**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#7) of seven residents reviewed for medication management were free from significant medication errors out of nine sample residents. Resident #7 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebrovascular disease (a condition that affects the blood vessels in the brain). On 6/20/25 certified nurse aide with medication authority (CNA-Med) #1 administered another resident's medications to Resident #7, including apixaban and clopidogrel (used to prevent blood clots), isosorbide (used to relax and widen the blood vessels and manage chest pain), lisinopril (used to treat high blood pressure), propranolol (used to lower heart rate and blood pressure), quetiapine (used to treat mental health conditions), Percocet (pain medication) and Fioreicet (used to treat tension headaches). The resident began to experience severe hypotension (a dangerously low blood pressure), required supplemental oxygen and was sent to the hospital. The resident received intravenous (IV) fluids, administered medications and was monitored in the intensive care unit (ICU). Specifically, the facility failed to ensure Resident #7 did not receive another resident's (Resident #8) medications. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 7/7/25 to 7/8/25, resulting in the deficiency being cited as past noncompliance with a correction date of 6/23/25.I. Medication error on 6/20/25The facility failed to ensure a licensed nurse administered medications to the correct resident. Resident #7 was administered another resident's (Resident #8) medications, which caused the resident to experience a change in condition and the resident was sent to the hospital for treatment. II. Facility's plan of correctionThe corrective action plan the facility implemented in response to Resident #7's medication error incident on 6/20/25 was provided by the nursing home administrator (NHA) 7/7/25 at 4:02 p.m. The stated purpose of the plan was to address the significant medication error and prevent any additional residents from suffering any adverse outcome.The plan revealed the following:A. Identification of other residentsThe resident (Resident #7) who received the wrong medications was immediately transferred to the hospital.An audit of all residents was conducted to ensure a photo was present in the electronic medical record (EMR). Four residents were identified to have missing photos in their EMRs. The missing residents' photos were uploaded to their EMRs, completed 6/20/25.B. Systemic changesAll applicable facility policies and procedures were reviewed and revised.The director of nursing (DON) reeducated licensed nurses on the facility's policies regarding medication administration and medication error reporting. All nursing staff were educated prior to working their next shift, completed 6/23/25.The DON completed corrective action and one-to-one education with registered nurse (RN) #1, completed 6/21/25. All nurses and CNA-Meds received a competency observation related to medication administration prior to working their next shift, completed 6/23/25.C. MonitoringThe DON or designee would observe medication administration five times per week for four weeks, then weekly for eight weeks. Observations would occur across shifts and with various staff members.The activity director or designee would audit resident photos in the EMR weekly to ensure all newly admitted residents had photos in their chart. The NHA implemented a performance improvement plan as a means to gather and process information from the audit. Findings would be reported at the monthly quality assurance meetings for a minimum of three months.The facility's determined date of compliance was 6/23/25.III. Professional referenceAccording to [NAME], P.A., [NAME], A.G et.al,, Fundamentals of Nursing, 10th ed., Elsevier, St. Louis, Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications:1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentation7. The right indication.IV. Facility policy and procedureThe Medication Administration policy, revised 6/20/25, was provided by the NHA on 7/7/25 at 4:02 p.m. It read in pertinent part, Identify resident by photo in the MAR (medication administration record).Ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time and right documentation.V. Resident #7A. Resident statusResident #7, age less than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis following cerebrovascular disease, depression and arthritis.The 6/11/25 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status (BIMS) assessment score of 14 out of 15. The assessment documented the resident needed supervision to substantial assistance from staff for most activities of daily living (ADL).B. Resident interviewResident #7 was interviewed on 7/7/25 at 2:08 p.m. Resident #7 said he went to the hospital recently. Resident #7 said he had just woken up and a nursing staff member came into his room and had a medication cup in her hand. Resident #7 said he thought the nursing staff member had mentioned his name but he was not sure. Resident #7 said when he took the medications, he had a hard time getting them washed down. Resident #7 said he quickly felt out of it and really sleepy. Resident #7 said if Resident #8 had not said something to the nurses he would have been dead. Resident #7 said he felt like he had been slapped in the head with a hammer after taking the medications. Resident #7 said he was always worried something like the incident would happen again. Resident #7 said he was blind in his right eye and could not see very well, so he had no idea there were more medications than usual in his medication cup until he swallowed them. Resident #7 said he had started looking at the medication cups and asking the nursing staff if the medications were his since the incident occurred. Resident #7 said he was worried because the doctors at the hospital said his blood pressure dropped so low it could lead to damage to his organs in the future.C. Record reviewThe June 2025 CPO revealed Resident #7 had physician's orders for the following daily scheduled medications: atorvastatin (used to treat high cholesterol) 20 milligrams (mg), empagliflozin (used to manage diabetes) 25 mg, fluoxetine (used to treat depression) 40 mg, gabapentin (used to treat nerve pain) 600 mg and 900 mg, sitagliptin (used to manage diabetes) 100mg, hydrocodone-acetaminophen (used to treat chronic pain) 10-325 mg and loperamide (used to treat diarrhea) 2 mg.-Resident #7 did not have physician's orders for apixaban, clopidogrel, isosorbide, lisinopril, propanolol, quetiapine, Percocet or Fioricet. A progress note, dated 6/20/25 at 9:15 a.m., revealed Resident #7 had a change in condition. Resident #7 had a blood pressure of 68/42 millimeters of mercury (mmHg) and an oxygen saturation (level of oxygen in the blood) of 74 percent (%). Resident #7 was receiving oxygen via a mask. Resident #7 had an altered level of consciousness; the resident was hyperalert and drowsy. Resident #7 was assessed by a registered nurse (RN) at his bedside, was placed in the Trendelenburg position (a body position used to help stabilize blood pressure) and was receiving 15 liters of oxygen via a non-rebreather mask. Emergency services arrived, began intravenous (IV) fluids and Resident #7 was transferred to the hospital.A physician's note, dated 6/20/25 at 9:29 a.m., revealed the physician was contacted at 9:13 a.m. on 6/20/25 and was notified Resident #7 had been administered the incorrect medications. The physician was onsite at the time and met with the nursing staff to go over what medications were administered to Resident #7. Resident #7 was given his prescribed morning medications along with apixaban 5 mg, clopidogrel 75 mg, isosorbide 30 mg, lisinopril 20 mg, propranolol 10 mg, quetiapine 75 mg, Percocet 5-325 mg and 50-325-40 mg. The physician assessed Resident #7 and found he was diaphoretic (excessively sweating) and was not feeling well. Resident #7's systolic blood pressure was in the 70s over a diastolic blood pressure in the 50s, his pulse was 110 beats per minute (bpm) and his oxygen saturation on room air was 80%. The physician documented these symptoms were likely due to the vasodilatory effect (when blood vessels widen causing increased flow of blood) of isosorbide. The physician requested emergency services be called so the resident could be transferred to the hospital for blood pressure support. Resident #7 was provided with supplemental oxygen and ultimately required 15 liters of oxygen via a nonrebreather mask in order to maintain his oxygen saturation. Resident #7 was placed in the Trendelenburg position which brought his blood pressure up to 89/59 mmHg and his pulse to 102 bpm. The note documented the physician contacted poison control and discussed the medications Resident #7 was administered. The poison control center advised the physician tha the isosorbide likely caused the vasodilation (widening of the blood vessels) and lowered Resident #7's blood pressure. A progress note, dated 6/20/25 at 10:05 a.m., revealed at 9:10 a.m. on 6/20/25 Resident #7 had a low blood pressure of 68/42 mmHg and appeared diaphoretic and lethargic. Resident #7 was responsive to verbal stimuli and said he just felt very sleepy. The DON and Resident #7's physician was notified at 9:14 a.m. Resident #7 was placed in the Trendelenburg position and his blood pressure came up to 88/65 mmHg at 9:20 a.m. Emergency services were contacted at 9:26 a.m. and arrived at the facility at 9:40 a.m. The emergency services immediately began administering IV fluids. Resident #7 was transferred to the hospital at 9:55 a.m. for hypotension (low blood pressure). A progress note, dated 6/21/25 at 11:38 a.m., revealed Resident #7 arrived back to the facility from the hospital and was assessed by the RN upon arrival. Resident #7 said he felt well and was happy to be back at the facility.Hospital notes, dated 6/21/25, revealed Resident #7 was admitted to the hospital on [DATE] after receiving the wrong resident's medications. Resident #7 was administered a number of medications in addition to his normal morning medications. Resident #7 was treated for iatrogenic shock (a life-threatening condition where blood pressure is too low to deliver enough oxygen to organs) and required pressor support (medications administered intravenously to increase blood pressure in patients experiencing hypotension or shock) to maintain adequate blood pressure for less than 24 hours. Resident #7 felt okay with returning to the facility despite the error. An interdisciplinary team (IDT) note, dated 6/23/25 at 10:02 a.m., revealed Resident #7 was inadvertently administered his roommate's (Resident #8's) medications on 6/20/25 at 7:45 a.m. The root cause identified was there was a new CNA-Med (CNA-Med #1) who was training and did not perform the two identifiers. Additionally, Resident #7's picture was not updated in the resident's chart. Preventative measures in place prior to the incident included having a registered nurse (RN) provide oversight for training the CNA-Med, Resident #7's name was on the door and the MAR was accurate with the resident's name and room number. New interventions included retraining all nursing staff on passing medications, including the six rights policy, medication error reporting process and using the two identifiers. A full audit was conducted on all nursing staff passing medications immediately prior to their next shift. CNA-Med #1 was suspended pending the incident investigation and the RN that was training CNA-Med #1 (RN #1) was reeducated as a corrective action.A medication error report, undated, revealed Resident #7 experienced a medication error on 6/20/25 at 7:30 a.m. The error was discovered at 7:45 a.m. by CNA-Med #1. Resident #7 was inadvertently given his roommate's medications by CNA-Med #1, who did not ask his two identifiers and addressed the resident by the wrong name. CNA-Med #1 said Resident #7 did not correct her when she addressed him by the wrong name. Contributing factors included lack of staff concentration, inexperienced staff and it being the trainee's (CNA-Med #1) first day with the trainer (RN #1) not being with her at bedside when the medications were administered. Resident #7 became hypotensive (low blood pressure) and hypoxic (low oxygen) and was sent to the hospital for treatment with fluids and pressors for support until the medications were no longer in his system. Resident #7 required 15 liters of oxygen with a nonrebreather mask, was placed in the Trendelenburg position, and required pressors and fluids in the ICU for several hours. Resident #7 was stabilized at the hospital and was admitted back to the facility the next morning (6/21/25).VI. Resident #8 interviewResident #8 was interviewed on 7/7/25 at 1:52 p.m. Resident #8 said Resident #7 was his roommate. Resident #8 said he took several medications including lisinopril, blood thinners, Seroquel (quetiapine), Percocet and oxycodone. Resident #8 said the nursing staff gave Resident #7 his medications by mistake and his blood pressure dropped really low. Resident #8 said he left the room and told the nurse Resident #7 had taken his medications by mistake and was acting funny. Resident #8 said Resident #7 kept saying he was tired.VII. Staff interviewsCNA-Med #1 was interviewed on 7/7/25 at 1:01 p.m. CNA-Med #1 said she arrived at the facility at 6:00 a.m. on 6/20/25 and waited at the nurse's station for thirty minutes for RN #1 who was supposed to train her. CNA-Med #1 said she and RN #1 started passing medications and RN #1 went through medications with her and let her pop medications out of their blister packs. CNA-Med #1 said she went into Resident #8's room with his medication cup in her hand. CNA-Med #1 said she addressed the resident who she thought was Resident #8 by name and administered his medications. CNA-Med #1 said she figured out her error when she went to administer Resident #7's medications and Resident #8 told her he could administer the medications to his roommate. CNA-Med #1 said she did not give Resident #7 his medications and went to the nurse's station to tell RN #1 what happened. CNA-Med #1 said RN #1 contacted the DON and assessed Resident #7's vital signs.CNA-Med #1 said that morning (6/20/25) was her first time ever administering medication and that she had not received any training prior to that morning on medication administration. CNA-Med #1 said RN #1 was using his cellphone and was not really paying attention to her that morning. CNA-Med #1 said she had taken her training for her medication authority two years prior but worked in a setting in which she did not get to pass medications.CNA-Med #1 said RN #1 had her continue to pass medications after the incident but she did not feel comfortable with doing so. CNA-Med #1 said the facility was going to have her come in to do training after the incident, but she said she later received a phone call to inform her she was relieved of her duties.RN #1 was interviewed on 7/7/25 at 1:21 p.m. RN #1 said he arrived at the facility that morning (6/20/25) and was not aware he was going to be training someone. RN #1 said CNA-Med #1 said she was a medication aide. RN #1 said CNA-Med #1 had worked at the facility for two weeks prior as a CNA and she had worked with him on Resident #7's unit the week prior. RN #1 said two other residents had to leave the facility for an outing and the bus was due to take off soon, so their morning was starting with a rush. RN #1 said the nurse from the previous shift administered medications to one of the residents leaving for the outing. RN #1 said he pulled medications for the other resident, checked them against the MAR, and wrote the resident's name on the cup. RN #1 said he observed CNA-Med #1 as she took the medication cup, asked the other resident his name and administered the medications to him. RN #1 said he showed CNA-Med #1 the facility's procedure for medication administration, got her familiar with the medication cart and let her get medications ready for the next residents. RN #1 said when it was time for Resident #8 to get his medications, CNA-Med #1 wrote the resident's name and room number on the medication cup and got his medications ready by cross-referencing the MAR. RN #1 said Resident #8 had almost 20 medications, so CNA-Med #1 took about 15 to 20 minutes to get the medications ready. RN #1 said he asked CNA-Med #1 if she felt comfortable giving Resident #8 his medications and CNA-Med #1 said she was and went to administer them. RN #1 said the medication cart was on the secured unit and Resident #8's room was on a different hallway, so CNA-Med #1 left the secured unit and administered the medications on the other hallway before returning to the secured area. RN #1 said he and CNA-Med #1 continued passing medications to other residents before getting to Resident #7. RN #1 said CNA-Med #1 prepared Resident #7's medications correctly, wrote his name and room number on the medication cup and went to the other hallway to administer the medications. RN #1 said CNA-Med #1 returned to the medication cart and initially lied to him and said Resident #7 took Resident #8's medications himself. RN #1 said CNA-Med #1 told him she handed Resident #8's medications to the resident, he set the medications on his bedside table, and Resident #7 must have taken them when she left the room. RN #1 said he tried to clarify the story with CNA-Med #1 but was not able to figure out what actually happened. RN #1 went into Resident #7 and Resident #8's room and spoke with them. RN #1 said the residents told him CNA-Med #1 walked into their room and gave Resident #7 the cup with Resident #8's medications. RN #1 said he realized Resident #8 took a lot of blood pressure medications, so he began taking vital signs on Resident #7. RN #1 said Resident #7 started to get fairly sleepy and his vital signs slowly started decreasing. RN #1 said he spoke with the DON who came and assessed the resident. RN #1 said while the DON was assessing Resident #7 he called emergency services. RN #1 said while these assessments were occurring, CNA-Med #1 was sitting in the DON's office.RN #1 said at other facilities he had worked at, he had gone through orientations on how to become a trainer, but had not received any information on how to train someone at the facility. RN #1 said he spoke with the DON after the incident and she told him he should have followed CNA-Med #1 and watched her pass medications. RN #1 said he asked the DON how many medication administrations he should have watched CNA-Med #1 for, but he said she could not provide a number, as there was no formal training program at the facility. RN #1 said he had assumed CNA-Med #1 would ask the residents their names.RN #1 said he had worked at the facility for four months prior to the incident. RN #1 said for medication administration he asked the residents their name and birthdate and confirmed their identity based on the picture in the resident's EMR. RN #1 said for residents with memory impairments, he would confirm the resident's identity by asking other staff members. RN #2 was interviewed on 7/7/25 at 2:53 p.m. RN #2 said she had worked at the facility since February 2025. RN #2 said she received three days of orientation when she first started working at the facility. She said during orientation, they went through a checklist of skills, including the six rights of medication administration. RN #2 said she had trained some new staff members since she started, but they were not new nurses, just nurses that were new to the facility. RN #2 said she had not received any training on how to train these newly hired staff, but would take the new person for a shift and go through the staff member's checklist with them. RN #2 said that was how she was trained her first few days. RN #2 said as a nurse, she was responsible for the CNA-Meds' actions. RN #2 said when she had a CNA-Med she knew she needed to make sure they were safe and did not overstep their scope of practice. RN #2 said CNA-Meds needed to know the six rights and administer medications as ordered to avoid any medication errors. RN #2 said if a medication error did occur, she needed to contact the DON and inform her of the error and follow any instructions the DON gave.CNA-Med #2 was interviewed on 7/8/25 at 10:01 a.m. CNA-Med #2 said for medication administration, she made sure she was administering the right medication to the right person at the right time. CNA-Med #2 said she had received training through an online training application on medication administration on the six rights, including right name, right date, right route. CNA-Med #2 said she had received a lot of training in-person lately on medication administration. CNA-Med #2 said she had not had to train anyone else on medication administration. CNA-Med #2 was interviewed a second time on 7/8/25 at 3:04 p.m. CNA-Med #2 said she checked the resident's name against the medication card and the chart when preparing medications. CNA-Med #2 said she then asked the resident what their name and date of birth were before administering their medications to ensure she correctly identified the resident.The DON and the regional nurse consultant (RNC) were interviewed together on 7/8/25 at 10:59 a.m. The DON said newly hired staff had an orientation and required training they needed to complete prior to working on the floor. The DON said once newly hired staff were on the floor, they had a competency checklist that their preceptor would go through and sign off on once each competency was completed. The DON said she had initiated an orientation process at the facility in which newly hired staff were taught the facility's rules and regulations.The DON said nurse preceptors or trainers were the most seasoned nurses, and were usually staff members who had been at the facility for a long time. The DON said she planned to develop a training plan for preceptors but had not yet launched one. The DON said training oversight was provided by herself and the assistant director of nursing (ADON). The DON said she or the ADON would check in daily and touch base with the staff member in training and their preceptor to see how they were doing. The DON said nurses and CNA-Meds needed to utilize the six rights of medication administration and use two identifiers. The DON said she did not think the facility had any formal training processes for medication administration, but it was in the checklist of competencies used for training newly-hired staff. The DON said precepting nurses were guided by the competency checklist and needed to have the training staff member give a verbal walkthrough or demonstration back to the preceptor to be signed off on the competency. The DON said for medication administration, the nurse or CNA-Med needed to have their computer open to the resident's EMR and check to make sure each medication was being passed to the right resident, medication, dose, route, time, and the correct documentation. The DON said the nursing staff member used those rights to check each medication against the MAR. The DON said the nursing staff member then used two identifiers to administer the medication to ensure it was the correct resident. The DON said the identifiers included asking the resident to say their name and date of birth , unless the resident needed different identifiers due to cognitive decline. The DON said in cases of cognitive decline, nursing staff could identify residents based on their photo in their EMR or confirm the resident's identity with other staff members. The DON said CNA-Meds and nurses were expected to know these steps from their schooling prior to being hired, and that medication administration was part of their competency checklist. The DON said it was important to keep the residents safe and ensure they did not get the wrong medications.The DON said on the morning of 6/20/25 CNA-Med #1 was training with RN #1. The DON said it was CNA-Med #1's first day on duty as a CNA-Med, but she had worked at the facility prior to the incident as a CNA. The DON said there were two residents going on an outing that morning, so RN #1 pulled the medications for the two residents that were going on the outing and observed CNA-Med #1 administer the medications to the resident. The DON said RN #1 watched a few more medication passes CNA-Med #1 performed and had her pull medications from the cart so she could use the six rights. When Resident #8's medications came up, CNA-Med #1 said she felt comfortable with administering the medications and knew the resident. The DON said CNA-Med #1 went into Resident #8's room and addressed the resident she thought was Resident #8 by calling him by his name. The DON said Resident #7 did not correct CNA-Med #1 when she called him by Resident #8's name, so she administered the medications and left the room. The DON said CNA-Med #1 did not ask Resident #7 his name or date of birth . The DON said CNA-Med #1 and RN #1 continued passing medications, and when Resident #7's medications came up and CNA-Med #1 tried to administer them the error was discovered. The DON said Resident #8 said CNA-Med #1 could give his roommate (Resident #7) his medications and identified himself as Resident #8. The DON said CNA-Med #1 did not administer Resident #7's medications and alerted RN #1 to the error. The DON said CNA-Med #1 told RN #1 something about setting the medications down on a table, and RN #1 figured out there was a medication error so he looked to see what medications Resident #8 took and left to assess Resident #7. The DON said she arrived at the facility at around 8:30 a.m. on 6/20/25. The DON said Resident #8 came to her office and told her Resident #7 had received his medications and that Resident #8 was worried about him. The DON said she went to assess Resident #7, who at that point was stable, but said he was a bit sleepy. The DON said she went to RN #1 who was talking with CNA-Med #1 to determine what happened, and the DON had RN #1 call Resident #7's family. The DON said she found the physician was in the building and brought the physician to Resident #7's bedside. The DON said her biggest concern at that point was the heart medications Resident #7 had received. The DON said they had taken a manual blood pressure and found Resident #7 had a blood pressure of 68/42 mmHg and his oxygen saturations were low. The DON said the facility staff put Resident #7 in the Trendelenburg position and gave him supplemental oxygen