. 6. Unwitnessed fall on 4/16/23 On 4/16/23 at 1:35 p.m., Resident #20 fell and sustained an abrasion to his hand. The fall investigation determined Resident #20 fell out of his chair onto his knees and scraped his hand. The previous intervention was listed as a wedge (cushion) for Resident #20's wheelchair. A new intervention was documented to ensure proper positioning in the wheelchair. The facility documented in the report they updated the care plan to reflect the recommendation. -The care plan was not updated until after the resident's second fall outside although the 4/16/23 fall was caused by staff. -The care plan was updated regarding the wedge cushion, but it was not observed in the resident's wheelchair (see observations above). 7. Unwitnessed fall on 5/17/23 On 5/17/23 at 12:42 a.m., Resident #20 was found sitting on the floor in front of his bed. The fall investigation determined he was getting up to go to the bathroom, slipped, and fell onto his buttocks. Previous interventions were documented as education and signage. A new recommendation was entered as a referral to physical therapy (PT). The facility documented in the report they did not update the care plan based on the new intervention. He suffered two skin tears on his right hand. -Although, the resident was going to the bathroom without assistance, the care plan was not updated with specific interventions about anticipating the resident's bathroom assistance needs and how often to provide the assistance. -He was already receiving PT at the time of this fall according to therapy notes. -The care plan was not updated after the 5/17/23 fall. 8. Unwitnessed fall on 6/8/23 On 6/8/23 at 9:28 p.m., Resident #20 was found sitting on the floor (with no noted injuries) in his room, holding his knees. The resident's roommate had to use his call light for assistance. The resident's wheelchair was four to five feet away from him. The fall investigation determined Resident #20 was headed to the bathroom when he slid down onto the floor off his bed. Previous interventions were documented as education and signage. A new recommendation was entered to maintain his wheelchair within easy reach of Resident #20. The facility documented in the report the care plan was updated with this recommendation. -However, observation and resident interview (above) revealed the resident's wheelchair was not consistently kept within his reach. -The care plan was not updated regarding timely bathroom assistance, although the resident fell attempting to go to the bathroom without assistance. -There was no recommendation for, or evidence of, PT or restorative services following this fall. Therapy notes revealed he was discharged from PT on 6/5/23, where he had been working on training in wheelchair propulsion and maneuvering within his environment. Resident #20's fall assessment completed 6/8/23 showed he had a fall risk score of 55, indicating high fall risk. -No further fall risk assessments were provided. -Review of the times Resident #20 fell revealed most of his falls happened late at night or early morning. However, there was no evidence the facility identified this trend to identify root causes, meet the resident's needs, and implement measures to meet those needs. Review of IDT notes on 6/13/23 revealed Resident #20 had many falls. Resident #20 utilized his wheelchair as a walker and agreed to utilize it how it was meant to be used. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/15/23 at 8:40 a.m. CNA #1 explained occasionally the facility was short staffed and they worked with what they had but it delayed the time it took to answer call lights. We manage the best way we can when we are understaffed. CNA #1 said Resident #20 fell a lot due to his Parkinson's disease and not waiting for the nursing staff to answer his call light. CNA #1 explained Resident #20's fall precautions were signs posted in his room and that staff needed to stop him if they saw him ambulating. Staff located fall precautions and care instructions in the care plan but CNA #1 did not know how to find care plans so she relied on signs posted in the residents' rooms. Nurse aide (NA) #3 was interviewed on 6/15/23 at 9:14 a.m. NA #3 stated a lot of falls occurred because call lights were not answered in a timely manner and residents would get impatient waiting for a response. She stated the facility was usually understaffed therefore staff did not answer call lights. She explained Resident #20 would get up independently and staff constantly needed to remind him to use his call light and wheelchair. Resident #20 typically did not like to wait for staff to answer his call light so he would walk himself where he needed to go. He was on hourly checks and staff reminded him not to walk around on his own. NA #3 did not know how to look up care plans and relied on signs posted in the residents' rooms or asked other floor staff what each resident needed specifically. Physical therapy aide (PTA) #1 was interviewed on 6/15/23 at 3:30 p.m. regarding Resident #13's fall and recovery. PTA #1 stated Resident #20 had just been discharged from physical therapy (PT) in June 2023. He was still being treated by restorative therapy because he had reached his maximum physical capability due to his diagnosis of Parkinson's disease and there was nothing more to be done with PT. The nursing home administrator (NHA) was interviewed at 2:00 p.m. on 6/15/23 and Resident #20's fall investigations were requested. The NHA said it would be a huge stack of documentation since the resident had frequent falls. She did not say why the resident fell so frequently or what prevention measures the facility was taking. At 2:30 p.m. on 6/15/23 she provided only four fall investigations: for 4/13/23, 4/16/23, 5/17/23 and 6/8/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), emphysema and chronic respiratory failure with hypoxia (low oxygen level). The annual MDS assessment dated [DATE] showed the resident had a BIMS score of 14 out of 15, indicating intact cognitive status. The patient health questionnaire (PHQ) indicated depression. He had no hallucinations or delusions, but exhibited verbal behavioral symptoms directed toward others and rejected care one to three days. He needed supervision, cueing and set-up for meals. He weighed 160 pounds, his weight loss was no or unknown and he had experienced weight gain without a plan to do so. B. Record review Resident #4's physician orders as of 6/14/23 showed an order for a regular diet, regular texture, regular consistency, ordered on 8/12/19, and supplement of choice for when resident refuses meals, ordered on 1/25/23. According to the June 2023 medication administration record (MAR) no nutritional supplements were documented as given as indicated in his care plan (see below). -However, 13 meal intakes documented Resident #4 ate nothing or 25% of his meals during June 2023 and he was not offered a supplement of choice (see below). The nutritional risk care plan was initiated 8/23/19 and last revised on 4/12/23 with a target date of 7/29/23. Interventions included monitor and record weights per facility protocol, offer snacks daily, provide supplementation as ordered, and registered dietician (RD) to evaluate and make recommendations. -The resident's preferences and frequency of weights and RD evaluations were not listed in the care plan. According to the resident weight records for March, April, May and June 2023, the following weights were recorded: 3/15/23 4:12 p.m. 166 Lbs (Wheelchair Scale) 3/23/23 1:24 p.m. 166 Lbs 3/31/23 2:58 p.m. 162 Lbs (Standing Scale) 4/3/23 4:54 p.m. 166 Lbs (Standing Scale) 4/11/23 12:02 p.m. 168 Lbs (Standing) 4/17/23 4:15 p.m. 164 Lbs (Standing Scale) 4/24/23 3:07 p.m. 168 Lbs (Standing Scale) 5/4/23 6:53 p.m. 162 Lbs 5/15/23 7:52 p.m. 162 Lbs (Standing) 5/22/23 12:25 p.m. 154 Lbs (Standing) 5/30/23 11:54 a.m. 148 Lbs (Wheelchair) 6/8/23 2:36 p.m. 154 Lbs (Wheelchair Scale) 6/9/23 9:36 a.m. 154 Lbs (Standing) 6/12/23 2:37 p.m. 158 Lbs (Standing) -There was no evidence of a re-weigh when the resident's weight dropped eight pounds from 162 lbs to 154 lbs between 5/15 and 5/22/23, or when the resident's weight dropped from 154 lbs to 148 lbs between 5/22 and 5/30/23, then increased again to 154 lbs on 6/8/23. There was no evidence of an RD assessment of the resident's weight loss from 166 lb to 158 lbs over the previous three months. 1/5/23 dietary notes documented the resident had weight loss of 7.5% and was averaging 30% of meals. He had returned from the hospital on [DATE] with weight loss. Dietary manager works with the resident to honor preferences regularly when he lets us know what he wants. -The resident's weight was not recorded in this dietary note. 1/26/23 dietary notes documented the resident had 12 pound weight loss in 90 days and had variable intake of 50% of meals, usually behavioral. Dietary manager works with the resident to honor preferences regularly when he lets us know what he wants. -The resident's weight was not recorded in this note. 3/10/23 dietary notes documented the resident had a 20 pound increase in weight in two months. He had variable intake around 70% of meals and some meals at 0-25%, usually behavioral. The resident was ordering Dominos pizza every day. Dietary manager works with the resident to honor preferences regularly when he lets us know what he wants. Recommend to stabilize at this weight. -No weight was recorded in this note. 3/23/23 dietary notes documented the resident had weight fluctuations and his weight increased 18 pounds in three months. He is at his baseline weight. He had variable intakes of 70% of meals, and some meals at 0-25%, usually behavioral. The resident was ordering dominos every day. Dietary manager works with the resident to honor preferences regularly when he lets us know what he wants. Recommend to stabilize at this weight. -No weight was recorded in this note. The certified dietary manager (CDM) assessment on 3/27/23 showed the resident's average meal intake was 39% and his current weight was 166 lbs and trending upward significantly. He had no difficulty eating and had preferences of bratwurst, milk, hard-boiled eggs and hot sauce. The RD assessment on 4/12/23 showed a weight of 168 lbs from 4/11/23. 6/15/23 dietary notes documented the resident had weight loss of 8.6% in 30 days on 5/30/23. Resident's weight on 5/30 seems inaccurate and the resident is now back up ten pounds. Intakes vary daily. The resident prefers Dominos pizza daily, and will refuse meals and drink supplements instead. Recommend meal alternatives and provide supplements when meals are refused. -However, per interview with the RD (below) the resident had run out of money and was unable to order pizza every day. His documented meal intakes (see below) were frequently zero to 25%, and there was no documentation (see physician orders above) that a supplement of choice was provided/offered when he refused meals. Review of Resident #4's meal intake records for June 2023 revealed he ate zero to 25% for the following meals: 6/1/23: Breakfast and Lunch 6/2/23: Lunch 6/3/23: Breakfast and lunch 6/4/23: Breakfast and lunch 6/5/23: Breakfast, lunch and dinner 6/7/23: Breakfast 6/10/23: Dinner 6/11/23: Lunch 6/12/23: Breakfast, lunch and dinner June 13: Dinner No amount was recorded for the following meals (left blank): 6/6/23: Breakfast and lunch 6/8/23: Breakfast and lunch 6/9/23: Lunch -There was no documentation the resident received a supplement of choice when he did not eat his meals. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed 6/14/23 at 10:10 a.m. She stated a weight discrepancy would trigger her to reweigh the resident. She stated she did not know if there was a specific weight change which required the nurse to be notified. The registered dietitian (RD) was interviewed 6/15/23 at 3:58 p.m. She stated Resident #4 had purchased Dominos pizza every day until he ran out of funds. He then refused to eat anything but Dominos pizza. He did like the supplements provided but he used them to supplement meals all the time. The current recommendation was to offer nutritional supplements if he refused meals to ensure that he had made an attempt to eat food first. She stated psychosocial behaviors are most related to his weight fluctuations and felt the facility was doing all they could within his preferences but refusing food had become a behavioral problem to get what he wanted such as Dominos pizza. He was able to get what he wanted when he wanted. She stated she tracked all resident preferences for foods and had a big board in the kitchen where it was visible for all staff to reference. Resident #4 had preferences for Polish sausages, hard boiled eggs and milk. He was responsive when she discussed his preferences with him but he often refused his preferred foods. She stated he had a history of weight loss and fluctuations, and that his weight seemed to be inaccurately documented at times. She stated if resident weights seemed abnormal, staff should be re-weighing the residents. She stated that the nutritional assessment should be done weekly with the director of nursing (DON) and dietary staff. Nurse aide (NA) #1 was interviewed on 6/15/23 at 4:26 p.m. She stated the process for weighing a resident was to assist the resident to the scale, zero the scale, ensure they were safe and have them hold onto the bar and then have them step off. She stated weights were recorded in the weight book and they wrote wheelchair next to the weight. Wheelchair weights were subtracted by the nurse before she documented the weight. The dietary aide (DA) #1 was interviewed in the kitchen on 6/15/23 at 4:30 p.m. She pointed out the white board and clipboard in the kitchen where resident preferences were documented. -However, she looked and confirmed that Resident #4 and his preferences were not listed on the whiteboard or clipboard. She said staff who knew him knew he really liked grilled cheese and Polish sausage. He will sometimes take the sides and will sometimes have two grilled cheese with a side of Polish sausage, but he prefers Domino's pizza. -DA #1 did not indicate awareness that ordering pizza daily was no longer an option for Resident #4. The DON was interviewed on 6/15/23 at 4:18 p.m.She stated a CNA could not see weight trends, should notify the registered nurse (RN) and offer nutritional supplements if Resident #4 refused his meals. She stated a consistent weight method was expected but sometimes residents refuse to stand or they did not feel good so they honor their choice and weigh them in their wheelchair. Every resident's wheelchair was weighed and documented on the weight form to be subtracted before the weight was documented. The wheelchairs were re-weighed periodically or if there are weight discrepancies to ensure accuracy. She stated RNs will notify her if they trend a weight loss, but she tracked all resident weights weekly and would request a resident be re-weighed with a five pound weight loss. She runs a weight report weekly and it is discussed with the RD at the weekly nutritional assessments. When asked who subtracted the wheelchair weight, the DON stated sometimes the CNA subtracts the wheelchair weight, sometimes the RN. III. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the June 2023 CPO, diagnoses included hypothyroidism, muscle weakness, a fractured tailbone with two other fractures in the pelvis, noninfective gastroenteritis and colitis, age-related osteoporosis and stage three chronic kidney disease. According to the 3/28/23 MDS assessment, Resident #13 had no cognitive impairment with a BIMS score of 15 out of 15. The MDS assessment indicated Resident #13 only needed assistance from staff for set up during meals. B. Record review A nutritional assessment was completed, upon admission, on 12/15/22. It documented Resident #13 was on a regular diet and not on any nutritional supplements. Meal intakes were marked at 70% with her current weight at 172 lbs. No concerns were noted for her weight. Her food preferences were listed as she liked gluten-free options, like oranges and tangerines and overall was not very picky. According to the resident's care plan initiated on 1/2/23, weight loss was not listed as a specific focus area with interventions in place. Resident #13 had an activity of daily living (ADL) self-care deficit referring to limited mobility from a fracture to the sacrum, sacral wing, and pubic ramus sustained on 1/7/23 from a fall in the facility. Interventions were entered for staff to provide milkshakes or liquid food supplements when the resident refused or had difficulty with solid food or provide nutritious foods that could be taken from a cup or mug where appropriate. The care plan documented the resident had osteoporosis and osteoarthritis. Interventions included to encourage adequate nutrition and hydration and encourage the resident to maintain weight in a normal range for her height. A review of Resident #13's weights since her admission, documented in the weights and vitals record revealed: 12/21/23, her first weight after being admitted was documented at 172 pounds (lbs). 1/23/23, after she returned to the facility from the hospital, Resident #13 had a weight of 172 lbs. Resident #13's weight was not obtained for February 2023. 3/10/23 Resident #13 had a weight of 150 lbs with a 12.8% weight loss within 90 days. Resident #13's weight was not obtained for April 2023. 5/22/23 Resident #13 weighed 152 lbs. 5/30/23 Resident #13 had a weight of 150 lbs. 6/9/23 Resident #13 had a weight of 120 lbs with a 20% weight loss within 30 days. -There was no evidence of a re-weight to determine if the weight loss was accurate. Resident #13 was added to the NAR meeting discussion on 3/10/23. Meeting minutes for 3/10/23 read, Resident #13 was reviewed at NAR for significant weight loss of 12.8% across 90 days. Resident was admitted with a weight of 172 lbs on 12/21 and now weighs 150 lbs. Resident is finally eating a bit better - previous weeks she had multiple fractures and was not eating much. Recommend interviewing the resident to understand if weight loss was intentional. Recommend weight maintenance. We will continue to follow at NAR for weight stability. NAR meeting minutes for 3/16/23 read, Resident #13 was reviewed at NAR for significant weight loss of 6.4% across 30 days. Resident is fixated on her weight. Resident is finally eating a bit better - previous weeks she had multiple fractures and was not eating much. Registered dietitian (RD) discussed weight loss with resident and she states she has not been wanting to eat as much because she had been laying around. Resident is getting out more and coming to activities so we expect to see intakes improve. Supplement initiated. Recommend weight maintenance. We will continue to follow at NAR for weight stability. A nutritional assessment was completed on 3/17/23. It documented Resident #13 was on a regular diet and received a nutritional supplement of choice twice a day. Meal intakes were marked at 58% with her current weight at 146 lbs. Her weight status was documented as trending downward significantly. Her food preferences were listed as she liked gluten-free options, was not a fan of chocolate, and liked beef and vegetable soup. An order was entered into the medication administration record from 3/15/23-5/16/23 documented to offer supplement nutrition (preferred vanilla) two times a day if her intake is below 100%. The resident only had three meals in May 2023 which were documented at less than 100% eaten and supplement shake was administered. The order was discounted on 5/17/23 due to the resident maintaining her weight. NAR meeting minutes for 3/23/23 read, Resident #13 was reviewed at NAR for significant weight loss of 12.8% across 90 days. Resident is coming out to eat more often and her intakes have improved dramatically. Expect weight to stabilize. We will continue to follow at NAR for weight stability. NAR meeting minutes for 4/13/23 read, Resident #13 was reviewed at NAR for previous significant weight loss. Resident is coming out for meals now and her intakes have improved dramatically. Weight has stabilized near 150#. We will d/c (discontinue) following at NAR. -The resident was not reviewed in NAR meetings when she had 30 lbs weight loss from 5/30/23 to 6/9/23 (see weights above). C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/15/23 at 8:40 a.m. She stated CNAs weighed the residents and the registered nurse (RN) charted the weights. If the weights looked inaccurate, the CNAs would inform the nurses and see if they needed to get the weight again. The CNAs charted the percentages of meals consumed by residents and if they did not eat enough they would ask the nurse for an Ensure (nutritional supplement). The CNAs did not know who routinely got Ensures since the nurses handed them out. Residents who requested an Ensure would get one as well. Nurse aide (NA) #3 was interviewed on 6/15/23 at 9:14 a.m. She stated the nurses provided the nutritional supplements and residents usually drank them. All alternative meals (other meal options for those who did not want what was on the menu) were kept at the nurses' station. She was not sure how the nurses knew who got a nutritional supplement when residents received them and who did not. Dietary aide (DA) #2 was interviewed on 6/15/23 at 4:30 p.m. She said residents' diets, consistencies and preferences were written on the whiteboard or in the clipboard in the kitchen. -However, she reviewed the whiteboard and the clipboard and said Resident #13's preferences were not listed. DA #2 explained the nurses handled nutritional supplements for the residents who did not eat enough. Based on observations, record review and staff interviews, the facility failed to ensure three (#4, #13 and #31) of five residents reviewed for nutrition/hydration maintained acceptable parameters of nutritional status to avoid unintended weight loss out of 24 sample residents. Specifically, the facility failed to timely assess the residents at risk for nutrition to ensure interventions were appropriate and implemented to prevent significant weight loss, consistently review residents identified at a nutritional risk as an interdisciplinary team, and effectively determine the accuracy of residents' weights. Resident #31 had chronic kidney disease and nephrotic syndrome that caused fluid retention and fluid loss, creating fluctuation in her weight. The resident had little appetite. Towards the end of May 2023 and consistently in June 2023, the resident complained of nausea and vomiting. The resident was placed on comfort care on 6/14/23. Resident #31 was weighed daily between 4/17/23 and 5/30/23. On 5/15/23 Resident #31 weighed 154 lbs. The resident was admitted to the hospital on [DATE]. The resident weighed 139 lbs on 5/20/23, indicating a 15 lb weight loss of 9.74%, which was severe. A 5/20/23 progress note identified the hospital did not remove excess fluid during her hospital stay. Record view identified Resident #31 was not reassessed after the significant weight loss to determine if additional interventions could be implemented. On 5/27/23, Resident #31 weighed 136 lbs. On 5/28/23 the resident weighed 118 lbs, identifying a weight loss of 18 lbs at 13.24%, which was severe. Progress notes identified the resident had periods of nausea and was prescribed medication to reduce the symptoms; however, record review identified the resident was not reassessed or reviewed to determine if nutritional interventions could be implemented. Resident #31 was weighed again on 5/29/23. The resident weighed 114 lbs, indicating an additional four lbs weight loss in a day and a two lb loss on 5/30/23 resulting in a weight of 112 lbs. The resident was weighed again on 6/2/23 and the resident gained back the two lbs. Between 6/2/23 and 6/13/23, the resident complained of nausea almost daily and had incidents of documented vomiting. The prescribed medication for the nausea was usually effective after administration. She reported little to no appetite. Even though the resident had a significant weight loss and had nausea, vomiting and loss of appetite, Resident #31 was no longer weighed daily and was not weighed again until 6/8/23 with a weight result of 100 lbs. The resident was not re-weighed to determine the weight's accuracy. According to the weight record the resident lost a total of 14 lbs in six days at 12.28% (considered severe) between 6/2/23 and 6/8/23. Resident #31 lost a total of 39 lbs with a 28.6% (considered severe) weight loss between 5/20/23 and 6/8/23. The resident was not reassessed or reviewed by the registered dietitian (RD) until 6/14/23, during the survey. New nutritional interventions to promote weight stabilization and appetite were not recommended from the RD until 6/14/23 and 6/15/23. Resident #13 experienced significant weight loss since her admission to the facility. The facility failed to ensure her weights were obtained timely. The resident admitted to the facility with a weight of 172 lbs. She sustained significant weight loss of 22 lbs in three months from 12/21/22 to 3/10/23. From 5/30/23 to 6/9/23 the resident sustained an additional 30 lbs weight loss. There were no additional measures implemented when the resident sustained an additional 30 lbs weight loss. For Resident #4, the facility failed to maintain adequate nutritional parameters by ensuring weights and weight loss/gain were accurately assessed, physician-ordered nutritional supplements were provided and documented when the resident refused meals and evaluate the care plan to determine if nutritional interventions were implemented and effective. Findings include: I. Facility policy and procedure The Nutrition Assessment policy, revised October 2017, was provided by the registered dietitian (RD) on 6/15/23. The policy read in pertinent part: As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident on admission and as indicated by change of condition that places the resident at risk for impairment. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering interpreting data and using the data to help define meaningful interventions for the resident at risk for or with impaired nutrition .Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the residents risk for nutritional complications. Such interventions will be developed with the context of the resident's prognosis and personal preferences. The Weighing and Measuring the Resident policy, revised March 2011, was provided by the nursing home administrator (NHA) on 6/15/23 at 3:07 p.m. According to the policy, the facility needed to determine the resident's weight and height to provide an ongoing record of the resident's body weight as an indicator of nutritional status and medical condition of the resident and determine the ideal weight of the resident. The policy identified the following guidelines to to promote an accurate weight assessment every time the resident was weighed, when possible: -Weigh the resident at the same time of day; -Use the same scale; -Use the same amount of clothing as prior weighing: and, -Ensure the weight scale was calibrated. The weighing and measuring policy directed staff to report significant weight loss or gain to the nurse supervisor. The policy identified the threshold for significant, unplanned, and undesired weight loss based on the following criteria: -In one month, 5% weight loss was significant; greater than 5% in a month was severe. -In three months, 7.5% weight loss was significant; greater than 7.5% in three months was severe. -In six months, 10% weight loss was significant; greater than 10% was severe. II. Resident #31 A. Resident status Resident #31, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included chronic kidney disease, stage 4 (severe), type 2 diabetes mellitus with diabetic neuropathy, congestive heart failure (CHF), nephrotic syndrome with unspecified morphologic changes (severe swelling), pleural effusion (fluid build up in the chest and lung cavity), aplastic anemia (lack of production of blood cells, and acidosis (too much acid in the body fluids). The 5/16/23 minimum data set (MDS) assessment revealed Resident #31 had short term memory problems. The MDS assessment indicated the resident had modified independence in decision making regarding tasks of daily life. According to the MDS assessment, Resident #31 exhibited fluctuating disorganized thinking and a continuous altered level of consciousness. The resident had an acute change in mental status for her baseline. The MDS assessment indicated Resident #31 was independent with eating and weighed 154 pounds (lbs). She had no known weight loss of more than 5% in one month or 10% weight loss in six months. The resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. B. Record review The 2/24/23 weight and vital summary record read the resident's admission weight was 156 lbs. The 3/10/23 nutrition/dietary note read Resident #31 was followed at NAR (nutrition at risk) meeting for four weeks as a new resident to establish weight baseline. She was down 14 lbs in two weeks. According to the note, the resident had excess fluid that required draining at the hospital, every two weeks. The note indicated the facility expected weights to go up and down related to disease progression of nephrotic syndrome. The note read intakes were extremely variable with an average intake of 40% of meals. The note identified the staff would continue to monitor in NAR for weight fluctuations. The 3/10/23 NAR meeting minutes record identified the resident had a 9% weight loss since her admission on [DATE]. The weight and vital summary record between 3/12/23 and 3/15/23 identified the resident's weight fluctuated between 150 lbs and 162 lbs. The nutrition at risk care plan, initiated 3/15/23, read Resident #31 was at a nutritional risk related to diagnosis of CHF, anemia, type 2 diabetes mellitus, vitamin D deficiency, hyperkalemia (increased blood potassium), chronic kidney disease, hypertension and reported lower appetite. According to the care plan, the resident was prescribed diuretic therapy which may cause fluctuations in weight. Interventions initiated on 3/15/23 included the following: -Administer medications as ordered by MD (medical doctor). Observe for and document any side effects. -Monitor and record labs as ordered. -Monitor and record weights per facility protocol or as ordered. -Offer snacks daily. -RD to evaluate and make recommendations PRN (as needed). -Serve diet as ordered. -The care plan did not identify additional nutritional interventions after the resident lost significant weight when the resident had a decrease in appetite related to nausea and vomiting (see below). The 3/16/23 nutrition/dietary note read Resident #31 was eating approximately 50% of her meals. The resident reported a low appetite. According to the note, the RD discussed a high calorie dietary supplement with the resident and she was receptive to the supplement. The nutrition note indicated staff would continue to monitor at the NAR meeting for weight fluctuations. The 3/16/23 NAR meeting record, provided by the facility on 5/15/23, read the resident was on a diet of no added salt (NAS) and controlled carbohydrates (CCHO). The NAR record indicated the resident was down a total of five lbs in 30 days. The resident was provided a supplement of choice once a day related to a low appetite, eating a variable amount of 50%. The 3/23/23 nutrition/dietary note identified the resident continued to be followed in the NAR meeting for weight fluctuations and had an intake of 50% at meals. Resident #31 continued to be receptive to her supplements and drank about half of it. -The 3/23/23 NAR record did not identify changes to the resident's weight or intake. The NAR meeting record under current weight was left blank. The 4/10/23 administration note identified the resident had an order to provide the resident with a supplement of choice, once a day for low appetite/intakes. The order directed staff to provide the resident the supplement as a p.m. snack. The 4/13/23 NAR record identified the resident's weight as of 4/13/23 was 150 lbs and she ate 50% to 75% of her meals. The 4/14/23 nutrition/dietary note read Resident #31 was followed in NAR with weight fluctuations related to fluid retention and weight drain at the hospital. According to the note, the resident accepted her supplement well and was on daily weights to monitor fluid retention. The note revealed the resident would be discontinued from NAR. -Review of the progress notes and assessments, identified Resident #31's nutritional status was not assessed or reviewed by the RD between 4/14/23 and 6/14/23 when she was having nausea, vomiting and weight loss (see below). The 4/22/23 health status note read the resident had complained of nausea and vomiting. Resident #31 was prescribed Zofran to help reduce the symptoms nausea and vomiting. The 5/15/23 weight and vital summary record identified she weighed 154 lbs. The 5/16/23 transfer to the hospital note read the resident was transferred to hospital related to low oxygen saturation levels, low resident response when spoken to and convulsions. The resident had three plus edema to bilateral lower extremities. The 5/19/23 admission summary note read the resident returned from the hospital after she had two blood transfusions. The note identified the hospital did not remove fluid from the resident. The 5/20/23 weight and vital summary record identified she weighed 139 lbs after her return from the hospital. -The record review identified the resident was not assessed by the RD after the change in condition and weight loss. The 5/21/23 health status note identified the resident's condition after hospitalization and blood transfusions. According to the note, the resident continued to sleep almost 20 hours a day. She had a despondent affect. The note identified the resident continued to drink water, tea and soda and had a fair appetite, eating 60% of her meals. The weight and vital summary record between 5/21/23 and 5/30/23 identified the resident was weighed daily. The 5/24/23 administration notes identified the resident vomited. She was provided with Zofran and it was effective. The resident's weight and vital summary record, by use of the wheelchair scale, identified weight fluctuation between 5/21/23 and 5/27/23: -137 lbs on 5/21/23 -126 lbs on 5/24/23 -136 lbs on 5/27/23 The weight and vital summary record on 5/28/23 indicated the resident weighed 118 lbs by use of the wheelchair scale, revealing an 18 lb loss in a day. The weight and vital summary record on 5/29/23 indicated the resident weighed 114 lbs by use of the wheelchair scale, revealing a 4 lb loss in a day. The weight and vital summary record on 5/30/23 indicated the resident was weighed and reweighed. Both weights on 5/30/23 indicated the resident weighed 112 lbs. -The weight record identified that the resident lost six lbs between 5/28/23 and 5/30/23. The weight and vital summary record identified the resident was weighed again on 6/2/23. The resident weighed 114 lbs. The 6/2/23 administration notes identified the resident vomited. She was provided Zofran which was effective. The 6/3/23 administration note identified the resident was nauseated and had dry heaves. She was provided Zofran which was ineffective. The 6/4/23 administration note read daily weights in the morning related to nephrotic syndrome with unspecified morphologic changes were no longer indicated. The 6/6/23 health status note read the resident complained of nausea. She was provided zofran. According to the note, the resident was educated on taking small sips of fluid. The note identified the resident had temporal wasting (loss of muscle mass around the temple caused by nutritional deficiency, weight loss). The 6/6/23, 6/7/23 and 6/8/23 administration notes read Zofran was effective for her nausea. The weight and vital summary record identified the resident was not weighed again until 6/8/23. The record identified the resident weighed 100 lbs, a loss of 14 lbs in a week, between 6/2/23 and 6/8/23. The review of the weight record between 6/8/23 and 6/15/23, did not identify the resident was reweighed after the identification of a 14 lb weight loss. The 6/9/23 health status note read the resident was not eating, slept 22 to 23 hours a day and had temporal wasting. According to the note, the physician spoke to the resident and she did not want hospic[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure adequate nutrition and assistance to prevent weight loss for one (#20) of five residents reviewed out of 29 sample residents. Resident #20 lost seven pounds over an eight day period, and experienced significant weight loss. Resident #20 had a 5% weight loss from 2/7/22 to 2/21/22 and a 7.5% weight loss from 2/7/22 to 4/19/22. The facility failed to assess and implement timely interventions, including dining assistance, to prevent the resident's significant weight loss. Findings include: I. Resident status Resident #20, age [AGE], was admitted on [DATE]. According to the April 2022 computerized physician orders (CPO), diagnoses included atrial fibrillation; rheumatic disorders of mitral, aortic, and tricuspid valves; and diverticulosis of intestine. The 2/10/22 minimum data set (MDS) assessment revealed that a brief interview for mental status (BIMS) assessment was not completed as the resident was rarely understood. The MDS revealed the resident required set up help for eating (using utensils to bring food and liquid to the mouth and swallow food and liquid once the meal is placed in front of the resident) and did not indicate a weight loss. II. Observations On 4/19/22 at 8:52 a.m., the resident was in his room, slumped in his chair, with his bottom near the edge of the chair and his head was to the left side of the back of the chair. A breakfast plate was in front of him on his side table. The food appeared uneaten and the orange juice was full with plastic covering the top of the glass. At 12:20 p.m., the resident was observed in his room slumped in his chair with a lunch plate in front of him on his bedside table. The food plate was untouched and the beverage cups were still full. The nursing supervisor/registered nurse (NS) was observed going into the resident's room assisting him a bite of food. The resident did eat the bite; it was meat that looked like stew meat. The NS then left the resident's room. Ten minutes later at 12:30 p.m., the NS was observed going back into the resident's room and assisting him another bite of meat. The resident took that bite and ate the meat. The NS was observed leaving the room after that bite of meat. At 12:36 p.m. the resident was observed sitting in his room with his lunch plate about two feet in front of him on the bedside table. The resident's tray revealed only a few bites of food were eaten. The NS was observed walking into the resident's room. The resident told the NS he needed to use the restroom and after using the restroom, he would eat the rest of his lunch. The NS was observed asking a certified nurse aide (CNA) to take the resident to the restroom. At 12:53 p.m., the resident was observed in his chair drinking juice. There were a few more bites of food eaten. It appeared the resident ate about 25% of his meat and vegetables; the macaroni and cheese appeared untouched. On 4/20/22 at 8:52 a.m., the resident was in the dining room for breakfast. He was sitting in his wheelchair at a table. He had scrambled eggs, pancakes and bacon on his breakfast plate. The breakfast appeared uneaten. The NS was observed walking into the dining room and asked the resident, Are you going to eat? She then assisted the resident a bite of pancake. The NS was observed walking away to assist another resident and Resident #20 was observed sitting in his wheelchair not attempting to eat or drink. At 8:57 a.m., administrative assistant (ADM) #1 was observed walking out of her office and asked the resident if he wanted another bite. The resident shook his head. A CNA then removed the breakfast plate from in front of the resident and did not offer an alternative. III. Record review Upon record review of the resident's documented weights, the resident had a 5% weight loss from 2/7/22 to 2/21/22 and a 7.5% weight loss from 2/7/22 to 4/19/22. Upon record review, the resident weighed 124 pounds (lbs) on 2/7/22 and weighed 107 lbs on 4/12/22. The 2/322 physician ordered Mirtazapine 15 mg once a day, to stimulate appetite. The 2/3/22 physician