with a nonrebreathing mask. The DON said Resident #7's blood pressure rose to the 80s and his oxygen saturations improved. The DON said emergency services showed up shortly thereafter and started IV fluids.The DON said CNA-Med #1 did not continue to pass medications after the medication error was discovered. The DON said CNA-Med #1 was in her office panicking and the DON sent her home. The DON said Resident #7 returned to the facility the next morning (6/21/25). The DON said the facility staff had called poison control and the poison control consultants were not worried about any of the other medications' side effects aside from the isosorbide, as that medication caused blood pressures to drop. The DON said Resident #7 needed IV pressors which could only be given in the ICU. The DON said Resident #7 had not had any health outcomes related to the medication error since his return to the facility. The DON said the facility, immediately after the error occurred, started reeducating the nursing staff on medication administration, including the six rights and using two identifiers, and medication error reporting. The DON said she also reviewed preceptor expectations with the nursing staff. The DON said she and the ADON monitored and audited medication administrations for each nursing staff member prior to their next shift. The DON said RN #1 may have precepted at the facility prior to the medication error but she was not sure. The DON said there had not been any training on the expectations of preceptors at that point. The RNC said she thought seasoned nurses would know how to teach newly hired staff.The pharmacy consultant was interviewed on 7/8/25 at 2:29 p.m. The pharmacy consultant said the pharmacy was contacted on 6/20/25 at 3:17 p.m. via email regarding Resident #7 getting another resident's medications. The pharmacy consultant said the facility asked the pharmacy about signs and symptoms to look for given the medications Resident #7 received and any possible interactions. The pharmacy consultant said Resident #7 was given quite a few hypertension medications (medications used to lower blood pressure). The pharmacy consultant said the pharmacist on call told the facility to monitor Resident #7's blood pressure for any signs or symptoms of hypotension and to notify the physician if those occurred. The pharmacy consultant said the pharmacist on call told the facility to monitor for signs or symptoms of bradycardia (slow heartbeat), bleeding, falls and respiratory suppression with the other medications Resident #7 received.The pharmacy consultant said she recommended the nursing staff administering medications check the name of the resident against the card of medications, the resident's chart and the resident's date of birth . The pharmacy consultant said in cases of medication error, the usual procedure was to contact the physician first, which is what the facility did, and wait to notify the pharmacy. The pharmacy consultant said since the physician was in the facility at the time the error occurred, the physician immediately sent Resident #7 to the hospital. The pharmacy consultant said if the situation had not been so serious, the nursing staff would have contacted the physician then contacted the pharmacy sooner. The DON and the NHA were interviewed together on 7/8/25 at 4:11 a.m. The DON said RN #1 was educated on medication administration prior to his dismissal. The DON said CNA-Med #1 was sent home on 6/20/25 and did not return to the facility. The DON said all floor nursing staff were educated on medication administration by 6/23/25. The DON and the NHA said the incident with Resident #7 occurred on 6/20/25 and they started educating staff on medication administration that day. The NHA said the facility administration team immediately met to discuss training and how to proceed. The NHA said the quality assurance and performance improvement (QAPI) team met on 7/2/25 and discussed the incident and how to move forward during the meeting.The NHA said the total completion date of their performance plan was 6/23/25, which included observations and auditing of medication administration, education and inservicing of the nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (#3) of three sample residents. Resident #3 was initially admitted on [DATE] and readmitted on [DATE]. The resident was at a high risk for falls related to being unaware of safety needs, paralysis, deconditioning, poor communication/comprehension, vision/hearing problems, gait/balance problems and incontinence. The resident was a substantial maximum assist of one staff member when the resident was able to use the bedside transfer pole. If the resident was unable to use the transfer pole, the staff were to use two staff persons with a Hoyer (mechanical) lift for transfers. The resident had a witnessed fall (lowered to the ground) during a transfer with the use of the transfer pole and one certified nurse aide (CNA) on 11/19/23 at 2:16 p.m. The resident was not assessed by a registered nurse (RN) before the resident was lifted from off the floor with a Hoyer lift and positioned into a chair. There was no documentation of injuries at the time of the fall. On 11/20/23 at 11:45 a.m., a nurse wrote that the resident complained of pain (10:30 a.m.) in the right leg, the right knee was swollen and painful to the touch. The nurse practitioner (NP) was contacted to determine the course of action. The NP ordered an x-ray of the resident's right hip and knee related to pain in these areas. The x-ray was taken at 4:23 p.m. (approximately four hours and 45 minutes later). At 5:00 p.m., the NP assessed the resident and reviewed the x-rays (approximately 24 hours after the fall). A fracture of the right femur was identified. The NP ordered the resident to be taken to the hospital using non-emergency transport. The transport service arrived at 5:20 p.m. and took the resident to the hospital. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 12/18/23 and 12/19/23, resulting in the deficiency being cited as past noncompliance with a correction date of 12/1/23. I. Facility action to 11/19/23 fall The Employee Huddle/Coaching for all nursing staff and leadership related to fall protocol was dated 11/20/23 (not timed) with signatures. The information that was presented included: after a fall, staff were to immediately notify a nurse; a registered nurse (RN) must assess the resident before staff assist the resident up from the floor; a total lift must be used to get the resident up; and neurological assessments were to be initiated for any falls, unless it was witnessed and there was no head involvement. For nursing staff: the RN in the building must assess the resident after a fall prior to assisting the resident up from the floor; a licensed practical nurse (LPN) may complete the risk management; a RN must place a note in the resident's chart of their assessment, a Fall Risk assessment must be completed after every fall; the provider/family must be notified after every fall and place this information in Risk Management; call the director of nursing (DON) for all falls; if injury or pain were noted, administer pain medication and obtain an order for x-rays as needed; and make sure this all information goes in your nursing note. The Action Plan for RN Assessment after a fall/fall process identified on 11/20/23. The identified concern was that during review of incidents, it was identified that a resident had a documented fall and the RN assessment was not documented. Plan one: reeducation was initiated with the nursing staff responsible for the documentation in regards to community expectations for documentation of assessment after a fall by a RN. The corrective action taken was education to nursing staff and was completed on 12/1/23. Plan two: the director of nursing ( DON) or designee was to audit all falls during clinical morning meetings to ensure a RN assessment was completed. If no RN assessment was documented, a late entry would be added. The corrective action taken was education to nursing staff and was completed on 12/1/23. Plan three: if a resident was noted to be on the floor, or had a change of plane, the resident should not be moved from that position until the RN completed an assessment. The nurse must be notified of the fall immediately, no one should get the resident up without a completed nurse assessment. The corrective action taken was education to nursing staff and was completed on 12/1/23. Plan four: the DON or designee would report the findings from the audits to the quality assurance performance improvement (QAPI) committee monthly for 90 days. The QAPI committee would identify any trends and take corrective action as needed. Agency staff would be educated to the process as it related to resident falls. This corrective action was ongoing until substantial compliance was achieved. II. Facility policy and procedure The Fall Management policy, dated 3/10/23, was provided by the DON on 12/19/23 at 11:51 a.m. The policy revealed the purpose of this fall management policy was to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. A fall reduction program would be established and maintained, to assess all residents to determine their risk for falls. A plan of care would be implemented based on the resident's assessed needs. Individualized care plan interventions would be implemented for those residents found to be at high risk for falls. The resident and the resident representative (if applicable) would be invited to all care plan meetings. Please note, interventions were to be re-evaluated when a resident fell for efficacy. Interventions that might be considered after identification of the root cause of a fall: assess the environment and make appropriate changes, bed in lowest position, placement of furniture, lighting personal items within reach, non-slip footwear, night light, walker, and wheelchair within reach if applicable. The call light and fluids should be within reach of the resident. Positioning devices (low bed, fall mat, defined perimeter mattress, cushions, seating system, wedges, pillows, and bolsters) utilized when applicable. Complete a thorough analysis of the fall to include the time of day, location of fall, and causative factors. Identify whether interventions were in place at the time of the fall. Interview staff and the resident if applicable to identify potential causative. The facility would review all falls during the morning QAPl meeting (Monday through Friday). A falls review would include the following: a review the Risk Management Incident form to ensure complete and appropriate parties were notified regarding the incident; review the interdisciplinary team (IDT) Risk Management form to ensure complete and appropriate interventions have been implemented; review that a care plan had been initiated; and provide revisions to the plan of care as necessary after falls. III. Resident #3 A. Resident status Resident #3, age [AGE], was initially admitted on [DATE] and readmitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included displaced comminuted fracture of the shaft of the right femur (hip), cerebral infarction (stroke) due to occlusion or stenosis of a cerebral artery, hemiplegia (paralysis) affecting right non-dominate side, abnormal posture, muscle weakness, mobility abnormalities, apraxia/aphasia (disorder of the brain) following cerebrovascular disease, attention and concentration deficit following cerebrovascular disease. The 11/30/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15 with no behaviors. The resident needed staff assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation or injury (dependent-a helper completed all of the activities for the resident). The resident's upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) were impaired on one side. The resident had additional diagnoses of fractures and other multiple trauma. IV. Record review Transfer Pole consent form was signed by the resident on 1/10/23. Care plan for a high risk for falls related to being unaware of safety needs, paralysis, deconditioning, poor communication/compression, vision/hearing problems, gait/balance problems and incontinence was revised on 4/20/21. The pertinent interventions were to ensure proper positioning in bed and wheelchair to reduce falls, encourage the resident to lay down and rest when fatigued. An intervention initiated on 8/29/23 was for two staff persons to assist with transfers. Fall risk assessment dated [DATE] at 2:36 p.m. was 18 or a high fall risk. Care Plan for activities of daily living (ADLs) for self-care performance deficit related to a stroke, limited ranges of motion, fatigue, musculoskeletal impairment, hemiplegia, activity intolerance, limited mobility, history of cerebrovascular accident, confusion, pain in the back, and impaired balance was initiated on 5/14/15. A revision on 12/12/23 revealed a recent decline with ADL/transfers related to a femur fracture. Some of the interventions included to encourage active participation in tasks, provide cuing with tasks as needed, encourage the resident to participate to the fullest extent possible with each interaction, and praise all efforts of self-care. Transfer pole to aid in transfers was revised on 