ordered half size meal portions if the resident requests. The nutritional assessment dated [DATE] indicated the resident's weight was 124 lbs. The assessment indicated the resident was on a regular diet and meal intake was 25-50%. The recommendations were to cut down on portion sizes and add more ethnically appropriate foods. The nutritional progress note dated 2/17/22 at 1:34 p.m. indicated the resident was discussed at a weight meeting as a new admission. The resident lost 4 lbs in one week. There was a concern the portion sizes may have been too large for the resident. The nutritional progress note dated 3/3/22 at 1:18 p.m. revealed the resident was discussed at a weight meeting for a loss of 5% of the resident's body weight in one month. The note stated the resident ate poorly and consumed less than 50% of meals. The note stated the resident complained about large portions which made it hard for him to eat. The intervention of attempting ethnically appropriate food was documented in the nutritional progress note. -Although, the resident portion sizes were decreased, previous to 3/10/22 (see below) there was no additional supplementation or interventions added to provide the resident with additional calories and protein with his ongoing weight loss. The nutritional progress note dated 3/10/22 at 11:08 a.m. revealed the resident was discussed due to a 9.7% weight loss in one month. The note documented the resident ate 26-50% of meals. Interventions included giving the resident Ensure supplements twice a day and offering snacks frequently including at bedtime. On 3/10/22 the physician ordered Ensure three times a day after meals for nutritional supplementation. The nutritional progress note dated 3/17/22 at 11:29 a.m. revealed the resident was discussed at a weight meeting due to a 9.7% weight loss in one month. The note stated the resident received supplements three times per day. The note stated the resident only ate 75% of one meal and refused to eat any more food. The intervention was to offer supplements between meals. The nutritional progress note dated 3/28/22 at 11:56 a.m. indicated the resident was discussed at a weight meeting for a 6.9% weight loss over a month. The note stated the resident ate poorly but appeared to have been eating more. The note indicated the resident's weight seemed to have stabilized. The nutritional progress note dated 3/31/22 at 12:32 p.m. indicated the resident was discussed at a weight meeting due to a 7.5% weight loss over 90 days. The note stated he ate poorly but had been eating meals to completion more often. The note stated the resident refused ethic cuisine and needed cueing to eat. -When the resident refused ethnic cuisine, there were no additional measures to determine his food preferences and offer the resident food he liked. The nutritional progress note dated 4/8/22 at 3:31 p.m. revealed the resident was discussed at a weight meeting for a 5% weight gain in one month and an 8.1% weight loss over 90 days. The note stated the resident ate poorly but had been improving since the CNAs helped the resident set up to eat and assisted him his first bite of food. The nutritional progress note dated 4/14/22 at 11:33 a.m. indicated the resident was discussed at a weight meeting for a 10% weight loss over 90 days. The note stated the resident ate poorly, less than 50% of his meals. The resident received supplements three times per day, which the resident drank. Interventions included: thicker silverware and discussion the resident may have needed to assisted with meals. The resident's care plan, initiated on 3/24/22 and revised on 4/19/22 (during the survey), revealed the resident had experienced a significant weight loss of 9.7% in 90 days as of 4/19/22. The interventions included: monitor/record/report to physician any signs and symptoms of emaciation, significant weight loss of three lbs in one week; provided supplements as ordered; served diet as ordered and monitored intake and recorded meals eaten; resident had a preference for Hispanic foods, offered as able. The nutritional progress note dated 4/19/22 (during survey) at 2:30 p.m. revealed the resident was seen for a weight loss of 9.7% body weight in 90 days. The note indicated the resident's intake was 26-50% of meals and the supplement Ensure which was consumed 75% of the time. The recommendations were: continuing to honor resident preferences, providing supplements as ordered and offering light snacks. IV. Staff interviews The NS was interviewed on 4/19/22 at 12:20 p.m. She stated the resident was fully capable of feeding himself. She said he just needed a little cueing. She stated she would assist him a few bites of food, leave, and check on him every five minutes or so. She stated he could be stubborn at times. She said he had a choice of meals and if he did not like something, he would be verbal about that. She stated the cueing had been working, as he started gaining back some weight. The dietary manager (DM) and registered dietitian (RD) were interviewed on 4/21/22 at 11:01 a.m. The RD stated the resident had been improving, as upon admission he was not eating as much. The RD said the resident was given supplementation and had just started eating in the dining room. The DM stated the resident was a tough one and he would not speak to the DM or some of the staff. The DM said he had been trying to work with the resident to obtain the resident's food preferences. The DM said he had tried sending the resident ethnically appropriate foods and the resident did not like that. According to the DM, the resident stated he wanted smaller portions so the kitchen cut back on his portion size. The DM said the resident's family asked if they could have tried thicker silverware (which was not observed to be using) that would be easier for the resident to use, which the DM did provide to the resident. The DM stated they have tried several interventions such as having the resident eat in the dining room and providing the resident with the supplement Ensure three times a day, which the resident drank almost 100% of the time. The RD stated the resident was started on the medication Mirtazapine (an antidepressant) which helped with the resident's appetite. The RD stated the last nutritional assessment was completed on 4/19/22. The recommendations from the nutritional assessment were to promote snacks, supplementation, help the resident understand how important communication was, spend more time with the resident to help him progress forward with thicker silverware to help promote his own plate to mouth if he was willing. The DM stated he was unsure if the resident received snacks during the day. The DM stated he was willing to try and have a dedicated staff member assist the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#19) of two out of 29 sample residents, received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Specifically, the facility failed to implement effective interventions for Resident #19 to prevent and appropriately address Resident #19 abusive behaviors towards other residents. The facility failed to protect residents from continued verbal and mental abuse from Resident #19. Interviews revealed a pattern of abusive behavior including threats of retaliation by Resident #19 towards other residents, resulting in feelings of fear, helplessness, social isolation, humiliation, and extreme anxiety. The staff failed to document the all of Resident #19 behavior, creating a limited management awareness of the frequency of the behaviors towards residents. The facility provided staff education on behavior management but the trainings did not improve the hostile living environment that the residents were subjected to from Resident #19. Interviews identified a staff complacency of Resident #19 behaviors and ineffective interventions to intervene when problems occurred. Facility actions did not show effective results until after an immediate jeopardy situation was identified on 4/20/22 and the facility implemented ongoing one-on-one supervision of staff providing continued mitigation of her behaviors and consistent attention. The facility also allowed her to have smoking privileges again which was identified to calm her nerves. Cross-reference F600 failure to prevent resident to resident abuse that contributed to the resident experiencing emotional and psychological harm. Findings include: I. Facility policy and procedures The Behavioral Assessment, Intervention and Monitoring policy, revised March 2019, was provided by the nursing home administrator (NHA) on 4/21/22 at 5:52 p.m. According to the policy, a behavior was a response of an individual to a variety of factors. The factors could include medical, physical, functional, psychosocial, emotional, psychiatric or environmental causes. The policy indicated behavior was influenced by past experiences, personality traits, environment, and interactions with other people. The policy identified behavior could always be a way for an individual in distress to communicate an unmet need, indicate discomfort, or express thoughts that could not be articulated. The policy read in part: As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: the residents usual pattern of cognition, mood and behavior; the residents usual method of communicating things like pain, hunger, thirst, and other physical discomfort; the residents typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers; and the residents previous pattern of coping with stress anxiety and depression . new or changes in behavior will be documented regardless of degree of risk to the resident or others . The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors .The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risks to the residents, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress .Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strive to understand, prevent or relieve the resident's distress or loss of abilities. Interventions and approaches will be based on detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. II. Resident status Resident #19, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the April 2022 computerized physician orders (CPO), diagnoses included toxic and Wernicke's encephalopathy (brain disease, damage or malfunction) major depressive disorder, single episode, anxiety, sleep disorder and pain. The 2/8/22 minimum data set (MDS) assessment revealed the resident's cognition was moderately impaired with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS identified the resident had inattention and disorganized thinking. Resident #19 required supervision for bed mobility, transfers, locomotion on and off the unit, personal hygiene, eating and toileting. The MDS indicated Resident #19 exhibited physical behaviors directed at others for one to three days during the MDS seven day look back period. According to the MDS, the resident also had verbal behaviors for four to six days out of the seven day look back period. The resident did not have rejections of care. III. Resident interviews Resident interviews conducted 4/19/22 and 4/20/22, identified residents felt they were verbally abused with her yelling and obscenities directed to them. They were fearful of the physical threats Resident #19 made towards them, so much so, several of the residents requested their names not to be identified, expressing worry that the resident would find out. The resident also revealed they saw her attempt to act on her physical aggression towards a resident and staff members. Additional resident concerns included helplessness, humiliation, triggers of post traumatic stress disorder (PTSD), and one resident stated the behaviors of Resident #19 prevented their family members from coming to visit them. Residents indicated staff's inaction to resolve the behaviors of Resident #19 reduced their confidence that the facility/management could and would be able to improve the abusive situation. According to the resident interviews, staff would talk to her reminding her that her behaviors were inappropriate and/or ask her to go to her room, she would leave but the resident would often return to the situation, even more upset, targeting specific residents. The residents identified a recent occurrence during the 4/19/22 Resident Council where she continued to call residents names and flipped off the Resident Council president and continued to return to the meeting with elevated aggression. Interviews identified staff did not know what to do when Resident #19's behaviors escalated. (Cross-reference F600, failure to prevent resident abuse.) IV. A frequent facility visitor interview confirmed Resident #19's abusive behavior toward other residents and residents' fear of her. A frequent facility visitor was interviewed on 4/20/22 at 3:15 p.m. She said Resident #19 wanted either good or bad attention from people. She said she had heard in the past of residents complaining about Resident #19's behavior and spoke to Resident #19, thinking her behavior could be reigned in. She said she had never seen her behavior first hand and when she did, it stunned her. The visitor explained she attended the recent Resident Council meeting when Resident #19 made a lot of noise. Resident #25 asked Resident #19 to remain respectful in the meeting and the AD spoke to Resident #19 twice, telling her if she continued to curse, she would have to leave. Resident #19 then called Resident #25 an obscenity. The resident left the meeting three times but continued to return. She flipped off Resident #25 and said I'm gonna kick somebody's obscenity. The visitor said the other residents handled the situation well. She said she thought the residents were afraid of Resident #19. She said to the best of her knowledge, Resident #19 had not hit anyone, but hearing the comments from the residents in the group interview (see above), maybe she had. The visitor said she was not aware until after hearing the residents' comments that Resident #19's behaviors also were at night, which could be quite disruptive. V. Observations On 4/18/22 at 5:55 p.m. during the evening meal service. Resident #19 was propelling herself with her wheelchair through the dining room. Resident #34 was yelling out in confusion for her dog. Resident #19 yelled back in a mocking tone, where's my dog, where's my dog. Resident #19 laughed and took herself outside to the courtyard. On 4/20/22 at 4:17 p.m. Resident #19 was heard down the hallway yelling from her room, the words were not distinguishable. -At 4:18 p.m. Resident #19 exited her room and entered the dining room. Resident #19 stopped in the middle of an entrance point of the dining room. -At 4:19 p.m. Resident #10 attempted to go navigate around Resident #19 and she tried to exit the dining room in her wheelchair. Resident #10 accidentally bumped the foot peddle of Resident #19 because of the limited space available for her to pass. Resident #10 quickly apologized and backed up her wheelchair. Resident #19 told Resident #10 I wish you would stop running me over, you do it all the time. Resident #10 said she would go the other way and proceeded to propel herself to the other side of the dining room. Resident #19 said as motioned to residents sitting at a dining table, You will probably just run over them too. On 4/21/22 at 9:48 a.m. the minimal data set coordinator (MDSC) sat in a chair across from the room of Resident #19. Resident #19's room door was closed. The MSDC identified she was providing one to one supervision of Resident #19. On 4/21/22 at 3:40 p.m. Resident #19 was observed on 4/21/22 at 3:40 p.m. with the MDSC during her one to one supervision as she wheeled throughout the facility. Resident #19 was smiling, and talking to the MDSC. She was not focusing on other residents and seemed to enjoy the positive attention. VI. Record review The April 2022 CPO for Resident #19 directed staff to monitor the behaviors of the resident. According to the CPO staff should look for signs of depression, crying, self isolation, feeling alone, restlessness, agitation, hitting, increased complaints, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, refusal of care and verbal and physical aggression. The CPO also directed staff to document the behavior findings in the progress notes if identified. The April 2022 treatment administration record (TAR) indicated Resident #19 exhibited behaviors between 4/1/22 and 4/20/22. According to the TAR under behaviors, staff should document a Y if staff monitor the resident's behaviors and none of the behaviors of depression, crying, self isolation, feeling alone, restlessness, agitation, hitting, increased complaints, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, refusal of care and verbal and physical aggression were observed. Staff should document a N if staff monitored the residents and observed any of the above behaviors. The TAR indicated Resident #19 had daily behaviors and on multiple shifts. Progress notes for Resident #19 identified showed limited behavior notes for Resident #19 and only two behavior notes for the month of April 2022, even though the CPO directed staff to document the behaviors in the progress notes which included an undocumented incident on 4/19/22 during Resident Council. On 4/19/22 a behavior note read Resident #19 was heard yelling down the hall. She was redirected to her room with no further incident. Additional notes were reviewed for the past few months. -The 10/15/21 behavior note read Resident #19 was teasing and making fun of other residents in the dining room. The resident became verbally abusive and was screaming loudly. According to the note, Resident #19 attempted to strike the nurse with her fists but was not able to make contact -The 12/5/21 behavior note read Resident #19 was rude and hateful, yelling at residents, telling them to shut up, and mocking other residents that needed assistance. According to the note, Resident #19 looked for weaker residents to pick on. -The 1/26/22 behavior note read the resident was yelling in the hallway. -The 4/3/22 behavior note read she was yelling and angry at residents for not allowing her to smoke with them. The review of the progress notes did not identify all the potentially abuse interactions as described by the as identified by resident and staff interviews,relating to Resident #19. The notes did identify the facility was aware of some of Resident #19's behaviors but allowed the behavior to continue to occur. The care plan for psychosocial well being, initiated on 3/5/19, identified Resident #19 had psychosocial difficulties related to lack of family support. The care plan indicated there were no new interventions to address her psychosocial difficulties since 3/5/19. The psychotropic medication care plan, lasted revised 8/16/21, and the anti-anxiety medication care plan, lasted revised on 5/7/2020, identified Resident #19 was administered psychotropic medications for her depression and anti-anxiety medication for her anxiety. The care plan indicated staff should monitor and record occurrences of targeted behavioral symptoms of pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per protocol. The cognition care plan, last revised 3/5/19, indicated Resident #19 had an impaired cognitive function/impaired thought processes. According to the cognition care plan staff should: -Ask Resident #19 yes and no questions, presenting one thought, idea, question or command at a time. -Reminisce with the resident using photos of family and friends. However, according to the psychosocial care plan, the lack of family support contributed to her psychosocial difficulties. -The impaired cognition intervention, initiated on 3/13/22, identified staff should provide one to one visits, redirection, and change environment when she was agitated. The activities related psychosocial care plan, last revised on 5/27/21 identified Resident #19 was independent with her emotional, intellectual, physical needs. According to the care plan, the resident liked being part of group activities by watching from the sidelines. According to the care plan, staff should thank Resident #19 for her attendance in the activity function. The care plan did not address the resident's behaviors during the activity towards other residents or how staff should address her behaviors during the activity. The behavior care plan, initiated on 3/5/19, last revised on 3/29/22, read Resident #19, yelled, cursed and was verbally and physically aggressive. Interventions included: -The intervention, last revised on 3/13/2020, read staff to provide the resident with opportunities for positive interactions and attention. The care plan indicated staff should stop and talk to her as they passed her by. -The intervention, last revised on 3/13/2020, read staff should discuss the behavior with the resident, explaining and reinforcing why behaviors such as aggression, yelling and cursing, were unacceptable and inappropriate. -The intervention, last revised on 4/16/21, read staff should remind the resident of the unacceptability of verbal abuse. The behavior care plan, last revised on 4/16/21, read Resident #19 had a potential for poor impulse control. The care plan indicated all interventions were last initiated and revised on 4/16/21. Interventions included: -Analyze key times, places, circumstances, triggers, and what de-escalates the behavior. According to the care plan, the analysis should have been documented. -Assess and anticipate the resident's needs. -Assess the residents coping skills, support system and understanding of the situation. According to the care plan, staff should allow time for the resident to express herself and the feelings towards the situation. -Give the resident as many choices as possible about care and activities. -Intervene as needed to protect the rights and safety of others. According to the intervention, staff should approach the resident in a calm manner and divert her attention. Staff should remove the resident from the situation and take her to a different location as needed. -Assist Resident #19 with developing more appropriate methods of coping and interacting. According to the intervention, staff should encourage Resident #19 to verbalize appropriately and inform staff when she was upset. -Minimize the potential disruptive behaviors of resident #19 by offering a task which could divert her attention to positive interactions. -Maintain separate smoking times and activities between Resident #19 and other resident's to facilitate a safe environment for other residents when Resident #19's verbal aggression increases. -Monitor the behaviors of Resident #19 q (every) shift and prn (as needed). The care planned intervention directed staff to document the observed behavior and the attempted interventions. The review of the behavior care plan identified the behaviors of verbal abuse and physical aggression were not new behaviors of Resident #19. The behavior care plan identified there were no new interventions put in place since 4/16/21. -Despite Resident #19's behavior care plans in place, most of the interventions were over a year old and were either ineffective or not consistently implemented by staff. The safety care plan, initiated 10/1/21 indicated Resident #19 was a long-term smoker and enjoyed her smoke breaks to calm her nerves. However, interviews with staff identified the resident was no longer allowed to smoke because she exhibited unsafe behaviors. Interventions added on 4/21/22 after the facility was informed of an immediate jeopardy situation related to her behaviors. The interventions included: -Staff were to provide one to one supervision at all times to ensure interactions with staff and residents were appropriate. Staff was directed to intervene as needed to protect the rights and safety of others. -Maintain separate smoke times and activities between Resident #19 and other residents to facilitate a safe environment for others. -Provide opportunities for positive interactions and attention. -Redirect the resident as needed, removing her from escalating situations. According to the intervention, offer the resident fluids or smoking if she does not want to leave the activity. The smoking care plan short term goal, initiated on 4/21/22, read the facility would assist the resident with the development of appropriate methods to cope and interact with others. Facility education in-service training was provided on 4/21/22 by the director of nursing (DON). The education provided indicated staff had both behavior management training and aggressive resident training in the past four months. -A behavior management training was conducted on 12/17/21. According to the training, staff should: Reduce noise level and stimulation; give residents choices whenever possible; answer call lights promptly; report any signs of pain; and, use appropriate body language when speaking with the residents. -A aggressive resident training was conducted on 2/7/22. According to the training, staff should: Try to identify the cause of the aggressive behavior; use a calm voice; change the resident's environment; provide redirection and a one to one visit; and always make sure the resident and other residents were safe. VII. Staff interview Staff interviews confirmed the facility was aware of Resident #19's aggressive behavior toward other residents but did not recognize the emotional and psychological harm residents felt as a result. Further, although staff were able to articulate interventions to address the resident's behavior, resident interviews (see above) and interview with the frequent facility visitor (see above) revealed these interventions were not effective in protecting the residents from Resident #19's abuse. The MDSC was interviewed on 4/20/22 at 11:31 a.m. The MDSC said all staff were responsible for checking in on residents when they were upset. She said she sometimes can hear Resident #19, loud and upset, from her office located outside of the dining room. She said when Resident #19 exhibits behaviors, staff try to keep residents safe by taking her out of the area, offering to sit and talk with her, offering to do her nails or redirecting her with coffee and by asking her what she needs. The MDSC said sometimes staff let her self-soothe but not when other residents were involved and at risk. The activity director (AD) was interviewed on 4/20/22 at 11:37 a.m. She said Resident #19 would blurt things out. The AD said on 4/19/22 during the Resident Council meeting, Resident #19 was loud and disruptive. The AD said she asked Resident #19 to leave the meeting and Resident #19 left but then came back moments later and called Resident #25 an obscenity. Resident #19 was asked to leave again but she returned and was again loud, rude and confrontational. The AD said Resident #19 called Resident #1 a thief. She said staff interventions to address Resident #19's behaviors were care planned. The director of nursing (DON) was interviewed on 4/20/22 at 11:26 a.m. The DON said she initiated