11/10/22. Substantial maximum assistance of one staff member if the resident was able to use the transfer pole was initiated on 11/19/19 and revised on 12/12/23. Staff were to use a Hoyer lift for safety until therapy recommendation with two staff initiated on 11/19/19 and revised on 12/12/23. Incident report for a witnessed fall on 11/19/23 at 2:16 p.m. This writer (LPN) came back from break and was informed the resident had been lowered to the floor during transfer by a CNA. The CNA said during the transfer, the resident pushed back and had to be lowered to the floor. The resident was assessed by this writer immediately upon arrival back to the area. The resident had no apparent injuries at his time. The resident was unable to give a description of the incident. The resident was helped off of the floor using a lift and placed into a chair. The resident sat up in a chair and was watching television. A physician was notified at 2:50 p.m. and the resident's son was notified at 2:53 p.m. Pain assessment dated [DATE] at 2:41 p.m. revealed a pain scale of 3 out of 10 (with 10 being the worse pain). The resident's acceptable pain level was 3 out of 10. A typed note by the DON revealed that on 11/20/23 at approximately 10:35 a.m., she spoke with LPN #2 related to the resident's swollen leg and the concern for a potential injury. A plan was discussed to call the resident's provider, notify them of the findings and ask if an x-ray would be appropriate. This typed note was dated 12/19/23 (not timed). Nurse note dated 11/20/23 at 11:45 a.m. by LPN #2 revealed the resident complained of pain in the right leg this morning. An as needed Hydrocodone-Acetaminophen tablet (analgesic) was administered to the resident this morning with her morning medications. At 10:30 a.m., the resident complained of pain in the same leg. The resident's knee was swollen and painful to the touch. The nurse practitioner (NP) was contacted to determine the course of action. The NP ordered an x-ray of the resident's right hip and knee related to pain in these areas. The resident's son was notified. Orders administration note dated 11/20/23 at 2:18 p.m. revealed an as needed Hydrocodone-Acetaminophen tablet (analgesic) was administered to the resident. It was ineffective and a follow up pain scale was 7 out of 10 (severe pain). Nurse note dated 11/20/23 at 4:54 p.m. by LPN #2 revealed the NP was at the facility and reviewed the resident's x-rays. The NP said there was a femur fracture. The resident's son was contacted and agreed for the resident to be sent to the emergency room using non-emergent services. Physician order dated 11/20/23 at 4:55 p.m. noted okay to send to the emergency room for evaluation. NP progress note dated 11/20/23 at 5:00 p.m. revealed this was a resident visit due to right knee pain. The NP opted to order an x-ray of the right hip and knee. This may be done using a portable unit at the facility. The resident was resting comfortably in bed and did not appear to be in any acute distress. Will base further treatment on the x-ray results, when available. Nurse note dated 11/20/23 at 5:35 p.m. revealed resident transported to the emergency room at 5:35 p.m. Nurse note dated 11/20/23 at 5:53 p.m. by LPN #2 revealed at 6:00 a.m. this nurse did not receive a report of this resident having been lowered to the floor the previous day (11/19/23). At 8:00 a.m., the resident was administered morning medication and complained of pain in her right leg with frequent complaints of pain the past morning. An as needed Hydrocodone-Acetaminophen tablet (analgesic) was administered to the resident. This LPN noted in the resident's chart, that the resident had a witnessed fall at approximately 9:00 a.m., on 11/19/23. The LPN went back into the resident's room around 10:30 a.m., to observe the effect of the as needed analgesic medication. The resident was awake and in pain. The bed sheets were off of the resident's leg and the right leg looked crooked. The resident's pedal pulses were assessed and were within normal limits. The right leg was cool to the touch and there was swelling around the knee. The DON was notified and wanted an x-ray to be done. This LPN asked if the resident should be sent to the emergency room, just in case the resident's leg was broken or should an in-house stat (immediate/rush) x-ray be performed. The LPN wrote that stat x-rays have taken upward of four hours to receive. The DON related to the LPN that it would be faster to do an in-house x-ray. The LPN notified the NP. The NP ordered a stat x-ray of the right hip and knee due to pain. The resident's son was notified, was okay with the orders and wanted updates. This LPN went back to the resident's room after lunch for the 2:00 p.m., medication administration. A member of social services was with the resident and the resident was complaining of pain in her right leg. The resident was administered another as needed Hydrocodone-Acetaminophen tablet (analgesic) with her other medications. It had been six hours since her first pain medication of the day. The resident slept on and off for the next two hours and still complained of pain in the right leg. At 2:30 p.m., this LPN came back to complete the resident's last medication administration for this shift. The x-ray technician had just completed taking the ordered x-rays. The technician notified this LPN that he/she wanted to view the resident's x-rays and acknowledged that he/she was not a radiologist. The x-rays revealed an apparent fracture of the right femur, with soft tissue swelling. This LPN notified the DON. The DON requested the NP review the x-rays and told the LPN not to call the family, until an official diagnosis of the x-rays was provided. This LPN was worried about it taking overnight (diagnosis results), when an apparent break was visible. The NP was in the facility and this LPN went to the provider's facility office to let her know what the x-ray looked like. The NP reviewed the x-rays and this LPN notified the resident's son. The son was notably upset. This LPN was told to call for a non-emergent ambulance for the resident. This LPN got all paperwork ready, called for a non-emergent transport and showered the resident's the x-rays, to help her understand why she was being sent to the emergency department. The DON and family were notified of the transfer. At 5:20 p.m., the non-emergent transport arrived at the facility. The non-emergent transport staff were upset that 911 had not been called to transport the resident related to a known fracture and the need for stabilization. Hospital admission history and physical dated 11/20/23 at 11:47 p.m. revealed the resident fell during a transfer. The resident was able to stand up on her own and was holding on to a pole. The resident decided to sit down and was assisted to the ground; unclear as to when the trauma happened. The resident's son reported that the resident was not assessed for 28 hours. The resident sustained a fall on 11/19/23 at her nursing facility. On 11/20/23 the resident was found to have the inability to ambulate, with a shortened and rotated right leg. The radiology report dated 11/20/23 at 4:23 p.m. revealed a nearly complete displaced distal femur metadiaphysis fracture. Hospital Discharge summary dated [DATE] at 11:41 a.m. revealed the reason for hospitalization was a right hip fracture requiring acute intervention. The resident came to the hospital from an outside long-term care facility after experiencing a fall. The resident fell after trying to sit down on her own at the facility and was not evaluated for two days. The resident was a one-person wheelchair assist to a wheelchair at baseline. Upon presentation, x-ray showed a displaced fracture of the right femur. Orthopedics was consulted and performed an acute open reduction and internal fixation (ORIF) in the operating room with a successful surgery. Fall Risk assessment dated [DATE] at 3:32 p.m. noted a score of 12 or high fall risk. A physician progress note dated 12/14/23 at 2:39 p.m. revealed the staff requested the resident be seen today. The resident was a chronic long term care resident at the facility with a post cerebrovascular accident with right hemiparesis. The resident fell with a resultant right femur fracture. The resident had chronic pain. Care plan for alteration in musculoskeletal status related to fracture of the right femur was initiated on 12/12/23. Some of the interventions were for staff to anticipate and meet the resident's needs. Staff were to ensure the call light was within reach and respond promptly to all requests for assistance. Staff were to follow physician orders for weight bearing status. Staff were to monitor and document the risk for falls. The staff were to educate the resident/family/caregivers on safety measures that needed to be taken in order to reduce the risk for falls. Staff were to monitor/document/report as needed any signs or symptoms or complications related to arthritis, joint pain, joint stiffness (usually worse on wakening), swelling, decline in mobility, decline in self-care ability, contracture formation/joint shape changes, Crepitus (creaking or clicking with joint movement); and/or pain after exercise or weight bearing. IV. Staff interviews The director of rehabilitation (DOR) was interviewed on 12/19/23 at 8:25 a.m. She said she had provided services to the resident. She said the resident received physical therapy services on 11/30/23 related to a right distal femur fracture. She said the resident continued to receive services at this time. She said the resident's right side was impaired. She said at present, the resident did passive ranges of motion to the lower extremities, strength exercises, leg exercises and standing. She said before the resident fell, she had a ceiling to floor transfer pole to aid in transfers. The DOR said the resident was able to hold on to the transfer pole with her left hand and pivot to a chair with two staff members present. She said therapy recommended the facility use a Hoyer lift with this resident. She said the resident was a two person transfer with a Hoyer lift. A review of the physical therapy notes revealed the resident was a moderate assist with two staff persons for safety reasons. She said in the past six months, the resident needed two staff persons for transfers related to the resident being a moderate assist about 50% of the time. The MDS coordinator was interviewed on 12/19/23 at 8:48 a.m. She said the current MDS section GG (functional abilities and goals) did not specify the number of staff to use for a transfer. The staff would ask and assess the resident to determine the specific methodology to use for a transfer. LPN #2 was interviewed on 12/19/23 at 9:10 a.m. She said the resident had a transfer pole in her room, could stand up and pivot by herself. She said some days she needed one staff person to help transfer and this was not unusual, with the use of a transfer pole. She said she was the resident's nurse on 11/20/23. She said she did not receive a report of this resident having been lowered to the floor by a CNA on the previous day (11/19/23 at 2:51 p.m.). She said after she received this information, she assessed the resident at 10:30 a.m. She said her husband, who was an RN and worked for the facility, came and observed the resident at 10:30 a.m., but did not assess the resident. She said he did not document that he observed the resident. She said being lowered to the floor with assistance was considered a fall. She observed the resident's right leg and it was crooked. The resident yelled out in pain and pointed at her right leg. This LPN observed swelling around the right knee. A stat x-ray was ordered by the NP at 11:00 a.m. At 2:40 p.m., the resident still complained of right leg pain. The resident would point at the right leg and moan. At 4:30 p.m., she administered the resident's evening medications and this was also when the x-ray was taken. She said the DON and NP wanted an in-house x-ray and it took almost 4.5 hours for the x-rays to be taken. After the x-rays were taken, the NP reviewed them, confirmed there was a fracture and gave an order to send the resident to the emergency room using non-emergent transport. She said nursing staff were not allowed to call a family member, until the x-ray results had been read and confirmed. She said she heard the conversation with the son using a speaker phone. She said he was upset that the resident had not been sent to the hospital for the fall and the facility had just now found out the leg was broken. She said at 5:20 p.m., the non-emergent transport service came to pick up the resident. They were upset because the facility knew the resident had a fracture, why did they not send her to the emergency room sooner. She told them this was the order from the NP and the resident's son had agreed to this transfer. She said it took the two transport staff and herself to stabilize the resident's leg and two additional facility staff members to move the resident from the bed to the gurney. The DON and the director of clinical risk management (DCRM) were interviewed on 12/19/23 at 12:46 p.m. They said the resident had a fall on 11/19/23 at 2:51 p.m. This was a witnessed fall. A CNA lowered the resident to the floor during an