a verbal abuse investigation on 4/19/22, of Resident #19 based on comments made by Resident #25. The DON said the physicians have not given Resident #19 any kind of psychiatric diagnosis. The DON said the resident's physician has tried different medications but they have not seemed to make much of a difference. The DON said the facility has made multiple attempts without success to find alternate placement for Resident #19 around the state, including psychiatric facilities and facilities near her family. The DON said her family had very little contact with Resident #19 or little involvement in her care. The DON said the facility continued to do 15-minute checks on Resident #19, redirecting, taking her out of the situation, and taking her to her room. The DON said Resident #19 was a tough one. She was alert and oriented. She said her BIMS was 10/15 when assessed in March of 2021. She said it was definitely a behavior with Resident #19 and it almost was like attention-seeking. The DON said she noticed that Resident #19 takes her anger/behaviors out on the person that was reprimanding her, so they have encouraged residents not to say anything to her because she takes it out on them. The DON said she would rather Resident #19 curse at the staff than at the residents. She said she had been trying for a year to manage Resident #19's behavior. The DON said there have been some staff-witnessed behaviors. She said on 4/19/22, the AD and a frequent facility visitor were witnesses to Resident #19's behavior during the Resident Council meeting. She said no one reported the incident to her or the NHA at that time. She said she reviewed the charted behavior notes but was not informed by staff what had occurred. The DON reviewed Resident #19's behavior notes from the past year. She said in July 2021, the resident cursed at staff twice. In August 2021, her behavior again was directed towards staff. There was a behavior identified in October 2021. In December 2021, she was noted to be rude and hateful, yelling at other residents and she attempted to strike a nurse. The DON said there was also one other behavior in April 2022, when the resident was told by staff she could not go outside and smoke because she no longer smoked. The DON said Resident #19's family would not purchase her cigarettes after the resident was found smoking cigarette butts in her room. The DON said Resident #19 still would go outside but not to smoke. The DON said she thought the decrease in smoking could have contributed to her behavior. The DON said Resident #19 seemed to get more animated and louder when there were people in the building she did not know. She said when the facility had new floors put in, the DON said Resident #19 was very boisterous and loud, teasing them. The DON said there had also been more families coming in recently. She said she thought that may bother Resident #19 because she did not have visitors or friends at the facility because of her behavior. The DON said the resident was better in the evening and she would sit near the nursing station and talk to the facility's evening nurse who she liked. The DON said the facility had spoken to Resident #19 about her behavior but the resident said she was raised with older brothers and was rough with them. The DON said the resident also worked with all men as a dispatcher for a trucking company, so she thought her manner of speaking and her behavior was okay because it was the environment she was accustomed to. The DON said Resident #19 said she did not see anything wrong with how she spoke to residents or why it upset them. She said she has been spoken to the same way her whole life. The DON said the only way they have found to mitigate the situation when Resident #19 exhibited behaviors, she was to have her leave the situation. The DON said she asked the AD why she did not have Resident #19 leave the Resident Council meeting. She said the AD said she did not know she could have her leave because she was fairly new in her position and she thought it was Resident #19's right to be there. She said other staff members did not hear anything that the DON was aware of, referring to behaviors during the 4/19/22 Resident Council. The DON said she was still getting statements from staff regarding the incident in the Resident Council meeting. The DON said she notified the police, the ombudsman, the resident's physician and attempted to reach the family of Resident #19 but had not heard back from them. The DON said the social service director (SSD) was in the process of interviewing residents and the facility was actively investigating the residents' concerns. The maintenance assistant (MA) was interviewed on 4/21/22 at 9:45 a.m. He said he was assigned to provide one-to-one supervision of Resident #19 for part of the morning of 4/21/22. He said he had been asked to make sure Resident #19 was not alone if she went out to the resident common areas. He said it was not uncommon for Resident #19 to call him names. The MDSC was interviewed again on 4/21/22 at 9:50 a.m. She said she had been instructed to monitor the whereabouts of Resident #19 starting on 4/21/22. She said she had a good rapport with Resident #19. The MDSC said Resident #19 was always a smoker, and the MDSC would offer her cigarettes. The MSDC said the one-to-one supervision was to redirect and de-escate Resident #19 if she exhibited any behaviors towards others. She said the goal of the one-to-one supervision was for the safety of Resident #19 and other residents. The social service director (SSD) was interviewed on 4/21/22 at 1:43 p.m. The SSD said part of her role was to provide emotional support for residents. The SSD said if residents were feeling down, she was always available to listen to them. She said she tried to get to know the residents. The SSD was asked about the plan to address Resident #19's behaviors. She said she has seen staff remove Resident #19 from the situation when her behaviors escalate. The staff try to give her space and explain to her that she can not call residents names, and walk her to her room. The SSD said they have tried offering Resident #19 mental health services but she has refused in the past. The SSD said they also make sure she did not have roommates. The SSD said residents have said Resident #19 yelled at them, but usually said it did not bother them. The SSD said she has asked the residents if they felt safe in the facility. She said no one has told her they did not feel safe and no one had mentioned they felt afraid. The SSD she said thought said residents were trying to cope with Resident #19. The SSD said that since (during the survey) the facility had learned the residents were expressing fear of Resident #19, the new plan moving forward was for Resident #19 to be assessed again by mental health services, to offer her medication to help her sleep better, and to give her smoking privileges back. Resident #19 would also be closely supervised for both her smoking and her interactions with other residents. She said Resident #19 has told her that she wants to be left alone and she wants to leave the facility. The SSD said the resident had been turned down for transfer by ten facilities in Colorado and because the resident had an interest in Texas, she would start looking at facilities there. The SSD said she would continue to communicate with residents and continue having residents complete abuse audit questionnaires. She said she routinely asked residents questions on abuse and would interview each resident at least quarterly. She said if she identified a concern, she would follow up with the DON. The SSD said if residents expressed concerns about a staff member, she would not share that information with the identified staff member but would refer it all the DON. Registered nurse (RN) #1 was interviewed on 4/21/22 at 3:40 p.m. RN #1 said Resident #19 will sometimes not get up for the day until the afternoon and sometimes she would seclude herself in her room. But, when she was up, she was very attention seeking and would yell out constantly. The RN said she had heard her yelling in the dining room and would check on her, but usually she was just yelling at the television located in the dining room. She said she was aware of an incident between Resident #19 and Resident #22. She said both residents were yelling at each other and both residents were removed from the dining room. RN #1 said staff assigned to the dining room would usually be the ones to address the residents' behaviors in the dining room. RN #1 said she has heard Resident #19 call staff members obscenity but that was just how Resident #19 was. Administrative assistant (ADM ) #1 was interviewed on 4/21/22 at 4:20 p.m. She said Resident #19 had a strong and loud personality. ADM #1 said she usually will just yell at the television in the dining room which will escalate other residents. She said Resident #19 liked to get other people's goat and liked to irritate residents. She said Resident #19 has to be taken out of activities such as bingo. She said she has heard Resident #19 call another resident an obscenity. She said when that happens, the resident is asked to leave. ADM #1 said Resident #19 knows who she can irritate, such as Resident #25 and Resident #10, and will focus on irritating those residents. ADM #1 said Resident #19 was fully aware of what she was doing; she wanted a response and sought out attention whether it was good or bad. She said she knew Resident #19 well. She said Resident #19 can be redirected with Pepsi and coffee mixed with hot chocolate and creamers. ADM #1 said Resident #19 enjoyed television and sports. She said Resident #19 likes someone to talk to and someone to take her out for cigarettes. ADM #1 said she had worked at the facility for years and felt she was in tune with the residents. She said it would be good if staff had work groups again. She said before COVID, the facility held staff in-services. Staff used to be able to share information about residents on approaches that were working and a general conversation on what staff was seeing with the residents. ADM #1 said the facility has talked about having small group inservices but it was just in the brainstorming stage right now. She said it could be beneficial for all the new staff to be able to ask questions of the senior staff on how they work best with the residents. The ADM #1 said [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide person-centered dementia care to five (#33, #14, #15, #29 and #91) of five residents reviewed out of 13 residents who resided on the dementia care secured unit (SCU). Resident #33 had dementia with lewy bodies and behavioral symptoms including repetitive verbalizations that affected her well-being and that of others around her. She had delusions and hallucinations, and talked loudly and often cursed to herself, causing other residents' anxiety to escalate. Resident #16, who was typically very quiet, walked by Resident #33 when she was cursing, yelled at her to shut the (obscenity)! and charged toward her. He would have possibly injured Resident #33 had a staff person not stepped between them and redirected him, apologizing and explaining that Resident #33 was not talking to him. The facility failed to address Resident #33's behavioral symptoms in a manner that effectively calmed and soothed her, and prevented psychosocial harm to herself and others. She was given antianxiety and antidepressant medications. Resident #15 had Alzheimer's disease, spoke Spanish only, and spent most of his time in his room alone, or sitting at a table in the SCU common area looking out the window or sleeping with his head on his arms. Only one staff person was observed speaking a few phrases of Spanish to him during meal service. Resident #15 was not provided with meaningful activities, music, or opportunities to go outside when the weather was nice. He was given antipsychotic medication. Resident #14 had dementia with behavioral disturbance and spent most of her days pacing in the hallway and common/dining area, carrying a baby doll, grimacing, moaning and whimpering. She did not like to sit at the dining room table to eat, and staff did not offer her finger foods and drinks that she could carry with her. She was observed taking food and drinks from other residents' tables and walking away with them. She was not provided with meaningful activities, one-to-one activities, tactile or sensory objects to manipulate. She was given antipsychotic and antidepressant medications. Resident #29 had dementia, delirium and mood symptoms and spent most of her days pacing to and from her room and into the common dining area, asking staff where she should go, what she should do, and what was next. She had purple, blue and red bruising and swelling to her face and eyes from a previous fall (cross-reference F689, falls/accidents). She was not provided with meaningful activities, one-to-one activities, pet visits or opportunities to go outside although the weather was nice. She was given antipsychotic and antidepressant medications. Resident #91 had Alzheimer's disease and depression. He was observed spending most of his time in his room, the television/dayroom and the common/dining area. He was admitted after a psychiatric hospital stay for treatment for suicidal ideations, and said he had contemplated suicide because he did not want to reside on the SCU. The facility contacted a mental health professional who visited and assessed him, but not until after his