assisted transfer with a transfer pole. They said there was no RN assessment of the resident before she was moved off of the floor, after the fall. An RN assessment should have been done prior to moving the resident form off the floor. They said the resident was assessed by a LPN and did not express any pain at the time of the fall. The resident started complaining of leg pain on 11/20/23 at 10:30 a.m. The LPN talked (11/20/23 at 10:30 a.m.) with the DON that the resident's leg was swollen and it was recommended to call the provider's office to get an x-ray. After the LPN told the DON about the resident's leg, the DON did not go and assess the leg. A stat x-ray was ordered by the NP on 11/20/23 at 11:45 a.m. and was taken at 4:23 p.m. (4.38 hours later). The NP assessed the resident on 11/20/23 at 5:00 pm. and reviewed the x-ray (fracture of the right femur). The NP gave an order for the resident to go to the emergency room using non-emergent transport services. The son was told that the resident would be sent non-emergent to the hospital and he agreed. The transport service arrived at the facility at 5:20 p.m. The non-emergent transport staff were not happy and stated 911 should have been called, because the resident had a known fracture and that needed stabilization. They said the facility was following the NP orders and the son had agreed with the order. The DON and DCRM said before the survey started, a lengthy discussion was conducted with the resident's representative and adult protective services (APS). The facility had identified on 11/20/23 there was an issue with a lack of an RN assessment after the resident's fall on 11/19/23. They did in-services starting on 11/20/23 for the facility's fall protocol for all nursing staff with signatures. The in-services were ongoing at this time. They said if a resident falls, an RN assessment must be performed and total lift must be used to move the resident off of the floor. They did a performance improvement plan (PIP) that started on 11/20/23 for the RN assessment after a fall and the fall process. This PIP had measurable goals and a timeline. They were still doing audits at this time and would evaluate again after 30 days. RN #1 was interviewed on 12/19/23 at 2:34 p.m. She said an RN should assess a resident after a fall before the resident was moved from off the floor. She said the assessment was done to look for any type of injuries, bleeding, bleeding from the head, other head injuries, neck injuries, fractures and broken bones. The DON was interviewed on 12/19/23 at 2:45 p.m. She said a RN should complete an assessment for a resident that had fallen before the resident was moved from off the floor and placed in a bed or chair. She said the RN looked for range of motion of extremity issues, fractures, bleeding, abhorrent pupil responses, extremity rotational abnormalities, pain, and for any visible or suspected injuries. An LPN could observe a resident and stay with the resident until the RN came to do the assessment. The LPN could not conduct an assessment for a resident that had fallen. The NP was interviewed on 12/19/23 at 2:50 p.m. She said the resident fell the previous day (11/19/23) before she assessed her on 11/20/23. She said the resident was unable to stand or bear her body weight on the side of the body that sustained the fracture. She said since she could not bear weight and had lost some strength, her bones had become brittle. She said she did not know how the fall occurred. She said the resident's leg might have caught or twisted while she was lowered to the floor. She said she assessed the resident, ordered an x-ray and reviewed the x-ray (displaced femur fracture). She said a stat x-ray of four hours was a good (acceptable) time in long term care facilities. She said she sent the resident to the emergency room with non-emergent transport services. The NP said the reason she ordered non-emergency transport services was that the fracture occurred the day before and the resident was stable. The resident's health would not have declined, while they waited on the non-emergent services. She said emergency services were for residents with chest pain, difficulty in breathing and a possible heart attack.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight ranges, for two (#6 and #9) of three residents reviewed out of 10 sample residents. Resident #6, who was on hospice services and was known to be at risk for nutritional problems due to early onset Alzheimer's disease, weighed 145.8 pounds (lbs) upon his admission to the facility on [DATE]. On 11/19/21, the resident weighed 139 lbs, a weight loss of 6.8 lbs, or 4.7%, in one month. The weight loss did not meet the parameters of 5% or greater in one month for significant weight loss, and the facility failed to implement any nutritional interventions to prevent further weight loss. On 1/1/22, the resident weighed 136.6 lbs, a loss of 9.2 lbs, or 6.3%, in less than three months. The facility again failed to implement any nutritional interventions despite the resident's continued trend of weight loss. On 2/1/22, Resident #6 weighed 131.6 lbs, a loss of five pounds, or 3.7%, in one month, and a loss of 14.2 lbs, or 9.7%, in less than four months. The facility did not implement any nutritional interventions despite the resident's continued weight loss. On 3/1/22, the resident weighed 126.2 lbs, a loss of 5.4 lbs, or 4.1% in one month, and a severe weight loss of 19.6 lbs, or 13.4% in less than five months. The resident was not placed on any nutritional interventions until 3/9/22, when the facility obtained an order for a nutritional supplement. Due to the facility's failures to implement timely nutritional interventions, Resident #6 sustained a severe weight loss of 19.6 lbs, or 13.4% in less than five months. Additionally, Resident #9, who was known to be at risk for nutritional problems due to dementia and protein-calorie malnutrition (inadequate intake of food), weighed 127.3 lbs on 11/2/22. The resident weighed 115.6 lbs on 12/5/22. This was a severe weight loss of 11.7 lbs, or 9.2%, in one month. The resident weighed 112.4 lbs on 1/2/23, which was an additional weight loss of 3.2 lbs, or 2.8%, in less than one month. The resident had received a nutritional supplement one time per day since 7/1/22, however, the facility failed to increase the nutritional supplement or implement any other nutritional supplements or fortified foods after the resident sustained the severe weight loss on 12/5/22. Resident #9's nutritional supplement was not increased to two times per day until 1/19/23, after the resident had sustained the additional 2.8% weight loss. A fortified pudding was not ordered as an additional intervention until 1/19/23. On 12/9/22, the interdisciplinary team (IDT) recommended an occupational therapist (OT) evaluate the resident during meals, however, the OT assessment did not occur until 1/20/23. On 3/2/23, the resident weighed 114.0 lbs, a gain of 1.6 lbs, or 1.4%, in two months. Due to the facility's failure to provide timely nutritional interventions, Resident #9 continued to lose weight following her initial severe weight loss of 11.7 lbs, or 9.2%, in one month. Findings include: I. Facility policy and procedures The Weight Policy, revised May 2021, was provided by the nursing home administrator (NHA) on 3/15/23 at 2:16 p.m. It read in pertinent part, Weights will be regularly monitored to assure the identification, evaluation and initiation of care planning for residents who have experienced actual weight loss or weight gain. All residents will be weighed each month. More frequent weights will be obtained as ordered by the physician, or requested by a licensed nurse or registered dietitian (RD). Any residents with a significant weight change x 1 month (greater than or equal to 5%) will be reweighed. The RD will review residents' weights monthly. A review and evaluation will determine if the resident is at his/her desired body weight or has a significant, unintended weight change. Significant weight changes include: 5% loss/gain in weight in a month; 7.5% loss/gain in three months; or 10% loss/gain in weight in six months. The RD along with the interdisciplinary team (IDT) will review residents with significant weight changes and develop a care plan accordingly. Individualized interventions will be recommended and initiated to meet weight goals as clinically possible depending on the resident's status. II. Resident #6 A. Resident status Resident #6, age younger than 70, was admitted [DATE] and discharged to another facility on 7/14/22. According to the July 2022 computerized physician orders (CPO), diagnoses included early onset Alzheimer's disease. The 4/21/22 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) was not conducted. According to the staff assessment for mental status, the resident had a short term and long term memory problem, and his cognitive skills for daily decision making were severely impaired. He required two-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. He was totally dependent on the assistance of one person for eating. He coughed or choked during meals or when swallowing medications. According to the MDS assessment, he did not have, or it was unknown if he had, a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months. B. Record review Review of Resident #6's nutrition care plan, initiated on 10/19/21 and revised on 6/9/22, revealed the resident was at risk for nutritional problems related to early onset Alzheimer's disease. Pertinent interventions included assisting the resident with meals as needed, monitoring weight monthly or as indicated, providing and serving supplements as ordered, providing the resident with double portions at meals, and referring to the RD as needed. Review of Resident #6's weight records revealed the following documented weights: -10/14/21: 145.8 lbs; -10/26/21: 140.0 lbs (a weight loss of 5.8 lbs or 4.0% in less than a month); -11/2/21: 140.9 lbs; -11/19/21: 139.0 lbs; -12/6/21: 140.2 lbs; -1/1/22: 136.6 lbs (a weight loss of 9.2 lbs or 6.3% in less than three months); -2/1/22: 131.6 lbs (a weight loss of 5 lbs or 3.7% in one month, and 14.2 lbs or 9.7% in less than four months); -3/1/22: 126.2 lbs (a weight loss of 5.4 lbs or 4.1% in one month, and a severe weight loss of 19.6 lbs or 13.4% in less than five months); -4/1/22: 129.8 lbs (a weight gain of 3.6 lbs or 2.9% in one month, following the addition of a nutritional supplement on 3/8/22. See physician orders below); -5/1/22: 127.6 lbs (a weight loss of 2.2 lbs or 1.7% in one month); -6/1/22: 131.6 lbs (a weight gain of 4 lbs or 3.1% in one month); and, -7/1/22: 131.4 lbs (a weight gain of 5.2 lbs or 4.1% in four months, following the increases of the resident's nutritional supplement. See physician orders below). Resident #6's July 2022 CPO included the following physician orders: -Weights monthly every day shift starting on the 1st and ending on the 1st every month. The order date was 12/6/21; and, -House nourishment (nutritional supplement) four times a day 4 ounces with peanut butter for weight management. The order date was 5/6/22. Review of the Resident #6's physician order history revealed the following orders: -House nourishment one time a day for weight management with peanut butter. The order date was 3/8/22. The order was discontinued on 3/11/22 when the supplement was increased; -House nourishment two times a day for weight management 4 ounces with peanut butter. The order date was 3/11/22. The order was discontinued on 4/21/22 when the supplement was increased; -House nourishment three times a day for weight management 4 ounces with peanut butter. The order date was 4/21/22. The order was discontinued on 5/6/22 when the supplement was increased; and, -House nourishment four times a day for weight management 4 ounces with peanut butter. The order date was 5/6/22. Review of Resident #6's medication administration records (MAR) from March 2022 through July 2022 revealed the nutritional supplement was documented as being offered to the resident. -The MAR did not document how much of the nutritional supplements were consumed by the resident at each administration from 3/8/22 through 4/21/22. Review of Resident #6's electronic medical record (EMR) revealed the following progress notes documented in pertinent part: 11/2/21: Quarterly Assessment. Resident continues to have a good appetite with 76-100% oral intake daily with snacks everyday, and continues to be mainly a totally dependent eater. CBW (current body weight): 140.9 lbs. Weight trend: 3.36% weight loss since admission. Registered dietitian (RD) will continue to monitor resident's plan of care and nutritional status as needed. -There were no further nutrition notes documented until 3/17/22, after Resident #6 sustained a severe weight loss. 3/17/22: Significant weight change. 11.1% weight loss in three months. Etiology: Hospice, declining mental status. Intervention: House supplement one time per day with peanut butter. Goal: Maintain current body weight (CBW) +/-5% (weight changes) monthly, comfort care due to hospice. RD will continue to monitor resident's plan of care and nutritional status as needed. 5/6/22: Significant weight change. Supplements: House supplement three times per day. Weight trend:12% weight loss in six months. Oral intake: 76-100%. Feeding ability: Usually total dependence, sometimes independent. Interventions/Recommendations: Increase house supplement to four times per day, continue to encourage oral intake, and monitor weight. RD will continue to monitor resident's plan of care and nutritional status as needed. 5/10/22: Interdisciplinary team (IDT) met to review resident's weight loss. Resident is currently triggering for significant loss of 14 lbs lost in 180 days, representing 12% loss. Resident is encouraged to increase oral intake at meals, typically eats 76-100% at meals. Nutritional interventions include: increase house supplement to four times per day. RD evaluated on 5/6. Physician and resident/representative notified of weight loss on 5/6/22. Weight may fluctuate due to disease process. Will continue to monitor and encourage oral intake. 6/7/22: Weight review: Weight on 6/1/22 of 131.6 lbs triggered a 5.3% weight gain. CBW of 131 lbs on 6/5/22 did not trigger significant weight gain. Weight gain is beneficial. Continue house supplement with peanut butter four times per day, continue to encourage oral intake, and monitor weight. RD will continue to monitor resident's plan of care and nutritional status as needed. Review of Resident #6's nutritional assessments revealed the following documentation in pertinent part: 1/21/22: Weight trend: 6.7% weight loss in 3 months. Registered nurse (RN) reports resident has great oral intake, no gastrointestinal issues, regular bowel movements, and no chewing/swallowing issues. RD will continue to monitor the resident's plan of care, nutritional status, and weight as needed. -A nutritional supplement was not started despite the resident sustaining a 6.7% weight loss over three months. 4/22/22: Nonsignificant weight loss. Nursing reports the resident eats/drinks everything, he won't stop himself, including supplements. However, despite great appetite resident still has weight loss. RD will increase supplement to three times per day from two times per day. Recommendations: Increase supplement to three times per day, provide/offer preferred foods/snacks/meal assistance as needed, and monitor weight. -The assessment documented the resident had nonsignificant weight loss, despite the resident sustaining a severe weight loss of 19.6 lbs or 13.4% in less than five months. III. Resident #9 A. Resident status Resident #9, age [AGE], was admitted [DATE]. According to the March 2023 CPO, diagnoses included dementia and protein-calorie malnutrition. The 1/12/23 MDS assessment revealed that the resident had severe cognitive impairment with a BIMS of zero out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. She required supervision and set-up help for eating. She had a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months, and was not on a prescribed weight loss regimen. B. Observation On 3/14/23 at 11:45 a.m., Resident #9 was seated in her wheelchair in her room. A full plate of food and a bowl of pudding was on the bedside table in front of her. The resident was staring straight ahead and was not making any attempt to feed herself. Her silverware was unwrapped and lying on a napkin next to the plate. The silverware was not weighted, and there were no finger foods on her plate (see care plan below). At 11:51 a.m., certified nurse aide (CNA) #1 entered the resident's room, sat down on the resident's bed, and began to physically assist Resident #9 to eat. The resident accepted the food that was offered. C. Record review Review of Resident #9's nutrition care plan, initiated on 7/14/22 and last revised on 1/13/23, revealed the resident was at risk for nutritional problems related to poor oral intake and dementia. The resident did better with finger foods or handheld foods. The resident had a significant weight loss in December 2022 and January 2023, and occupational therapy was consulted. Pertinent interventions included assisting the resident with eating, providing a nutritional supplement daily and a fortified pudding daily, providing adaptive eating equipment as ordered/needed, monitoring/recording intakes each meal, monitoring/recording weights as ordered, and encouraging oral intakes and fluids. Review of Resident #9's weight records revealed the following documented weights: -7/9/22: 127 lbs; -7/17/22: 127.2 lbs; -7/24/22: 127 lbs; -There was no weight documented for August 2022; -9/6/22: 127.1 lbs; -10/3/22: 127.2 lbs; -11/2/22: 127.3 lbs; -12/5/22: 115.6 lbs (a severe weight loss of 11.7 lbs or 9.2% in one month); -12/7/22: 116.2 lbs (reweigh); -12/25/22: 116.2 lbs; -12/30/22: 117.7 lbs; -1/2/23: 112.4 lbs (an additional weight loss of 3.2 lbs or 2.8% in one month); -1/13/23: 112.4 lbs; -2/1/23: 112.6 lbs; and, -3/2/23: 114 lbs (a weight gain of 1.6 lbs or 1.4% in two months, following the increase in the resident's nutritional supplement and the addition of the fortified pudding on 1/19/23. See physician orders below). Resident #9's March 2023 CPO included the following physician orders: -Weights monthly every day shift starting on the 1st and ending on the 3rd every month. The order date was 7/25/22; -Pudding two times a day for weight loss 4 ounces after lunch and dinner. The order date was 1/19/23; -House Nourishment (nutritional supplement) two times a day for weight loss 4 ounces between meals. The order date was 1/19/23; and, -Resident to have a large handled bent spoon and built up handled fork for all meals to support self feeding. The order date was 1/24/23. Review of the Resident #9's physician order history revealed an order for House Nourishment one time a day for nutritional support. The order date was 7/11/22. -There were no other physician orders for nutritional supplements or fortified foods in the resident's physician order history prior to 1/19/23. Review of Resident #9's MAR from November 2022 through March 2023 revealed the nutritional supplement and the fortified pudding were documented as being offered to the resident. -The MAR did not document how much of the nutritional supplements were consumed by the resident at each administration. Review of Resident #9's EMR revealed the following progress notes documented in pertinent part: 12/9/22: Significant weight change. The Interdisciplinary team (IDT) met to review resident's weight loss. Resident is currently triggering for significant loss of 12 lbs lost in less than one and three months, representing 8.7% loss. Resident is encouraged to increase oral intake at meals, typically eats 26-100% at meals. Nutritional interventions include: encourage oral intake, consulted occupational therapy (OT) to assess resident during meals. Registered dietician (RD) evaluated on 12/8/22. Physician and resident/representative notified of weight loss on 12/8/22. Weight may fluctuate due to diuretic (medication which helps rid the body of salt and water) use/disease process. Will continue to monitor and encourage oral intake. -There was no OT evaluation for December 2022 in Resident #9's EMR, and the facility was unable to provide documentation that an evaluation had occurred (see therapy evaluations below). -Resident #9 did not have a physician's order for a diuretic medication despite the progress note documenting the resident's weight may fluctuate due to diuretic use. -The resident's nutritional supplement was not increased and no fortified foods were added as nutritional interventions despite the resident's severe weight loss (see physician's orders above). 12/27/22: Weight review follow-up. Current body weight (CBW): 116.2 lbs. Weight trend: 8.6% weight loss in almost three months. Full nutritional assessment on 12/8/22 for weight trend: 7.9% weight loss in one month, 8.3% weight loss in two months from weight of 116.6 lbs on 12/8/22. Weight stable and no changes in resident status or appetite since nutritional assessment. RD will continue to monitor resident's plan of care and nutritional status as needed. 12/31/22: Weight review follow-up. CBW: 117.7 lbs on 12/30/22. 1.5 lb weight gain in five days, weight gain is beneficial. Full nutritional assessment on 12/8/22. No other changes in resident status or appetite since nutritional assessment. RD will continue to monitor resident's plan of care and nutritional status as needed. 1/13/23: Significant weight loss. IDT met to review resident's weight loss. Resident is currently triggering for significant loss of 15.3 lbs and 15 lbs lost in less than two months and six months, representing 11.7% and 11.5% loss. Resident is encouraged to increase oral intake at meals, typically eats 26-75% at meals. Nutritional interventions include: encourage oral intake, super pudding daily, consult community OT. RD evaluated on 1/13/22. MD (medical doctor) and resident/representative notified of weight loss on 1/13/22. Weight may fluctuate due to diuretic use/disease process. Will continue to monitor and encourage oral intake. -Resident #9 did not have a physician's order for a diuretic medication despite the progress note documenting the resident's weight may fluctuate due to diuretic use. -The resident's nutritional supplement was not increased and no fortified foods were added as nutritional interventions until 1/19/23, despite the progress note documenting the resident was on a fortified pudding daily (see physician's orders above). 2/9/23: IDT met to review resident's weight loss. Resident is currently triggering for significant loss of 15 lbs lost in less than three months, representing 11.5% loss. Resident is encouraged to increase oral intake at meals, typically eats 51-100% at meals. Nutritional interventions include: finger foods when able, encourage oral intake, speech therapy consult, weighted utensils. RD evaluated on 2/9/23. physician and resident/representative notified of weight loss on 2/9/23. Weight may fluctuate due to diuretic use/disease process. Will continue to monitor and encourage oral intake. -Resident #9 did not have a physician's order for a diuretic medication despite the progress note documenting the resident's weight may fluctuate due to diuretic use. -There was no speech therapy evaluation for February 2023 in Resident #9's EMR, and the facility was unable to provide documentation that an evaluation had occurred (see therapy evaluations below). -The resident did not have a physician's order for finger foods and no finger foods were observed during observation of the resident at lunch on 3/14/23 (see observation above). -Resident #9 had a physician's order for weighted utensils, however, the resident had not been provided with weighted utensils at lunch on 3/14/23 (see observation above). 3/9/23: Significant weight change. IDT met to review resident's weight loss. Resident is currently triggering for significant loss of 13 lbs lost in less than six months, representing 10.2% loss. Resident is encouraged to increase oral intake at meals, typically eats 51-100% at meals. Nutritional interventions include: weighted utensils, continue house supplement two times daily, fortified pudding two times daily. RD evaluated on 3/9/23. Physician and resident/representative notified of weight loss on 3/9/23. Weight may fluctuate due to diuretic use/disease process. Will continue to monitor and encourage oral intake. -Resident #9 did not have a physician's order for a diuretic medication despite the progress note documenting the resident's weight may fluctuate due to diuretic use. -Resident #9 had a physician's order for weighted utensils, however, the resident had not been provided with weighted utensils at lunch on 3/14/23 (see observation above). Review of Resident #9's nutritional assessments revealed the following documentation in pertinent part: 12/8/22: Weight trend: 7.9% weight loss in one month, 8.3% weight loss in two months. Weight loss unintended and unfavorable. Resident appears thin. RD spoke with registered nurse (RN) due to resident's mental status. RN reports resident is doing well but has had a decreased appetite recently. RN reports resident eats less when she eats in her room and thinks it would be beneficial for resident if she had assistance during meals. RD will speak with OT about assessing resident. RD discussed with RN about adding another house supplement, RN reported resident doesn't finish the one she has now so she doesn't think she would drink another one. RN reports she thinks the most beneficial intervention for resident would be to have assistance during meals so her oral intake would increase. -There was no OT evaluation for December 2022 in Resident #9's EMR, and the facility was unable to provide documentation that an evaluation had occurred (see therapy evaluations below). -No other nutritional interventions were put into place despite the RD documenting, per the RN, that the resident did not drink the nutritional supplement she was receiving daily. 