statement was reported during the survey. Resident #91 was not provided with meaningful activities or opportunities to go outside, other than for supervised smoke breaks. Resident #91 was given antipsychotic medication. The facility's failures to provide adequate dementia care services contributed to Resident #33's behavioral symptoms worsening and negatively affecting others, putting her at risk for verbal abuse and injury. The facility failure to provide dementia care and a homelike SCU negatively affected residents' quality of life and prevented residents from reaching their highest practicable psychosocial well-being. Cross-reference F758, unnecessary antipsychotic medications. Findings include: I. Facility policies The Dementia-Clinical Protocol policy, revised November 2018, was provided by the director of nursing (DON) on the afternoon of 4/21/22. The policy required in pertinent part the following: For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. -Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. -The facility will strive to optimize familiarity through consistent staff-resident assignments. -Direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing, dressing, mealtimes and therapeutic and recreational activities will be supervised and supported throughout the day as needed. -The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. -Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools). -Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT. -The physician will help define potential benefits and risks of medical interventions (including cholinesterase inhibitors and other medications used to enhance or stabilize cognition) based on individual risk factors, current conditions, history and details of current symptoms. -The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements. -Medications will be targeted to specific symptoms and will be used in the lowest possible doses for the shortest possible time, unless a clinical rationale for higher doses or longer-term use is documented. -If a psychiatric consultant is called to help manage behavioral or psychiatric symptoms in the individual with dementia, the IDT will retain an active role by reviewing and implementing the consultant's recommendations, addressing issues that affect mood, cognition, and function, monitoring for complications related to treatment, and evaluating progress. -The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician. -The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors. -The physician and staff will review the effectiveness and complications of medications used to try to enhance cognition and manage behavioral and psychiatric symptoms and will adjust, stop, or change such medications as indicated. II. SCU environment observations The SCU environment had a lingering urine odor, noticeable from the entryway. The environment was not homelike, welcoming or conducive to spontaneous activities. A long hallway led to a television/day room and lounge chairs, but residents rarely entered the room and were not encouraged by staff to do so. The dining/common area was filled with square four-top dining tables. Several residents tended to gather near a table at the doorway where staff typically sat. There were no magazines, newspapers, puzzles, art supplies or tactile items to invite spontaneous activities or to promote a homelike environment. There was no private cordless phone. When residents received or made a call, staff removed the phone from the cabinet above the kitchen countertop area, and seated the resident next to the kitchen counter in the middle of the common area. There was no privacy for phone calls, and the room was typically loud, with hard floors and table tops echoing the sounds of residents and staff talking. There was no independent access to the outdoor secure courtyard. The only door to the outside was a fire door that sounded an alarm if opened. The window looked out onto a sidewalk that was deeply cracked, uneven, and surrounded by landscape rocks, creating an unwelcoming and unsafe environment (cross-reference F689, accident hazards). The SCU was typically staffed with two certified nurse aides (CNAs). There was no consistent social services or activity programming to promote highest practicable well-being and quality of life for the residents. The nurse entered the SCU only when requested by the CNAs or to give medications. The activity director entered the SCU occasionally to conduct a brief group activity, and then left the SCU. Review of the facility's resident roster matrix revealed that out of 13 residents who resided on the SCU, 12 residents were given antipsychotic medications and seven had experienced falls. Review of resident care plans revealed more of a focus on medications than individualized assessments and responses to root causes and unmet needs. III. Resident #33 A. Resident status Resident #33, under age [AGE], was admitted on [DATE]. According to the April 2022 computerized physician orders (CPO), diagnoses included progressive supranuclear ophthalmoplegia (a brain disorder that causes serious problems with walking, balance, eye movements and later swallowing); major depressive disorder; Parkinson's disease; dementia with lewy bodies; and anxiety disorder. The 3/18/22 minimum data set (MDS) assessment documented severe cognitive impairment per staff assessment. Resident #33 was unable to complete the brief interview for mental status (BIMS). She had delirium symptoms of hallucinations and delusions, trouble concentrating and poor appetite. She had behaviors that affected others but no care rejection. She had wandering behavior but it was not documented how it affected her or others, or if her behavior put her at risk. Resident #33 required limited physical assistance with transfers, ambulation, eating and personal hygiene; and extensive assistance with dressing and toilet use. She had unsteady balance and gait. Her fall history was blank. She took antianxiety and antidepressant medications daily. Her preferences were not documented on the above quarterly MDS assessment, but her 6/15/21 annual MDS documented it was very important to her to have snacks between meals and family involvement. It was somewhat important to her to keep up with the news, do things with groups, go outside in good weather, and participate in religious services. B. Observations An initial tour of the SCU on 4/18/22 at 1:15 p.m. revealed Resident #33 was standing in the common area, looking at the floor, talking loudly in a two-way conversation with herself. Nearby, a female resident with a walker was pacing up and down the hallway, circling the common area, talking loudly and disrupting other residents. Certified nurse aide (CNA) #1 was encouraging her to sit down because she had been standing for a long time. A male resident paced in the hallway and common area, walking toward another resident's room until a CNA redirected him back into the hall. Resident #90, who was sitting in a chair in the common area near Resident #33, said, Communication is hard and I don't want to be here. He said he was looking for a phone book and a pencil. (Resident #90 was moved to a room on the open unit at 4:00 p.m. that day.) CNA #1 said the SCU was typically staffed with two CNAs, which they needed, and the nurse covered the [NAME] hall and the SCU. Observations of the SCU and Resident #33 were conducted throughout the survey on the afternoon of 4/18/22, and throughout the day on 4/19, 4/20 and 4/21/22, and included the following of note: On 4/18/22 at 5:00 p.m., Resident #33 was being fed her dinner by a CNA. On 4/19/22 at 8:21 a.m., Resident #33 was being fed her breakfast by staff. A few minutes later she was saying to herself, You have to eat, honey, you do, as a CNA was scraping off her plate into the trash. Throughout the day on 4/19/22, Resident #33 remained in the common area, sitting or standing, looking down, constantly talking to herself. On 4/19/22 at 4:35 p.m., Resident #33 was talking loudly to herself. Resident #13, who was sitting nearby, loudly told her to Stop! On 4/19/22 at 4:59 p.m., Resident #33 was talking and cursing loudly and approaching other residents aggressively, including Resident #13 who was talking loudly near her. CNA #3 intervened to protect other residents who were standing or sitting nearby. On 4/19/22 at 5:11 p.m., Resident #33 was still talking loudly and as dinner was served, her voice and her cursing grew even louder. Resident #16, who was walking out of the dining room, yelled in Resident #33's face, Shut the (obscenity! and charged toward Resident #33. CNA #3 stepped between them, apologized to Resident #16 and reassured him, saying, She wasn't talking to you. CNA #3 redirected Resident #16 into the hallway as he said, She was looking right at me! On 4/19/22 at 5:13 p.m. several residents were eating dinner but Resident #33 was standing up near the dining room entry door, talking loudly to herself. Resident #13 was yelling at Resident #33 to stop it, oh my god! CNA #3 reassured Resident #13 that she would take Resident #33 to her room in a minute. At 5:16 p.m. CNA #3 tried to walk Resident #33 down to her room to eat but she refused, locking her feet and legs firmly in place, looking down at the floor and talking loudly. At 5:19 p.m., she was walking around the dining room, looking down at the floor and talking and cursing loudly to herself while other residents were trying to eat. Resident #13 said to her, Oh, knock it off! CNA #3 continued to separate Resident #33 from other residents who were walking by her while CNA #12 was assisting other residents in their rooms. At 5:23 p.m., Resident #33 was still standing up looking at the floor, talking to herself but more quietly. Resident #13 was watching her, and was not eating. At 5:31 p.m., Resident #33 continued to stand up and talk to herself. Her dinner was in her room where staff had tried to redirect her, and she had not eaten. At 5:32 p.m., CNA #12 asked the residents if they were finished with dinner, and if it was good. One resident responded that it was not very good, and she replied, I'm sorry, hopefully it will be better tomorrow. On 4/20/22 at 8:45 a.m., Resident #33 and other residents had finished breakfast. Resident #33 had her head down and was talking softly to herself, sitting at a table across from a staff person. Her glass of water was still full and her cranberry juice was two-thirds full. At 8:53 a.m., CNA #10 turned on some music. This was the first time music was observed playing in the common area on the SCU. As the music played, Resident #33 started talking louder. On 4/21/22 at 10:00 a.m., Resident #33 was standing up in the common area, talking to herself loudly, and very close to other residents and staff. A group of residents was standing around, no activities were happening. A third CNA was coming on duty and getting report from another CNA. She said it was good to have three CNAs. Resident #33 was observed during the survey from 4/18 through 4/21/22 spending most of her time in the common area, unengaged, standing or sitting with her head down, talking to herself. When she was not visiting with her husband, she talked to herself and looked miserable, either grimacing or with a flat affect. The facility failed to provide adequate dementia care services to help Resident #33 reach her highest practicable level of well-being, and negatively affected the well-being of other residents near her. C. Staff interviews On 4/20/22 at 10:30 a.m., Resident #33 was not in the common area. CNA #12 was interviewed and said Resident #33 was in her room, and her husband would be visiting her soon. Regarding the altercation with Residents #33 and #16 the previous day, she said Resident #16 was typically quiet but he responded aggressively to Resident #33 about once every week or two. She said Resident #16's anger toward Resident #33 was easily triggered, but also easily diffused. She said Resident #13 got escalated with Resident #33 and would usually say hey, stop it! but usually did not get agitated. Resident #6 would often yell at Resident #33 to shut the hell up! CNA #12 said the staff response to Resident #33's behaviors depended on their training. She said Resident #33 could be redirected by taking her to her room to calm her down with nobody else around, as well as telling other residents she was not directing her words at them. When she was not redirectable and being loud, CNA #12 said she would take other residents into the other common area. She said when Resident #33 was yelling and cursing loudly, she could intervene by taking her for a walk or calling her husband and letting her talk with him. She said Resident #33's husband visited her daily between 10:00 and 11:00 a.m., and he called her twice a day, and told them he was available if they needed him to talk with Resident #33. CNA #12 said she was used to working on the SCU with just two CNAs but some staff get very frustrated. She said it was a tough situation when staff did not have the correct training to deal with the situations. I usually respond with redirection and then report it to the nurse. CNA #12 said she knew Resident #33 got Ativan (an antianxiety medication) and that does calm her down. She said Resident #33's visits and phone calls from her husband really do help her a lot. Regarding Resident #33's behavior, CNA #12 said, I do think it overstimulates the other residents and brings a lot of anxiety to have that constant yelling and not knowing