1/5/23: Weight trend: 11.7% weight loss in two months, 11.8% weight loss in six months. Weight loss unintended and unfavorable. Resident appears thin. Resident is now off of isolation due to COVID-19, nurse reported no adverse reactions at this time, lots of sleeping, some decreased oral intake due to lots of sleeping, good appetite when awake. Last note RD stated she would ask OT to assess resident, OT was not able to assess resident due to resident therapy provided by outside community provider. RD spoke with the outside provider's RD to consult OT. OT has been consulted. RD and outside provider's RD also agreed to try fortified pudding for resident. RD will order. -The OT consult did not occur until 1/20/23, 15 days after the nutritional assessment was conducted (see therapy evaluation below). -The physician's order for fortified pudding was not obtained until 1/19/23, two weeks after the nutritional assessment (see physician's orders above). 2/7/23: Weight trend: 11.5% weight loss in three months, 11.4% weight loss in six months. Weight loss unintended and unfavorable. Resident appears thin. RD spoke with resident RN. RN reports resident is doing well, has a good appetite, does well with finger foods and continues to need assistance with non-finger foods. RN reports resident may not need to be on pureed diet, RD will contact outside provider for speech consult. RN reports resident has not been getting weighted utensils, RD will contact outside provider also about putting weighted utensils order in. No other questions/concerns for RD at this time. RD will continue to monitor resident plan of care and nutritional status as needed. -There was no speech therapy evaluation for February 2023 in Resident #9's EMR, and the facility was unable to provide documentation that an evaluation had occurred (see therapy evaluations below). -The resident did not have a physician's order for finger foods and no finger foods were observed during observation of the resident at lunch on 3/14/23 (see observation above). -Resident #9 had a physician's order for weighted utensils, however, the resident had not been provided with weighted utensils at lunch on 3/14/23 (see observation above). 3/9/23: Weight trend: 10.2% weight loss in six months-unintended and unbeneficial. Few pound weight gain over one month, weight gain is beneficial. Resident appears thin. Resident reports she would like to maintain weight. RD informed resident of CBW and body mass index (BMI), resident still wants to maintain weight but will be okay with some weight gain. Resident reported she is doing well, appetite is 'pretty good' , and she is not always getting her house supplements. RD will speak with nursing staff about offering house supplement two times a day. Suspected etiology for initial weight loss was poor oral intake at the time. Weighted utensils have helped increase oral intake. Resident had no questions/concerns for RD at this time. RD will continue to monitor resident plan of care and nutritional status as needed. -Resident #9 had a physician's order for weighted utensils, however, the resident had not been provided with weighted utensils at lunch on 3/14/23 (see observation above). A physician's progress note dated 12/13/22 documented the following in pertinent part, Nursing concerns: No concerns expressed by unit nurses. Resident was seen at the lunch hour. She was eating her lunch. She had no concerns. Appearance: well-nourished, well developed, alert, in no acute distress, eating a hamburger. -The progress note did not indicate the physician was aware of the severe weight loss the resident had sustained on 12/5/22. An occupational therapy evaluation dated 1/20/23 documented in pertinent part: Situation: Review of eating set up due to weight loss. Background: Resident lives at skilled nursing facility. Facility reports 14 lb weight loss in three months. Assessment: Resident was in her room when OT visited. Resident was agreeable to trialing use of adaptive utensils for eating apple sauce and fruit cup. Resident demonstrated improved intake with curved spoon and built up fork. OT discussed with RN and kitchen staff. OT will send order for use. Recommendation: Provide order for use of adaptive silverware. Complete follow up if any changes in weight or staff concerns reports. -There was not an OT evaluation for December 2022 or a speech evaluation for February 2023 in Resident #9's EMR and the facility was unable to provide documentation that the evaluations had occurred (see nutritional assessments above). D. Staff Interviews Certified nurse aide (CNA) #1 was interviewed on 3/14/23 at 12:10 p.m. CNA #1 said Resident #9 usually ate pretty well when staff assisted her. She said she would usually eat the fortified pudding that was sent from the kitchen. Licensed practical nurse (LPN) #1 was interviewed on 3/14/23 at 12:22 p.m. LPN #1 said Resident #9 had lost a large amount of weight in December 2022. She said the resident's weight had been stable since January 2023. She said Resident #9's nutritional supplement was increased to two times per day on 1/19/23. LPN #1 said the resident also started on fortified pudding two times per day on 1/19/23. She said the resident could eat by herself, but usually required assistance. She said her meal intake was greater when staff assisted her. LPN #1 said the resident did drink her nutritional supplement and eat the fortified pudding. She said the amount of the nutritional supplements should be documented on the resident's medication administration record (MAR) every time the resident received the supplements. LPN #1 said Resident #9's MAR did not include documentation of how much of the supplements were consumed by the resident, however, she said that was supposed to be documented to determine if the interventions were beneficial. IV. Additional interviews The director of nursing (DON) was interviewed on 3/15/23 at 11:56 a.m. The DON said resident weights were obtained monthly. She said the RD monitored the weights. She said if a significant change in weight occurred for a resident, the RD would request a reweigh to ensure the weight was accurate. The DON said if the RD noticed a weight loss, or that a resident was not gaining back weight that was previously lost, then she would change the nutritional interventions. The DON said she was not working at the facility when Resident #6 resided there. She reviewed his weight records and confirmed the resident's weight had been trending down prior to his severe weight loss in March 2022. She confirmed the resident did not have any nutritional supplement orders put in place until 3/8/22 despite the resident's weight loss trends prior to 3/1/22. She further confirmed there was no documentation of how much the resident consumed of his nutritional supplement until 4/22/22. The DON said a nutritional intervention for Resident #6 should have been put into place sooner than it was. She said the amount of the nutritional supplement consumed by the resident at each administration should have been documented from the time the intervention was put into place on 3/8/22. The DON said Resident #9 used to eat on her own, however, the resident now required a staff person to physically assist her with eating. She said the resident would eat fairly well when someone assisted her. The DON said Resident #9 had a significant weight loss between November 2022 and December 2022. She said the resident was on a nutritional supplement one time a day, but did not have orders for any fortified foods prior to her weight loss. She said the nutritional supplement should have been increased or another nutritional intervention put into place at the time the weight loss was discovered on 12/5/22. The DON confirmed the resident's nutritional supplement was not increased and the fortified pudding was not ordered until 1/19/23. She said the percentage of the supplement should be documented for each administration so the RD could determine if the interventions were effective. The RD and the regional registered dietitian (RRD) were interviewed together on 3/15/23 at 12:31 p.m. The RD said she monitored resident's weights monthly or more frequently if needed. She said she conducted a monthly weight trends audit on residents in an attempt to catch insignificant weight losses before they turn into significant weight losses. She said if a significant weight loss was observed, she would have nursing staff obtain a reweigh on the resident to determine if the weight was accurate. The RD said if the weight was determined to be accurate then she would talk with the resident, or the nursing staff if the resident was cognitively impaired, to see if the resident had had a loss of appetite and if the resident would accept a nutritional supplement or fortified foods that added more calories and protein to the resident's diet. She said she would have a discussion with the IDT to determine what nutritional interventions should be put into place for the resident. The RD said residents were put on nutritional supplements or fortified foods on an individualized basis. She said residents could be started on nutritional interventions if they were at risk for weight loss, had poor oral intake, or had sustained a weight loss. She said nursing staff was responsible for documenting how much of a nutritional sup[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Resident #206 A. Resident status Resident #206, over the age of 50, was admitted on [DATE]. According to the December, 2019 CPO, diagnoses included schizophrenia, anxiety, chronic kidney disease, and acute kidney failure. The 11/27/19 MDS assessment revealed the resident did not have a BIMS assessment conducted. He did not have verbal and physical behaviors directed at others documented. He required extensive two person assistance with all activities of daily living (ADLs). He was always incontinent of bowel and bladder. B. Record review The behavior care plan, initiated 12/2/19 revealed Resident #206 had a potential psychosocial well being problem related to diagnoses of anxiety and schizophrenia. Resident #206 also had inpaired visual function related to blindness. Interventions included to give Resident #206 time to answer questions and to verbalize feelings perceptions, and fears as needed. Give resident opportunities to talk with others. Provide a quiet place for him to have conversations. Resident #206 prefered to have room and things arranged to promote independence. 1. Facility failure Record review revealed the facility was aware Resident #206 did not have verbal and physical behaviors against others. However, the facility was aware that the assailant in the incident did have previous verbal and physical behaviors prior to admission to the facility. The facility put interventions in place such as moving resident #206 to a quiet environment, and giving the resident opportunities to talk to others. However, there was no discussion of moving the assailant from the room instead of the victim.The facility intervention was to let the assailant choose future roommates to prevent behaviors. The facility also did not ensure that resident #206 was safe from the assailant's escalating behaviors by checking on the resident during the night and day and did not interview staff regarding any commotion during the night and day. 2. Investigation review The investigation report of resident physical abuse dated 11/30/19 revealed the LPN #1 notified the DON that Resident #206 reported being hit three times in the head in his bedroom by his roommate that night. Resident #206 and the assailant were interviewed the morning of 11/30/19. The DON and NHA were notified of the events. The police were notified and an occurrence report to the state regulatory agency was reported. Resident #206 was checked for any injuries and was assigned to a different room. There was no evidence the assailant was educated about his behaviors or any monitoring of resident #206 and no assessments to ensure resident #206 had any injuries. a. Facility interviews LPN #1 interview dated 11/30/19 revealed the morning of 11/30/19 that Resident #206 approached her and said he was hit in the head three times by his roommate during the night.The roommate was questioned by LPN #1 who admitted hitting Resident #206. She said she immediately reported the incident to DON, NHA, and the two residents were separated. The facility interviewed five residents on the hall who said they were not afraid of the assailant. However the facility did not interview all residents on the hall. The facility also did not interview any certified nurse aides (CNAs) during the night shift or morning shift to see if there were any mention or observations of incident during the night. b. Facility conclusion The facility felt the incident that occurred on around 11/30//19 was substantiated and considered physical abuse as Resident #206 was physically attacked by roommate and LPN#1 reported incident timely and residents were separated. The NHA said he felt the facility was justified in their actions and the investigation. However, the facility failed to keep Resident #206 safe from being physically abused and did not interview all staff on the shift. Based on observations, record review and interviews; the facility failed to ensure residents' right to be free from abuse for three (#13, #206 and #103) of five residents investigated for abuse out of 40 sample residents. The facility failed to ensure Resident #13 was free from verbal abuse and mental anguish. The resident was unable to speak for herself. The resident was observed, by staff, as crying and tearful following the allegation involving certified nurse aide (CNA) #10. Additional allegations of abuse were discovered during the investigation for CNA #10. A resident alleged CNA #10 yelled at other residents and verbally abused resident #102. In addition, the facility failed to ensure safety for Resident #206 and Resident #103 resulting in physical abuse. Cross-reference F610: Evidence that all alleged violations are thoroughly investigated. Findings include: I. Facility policy and procedure The Abuse and Neglect Prohibition policy revised July 2018, provided by the nursing home administrator (NHA) on 12/18/19 at 11:30 a m. revealed, in part, Each resident has the right to be free from abuse .