if it's directed toward you or not. It can definitely seem like it sometimes. She said Resident #33's behaviors were typically intermittent throughout the day. On 4/19/22 at 11:15 a.m., Resident #33 was observed sitting in her room next to her husband, who was visiting, and quietly talking with him and not to herself. The director of nursing (DON) was interviewed on 4/20/22 at 11:30 a.m. She said the incident with Residents #33 and #16 was not reported to her by staff on 4/19/22. She said Resident #33's behaviors had been worse the last month and a half, and she was now on liquid Ativan. She said she had noticed Resident #33 was talking angrily and cursing to herself more, but no staff had told her it was upsetting anybody else. She said the CNAs had good luck with redirecting her if they could get her to a quieter area, like the TV area or down the hall, separated from others so she was not hearing other people, the television, the reading activities or other people talking. When separated and more quiet, she does tend to calm. She's a totally different person when her husband is here. She will sit and converse with him. She doesn't talk to herself when he's here. The DON said Resident #33 probably had more psychiatric issues than she had ever been diagnosed with, but it was hard to say because her husband did not observe her behaviors. Her whole personality changes when he's here. She said Resident #33's husband visited daily and called often, which definitely helped to calm her. The social services director (SSD) was interviewed on 4/21/22 at 3:05 p.m. She said for residents on the SCU, she addressed dental, vision, hearing, mental health or behavioral needs, basically doing everything outside the realm of psychotropics and activities. She said residents would let them know if there were things they needed. She said she thought staff were very observant and met the SCU residents' needs accordingly. She thought residents were kept clean and well taken care of, and said they sent housekeeping back there, and more often than not there were no behavior issues that affected others. She said she had never noticed anyone really had an issue with Resident #33's behavior. She's not very cognitive, and she's having some delusions and things of that nature. I don't see residents react to things she says and she's never directed it at anyone. You have folks back there humming consistently, and they don't react really to other residents' behaviors. D. Record review Record review over the past six months revealed Resident #33 had experienced falls and weight fluctuations, behavioral symptoms and psychoactive medications. Resident #33's SCU placement care plan, initiated 8/6/2020 and not revised, identified dementia with lewy bodies, wandering, requires low stimuli, exit seeking. The goal was to remain safe within the facility and decreases in behavioral issues. Interventions were: ensure environment is free of hazards; maintain daily routine as much as possible, avoid unfamiliar situations and caregivers as much as possible; activities outside of the unit with appropriate supervision, assess for over-stimulation; redirect as possible to activities or change topic if behaviors evident; evaluate need for SCU placement per facility protocol and as needed; administer medications as ordered; assess/record/report adverse effects/ineffective outcomes to physician; educate and provide family support; pharmacy consult to review medications per facility protocol; report significant changes to physician/family/nurse; assess/record/report behaviors/interventions/outcomes to nurse/physician every shift and as needed. Resident #33's social needs care plan, initiated on 7/15/2020 and revised on 4/30/21, identified she was dependent on staff for meeting her emotional, intellectual, physical and social needs. The goal was participation in activities of choice one to three times weekly. Interventions included: enjoys listening to late 50s and early 60s music, visiting with her spouse and spending time on the phone talking with him; riddles and jokes both through books and handouts and spontaneous will be shared; access to telephone at her convenience; converse with resident during care; assist with arranging community activities, arrange transportation; assist/escort to activity functions; one-to-one as needed/requested; activities which do not involve overly demanding cognitive tasks; engage in simple, structured activities; encourage ongoing family involvement; invite her family to attend special events, activities, meals; establish and record prior level of activity involvement and interests by talking with her, caregivers, family on admission and as necessary; introduce to residents with similar background, interests and encourage/facilitate interaction; provide a program of activities that is of interest and empowers resident by encouraging/allowing choice, self-expression and responsibility; provide with a variety of snacks/beverages; provide the opportunity to participate in outdoor activities as weather permits; provide opportunity to participate in religious services; review activities needs with the family; and thank resident for attending activity functions. Resident #33's behavior problem care plan, initiated 7/20/2020 and revised 4/30/21, identified verbal aggression, yelling, impulsive behavior, wandering, resistive to care, throwing self on ground. Interventions included: one-to-one staff redirection, enjoys talking to husband often; administer medications as ordered; intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed; monitor behavior episodes and attempt to determine underlying cause; consider location, time of day, persons involved, and situations; document behavior and potential causes; provide a program of activities that is of interest and accommodates resident's status. Resident #33's cognitive function/dementia care plan, initiated 7/20/2020 and not revised, included these interventions: administer medications as ordered; communicate with resident and husband regarding capabilities and needs; reduce any distractions: turn off TV, radio, close door etc. Resident understands consistent, simple, directive sentences. Provide her with necessary cues-stop and return if agitated. Keep routine consistent with consistent caregivers to decrease confusion. Reminisce with Resident #33 using photos of family and friends. Review of Resident #33's interdisciplinary team (IDT) progress notes for the past six months revealed minimal documentation regarding her behavioral symptoms, dementia care needs, and supervision/engagement. The following pertinent notes were documented: -12/13/21, Resident is active and independent, she has the right to choose which activity she wants to participate in. She participates in 1-3 activities weekly. -12/16/21 at 7:00 a.m., Resident very agitated and kept pulling her clothes off, pulled pants down and took a step before CNA could get to her she fell landing on buttocks, fall witnessed by CNA. Resident did not hit head, no apparent injury noted at this time. -1/16/22 at 1:58 p.m., Resident is very combative. She is refusing to take medication, throwing them on the floor, and spitting them out. She is being physically aggressive. She is cussing and screaming while wandering around the unit. -1/18/22 at 10:36 a.m., Resident continues to act aggressively to staff. Continues to pace, scream, cuss, and yell at staff and other residents. She is refusing to take medication most of the time. She will not redirect. Recommendation: change in medications. -2/3/22 at 9:59 a.m., Resident doesn't participate much in group activities anymore but we are able to still do one on ones with her at this time. -2/17/22 at 1:22 p.m., Food is used with her as a behavioral calming method. -There was no documentation of Resident #33's verbal behaviors, other residents' response to it, or the verbal altercation with Resident #16 on 4/19/22 (see observations above). Behavior documentation on the April 2022 treatment administration record (TAR) revealed the resident was monitored for the following behaviors: (specify) itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care every shift for Zyprexa (antipsychotic), start date 11/10/2020. -However, the resident was taking Ativan, an antianxiety medication, not Zyprexa. Nonetheless, the behaviors were not specified or resident-centered. Nursing staff marked Yes for behaviors 17 times on the day shift, seven times on evening shift, and none on the night shift. -No non-pharmacological interventions were documented on the TAR prior to administering as-needed Ativan. IV. Resident #14 A. Resident status Resident #14, age [AGE], was admitted on [DATE]. According to the April 2022 CPO, diagnoses included dementia with behavioral disturbance and major depressive disorder, single episode, severe with psychotic features. According to her 2/3/22 MDS assessment, she had severe cognitive impairment; delirium symptoms including inattention, disorganized thinking and delusions; behavioral symptoms not directed toward others such as pacing, rummaging and disruptive sounds, but no rejection of care. Her balance was unsteady and she required extensive assistance for dressing, toilet use, hygiene; set up help, supervision, oversight, encouragement and cueing for eating; and supervision, oversight, cueing and physical assistance with ambulating in the corridor. She was frequently incontinent and needed extensive assistance with dressing, toilet use and personal hygiene. She took antipsychotic and antidepressant medications. The preferences that were important to her included caring for her personal belongings, snacks between meals, family involvement, use of the phone in private, reading books/newspapers/magazines, listening to music, being around animals, and spending time away from the nursing home. B. Family interview Resident #14's family member was interviewed on 4/20/22 at 9:25 a.m. Regarding the SCU environment, she said she was concerned about Resident #14's roommate (Resident #33) who seemed to be kind of upset and was yelling all the time, more like talking to herself. She said it was disturbing to her because she is my mother's roommate and that's got to be a little tough. My mom won't sleep in her bed anymore. She said she slept on one of the lounge chairs in the dining room/common area. They kind of let her sleep where she wants to, and I don't know if it has anything to do with the roommate either. I got a glimpse of mom's old personality about a month and half ago when that lady was yelling, not yelling at anybody, just herself or an imaginary person. My mom just looked at me and rolled her eyes. I don't think there's anything to be done about it, I think it's the disease of that lady. She said she was concerned about the antipsychotic medication Resident #14 was taking, and would like to see her off other than pain meds and her antidepressant; I'd like to see how she does off of all of it because I have heard that there are dangers with that stuff and dementia. Regarding activities, she said Resident #14 was not really interested in anything anymore other than walking. She used to like to just sit outside when she was in the assisted living. My understanding is they have a courtyard so I'll see if she'll sit out there with me. She pretty much doesn't really participate in activities. She used to. She said she suggested to the facility that Resident #14 might like a doll to carry around, because she did that at her previous assisted living facility. The family member said Resident #14 started moaning and crying at her previous facility. She had chronic back pain and her knees are like bone on bone. She used to get cortisone shots in her knees but that's not possible anymore. She said the doctors put her on oxycodone and she was initially concerned about opioids but, if that's what it takes for her to have a pain free existence, so be it. She said Resident #14 needed finger foods because she's not one to sit and eat a meal, but needs something she can carry around and [NAME] on. The family member said when she visited Resident #14 in the facility, she still paced but did not moan and cry, possibly because she spoke with her, walked around with her and engaged her. C. Observations Observations of Resident #14 were conducted throughout the survey on the afternoon of 4/18/22, and throughout the day on 4/19, 4/20 and 4/21/22, and included the following of note: On 4/18/22 at 5:00 p.m., the residents on the SCU had been served their dinner. Resident #14 was sitting at a dining room table moaning, holding a cookie and trying to eat spaghetti with her fingers at the same time, while also holding her baby doll. She had a glass of strawberry supplement near her plate. At 5:05 p.m. she was not eating. At 5:06 p.m. she stood up from the table and CNA #1 helped her sit back down and encouraged her to eat. At 5:08 p.m. Resident #14 had finished her strawberry drink but had not eaten anything. At 5:15 p.m. she was moaning and crying, backing her chair away from the table, and had not eaten anything more. At 5:20 p.m. she was walking around the dining room. She had eaten her cookie and drank her supplement but nothing else, and she was not offered finger foods or a different entree. Her spaghetti and sliced zucchini were left on her plate and a few minutes later were scraped into the trash can. At 5:24 p.m. Resident #14 was walking throughout the common area and hallway, moaning and crying, une[TRUNCATED]