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Mental abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation .Physical abuse includes, but is not limited to, hitting, slapping, pinching and kicking . II. Resident #13 status Resident #13, age [AGE], was admitted on [DATE]. According to the December 2019 computerized physician orders (CPO), diagnoses included muscle weakness, abnormalities of gait and mobility, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder and vascular dementia. The 12/8/19 minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS) score completed. No behaviors were marked. For functional status, the resident was extensive assistance for bed mobility, transfers, eating, toileting and personal hygiene. a. Observations The resident was observed from 12/16/19 through 12/18/19. She was in a wheelchair. She was observed in the dining room during meals and in front of the television at times. She was dependent on staff. She was limited in movement and was unable to engage in a conversation. She was able to nod her head yes or no. b. Record review and interviews The care plan, revised 11/2/17, revealed, (Resident) has a history of emotional trauma. Interventions included: Watch for signs of distress while in a group setting and while conversation is going on around her .staff will refrain from asking details about (residents) past trauma but rather simply know that it exists. The care plan, revised 8/27/17, revealed, (Resident) has a communication problem related to vascular dementia. Interventions included: Anticipate and meet needs .Observe/document for physical/nonverbal indicators of discomfort or distress and follow up as needed . Review of the abuse investigation revealed the following: -Date of incident: 11/20/19. Time of incident: 5:00 p.m. -Date the investigation initiated: 11/21/19. Time investigation was initiated: 2:12 p.m. -Resident involved: Resident #13. Type of investigation: Verbal. -Suspected perpetrator: CNA #10 -Description: Staff indicated that a CNA was helping a resident to bed when he turned to another CNA and said, I can make her really upset. It was reported that he proceeded to say, Resident's name, I am going to the bank and I am going to take all of your money. Nursing has reported that this resident has been crying more recently. Investigation was initiated. Notably, the reporting party did not hear this first hand. CNA who witnessed this is being contacted. CNA accused of the incident has been suspended. -Staff interviewed: CNA #8, CNA #6 and licensed practical nurse (LPN) #1 (documented as RN) -Residents interviewed: four residents were listed including Resident #15 -Summary: There were conflicting stories about what happened. Therefore, the incident could not be substantiated. Residents interviewed denied witnessing event/behavior. RN (LPN) denied witnessing. CNA #6 denied any concerns of verbal abuse. CNA #8 expressed that assailant antagonizes residents at times. And tries to get responses out of them. -Conclusion: Due to conflicting stories, the incident could not be substantiated. -Action: CNA#10 was suspended for the duration of the investigation. Police were informed of the incident. Management will be watching the accused closely. CNA #10 educated on verbal abuse and reassigned to a different hall. Review of the progress notes revealed the following: -12/4/19: Social services note- (Resident) was unable to provide any sort of answer to the questions and complete the BIMS. Staff reported she was not able to be oriented by the season or location of her room, but she was able to recognize staff's faces and was aware she was in the nursing home. Staff reports she is easily irritated approximately once a day. -11/21/19: Nursing note- Resident tearful, following reported verbal abuse in the dining area. Staff provided comfort measures and tender loving care (TLC) at night (HS) with some good effect. This was completed by registered nurse (RN) #3. c. Interviews completed during the survey Resident #41 was interviewed on 12/17/19 at 11:25 p.m. She said when she was first admitted , she was in a lot of pain. She said a male CNA came in and said, Those aren't even real tears. You dont even sound like you are crying. She was unable to remember who the CNA was. Staff was aware. CNA #2 was interviewed on 12/18/19 at 8:37 a.m. She said she had heard of verbal abuse occurring. She said she did not witness it but it was dealt with that day by administration. She said this incident occurred about three weeks ago with CNA #10. She said CNA #10 was making inappropriate jokes to Resident #13 about stealing her identity. She said Resident #13 had spent the rest of that day crying and in her room. She said this resident did not want to come out of her room. She said nobody should have said that to her. The director of nurses (DON) was interviewed on 12/18/19 at 3:04 p.m She said she was unable to remember this incident. The NHA was interviewed on 12/18/19 at 4:25 p.m. He said they had an investigation completed for this allegation. He said he talked to CNA #10 but did not ask him about this particular incident. He said he asked this CNA if he had seen anything related to abuse. CNA #8 was interviewed on 12/18/19 at 5:07 p.m. She said this incident occurred at the dining room table. She said they were helping feed the residents at the dinner meal. CNA #10 looked at her and said You want to see me make her mad? She said he was teasing her about taking all of her money. She said she felt uncomfortable with the event. She said she had seen retaliation before. She said CNA #10 had picked on a couple of other residents. She said other residents had also witnessed him being rude. CNA #6 was interviewed on 12/18/19 at 5:11 p.m. She said they were helping feed the residents in the dining room. She said she was focused on her own financial difficulties. She said this resident did get agitated and tried to hit CNA #10. Resident #15 was interviewed on 12/19/19 at 11:19 a.m. She said she was usually focused on her own things. She was unable to provide any feedback related to the event in the dining room. Resident #9 was interviewed on 12/19/19 at 11:54 a.m. He said he had observed verbal abuse. He said it seemed to be more rampant. He said CNA #10 had been verbally abusive to some of the aides and the residents. He said Resident #102 was at the dining table one time being picky with her food and she had been missing her daughter. CNA #10 told her Either shut up and eat or go to your room. He said this CNA scared the residents. He said CNA #10 would go up behind them and whistle loudly in order to scare them. The NHA was interviewed on 12/19/19 at 12:45 p.m. He said CNA #8 reported this incident to LPN #1 and then this LPN reported the incident to the NHA. He said they suspended CNA #10 pending investigation. He said he interviewed three residents that were down the same hall as this CNA worked. He said the fourth resident interviewed was in the dining room at the time of the incident. He said they usually tried to interview six residents. He said that he was the one who was in charge of completing the investigations. LPN #1 was interviewed on 12/19/19 at 1:05 p.m. She said she was not the nurse on duty during the incident. She did not see or hear of any abuse. LPN #4 was interviewed on 12/19/19 at 1:12 p.m. She said CNA #8 had told another CNA about the incident and that Resident #13 had been crying a lot. She said CNA#10 told one of the CNAs, I know how to make her cry. She said he told the resident he was going to take all her money. She said this was not the first time she had heard this happening from CNA #10. She said resident #13 was unable to advocate for herself. She said residents had reported that CNA #10 had yelled at them. She said Resident #13 had been crying all day, the next day. The NHA was interviewed on 12/19/19 at 1:31 p.m. He said they focused on the hall this CNA worked for his investigation. He said he was not aware the LPN he interviewed was not on duty the time of the incident. He said Resident #13 always acted upset with CNA #10. He confirmed he failed to prevent further allegations of abuse by CNA #10 by not completing a thorough investigation. He said now that he was aware of a pattern, they would do a more thorough investigation. He said he had not initiated an investigation for the incident with Resident #102. He said he was going to lump the allegations together for one investigation involving CNA #10. He said he also recently discovered some allegations of CNA #10 treating other staff members in an appropriate manner leading to an additional investigation. He said CNA #10 was suspended pending investigations for the additional allegations discovered during the survey process. III. Resident #103 A. Resident status Resident #103, age [AGE], was admitted on [DATE]. According to the December 2019 CPO, diagnoses included bipolar disorder, lack of normal physiological development in childhood, symbolic dysfunction and difficulty in walking. According to the 12/3/19 MDS assessment, the resident had intact cognition with a BIMS score of 15 out of 15. The resident did not demonstrate any behaviors. The resident required staff supervision for bed mobility, transfers, dressing, eating, toileting and personal hygiene. B. Record review The care plan for the potential to be physically aggressive (slapping others) related to cognitive deficits and confusion secondary to intellectual or developmental disability was initiated on 11/27/19. Some of the interventions were to provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of the source of the agitation, assist to set goals for more pleasant behavior and encourage the resident to seek out a staff member when agitated. The resident had physical aggression triggers that included being asked overwhelming questions, being questioned and not receiving an adequate explanation of a situation. When the resident became agitated; intervene before agitation escalates, guide the resident away for the source of distress, and engage the resident calmly in conversation. A summary of the facility's abuse investigation dated 11/27/19 at 4:00 p.m., revealed that on 11/27/19, Resident #103 and Resident #7 were engaged in a conversation related to the death of their relatives. Resident #103 was slapped with an open hand on the left arm by Resident #7. Then Resident #103 responded by slapping with an open hand Resident #7 on the left arm. After the incident, both residents were separated by staff members and both residents were placed on frequent checks by staff. The police were contacted and a case number was assigned. Resident #103 was moved to another room per her request. There was no pain evaluation assessment performed after the incident on 11/27/19. A pain evaluation assessment was performed two days after the event on 11/29/19 at 1:03 p.m. The pain scale on this date was zero or no pain. There was no skin - head to toe assessment performed after the incident on 11/27/19. The next skin assessment was performed four days after the event on 12/1/19 at 11:47 a.m. This assessment revealed the resident had a rash under her pannus. C. Resident interview Resident #103 was interviewed on 12/18/19 at 2:09 p.m. She said she was seated in the dining room, Resident #7 walked by and started talking about how all of her family were dead. She told the resident all of her family were also dead and to stop talking about this issue. She said Resident #7 slapped her on the left upper arm. She retaliated with a slap/push to Resident #7's arm. She said there were no further problems between them and she just tried to ignore or walk away from Resident #7 when she came near her. IV. Resident #7 A. Resident status Resident #7, age [AGE], was admitted on [DATE]. According to the December 2019 CPO, the resident had diagnoses of anxiety, major depression, and bilateral hearing loss. According to the 12/8/19 MDS assessment, the resident had severe cognitive impairment with a BIMS score of two out of 15. The resident did not demonstrate any behaviors. The resident required staff supervision for bed mobility, transfers, eating, toileting and personal hygiene. The care plan for agitation when the resident became confused or scared was initiated on 11/27/19. The plan revealed the resident's memory was significantly impaired. The resident relearned about her family's deaths several times each day which could lead the resident to express verbal or physical aggressive behavior. Some of the interventions were to assist the resident to develop more appropriate methods of coping and interacting (talking through issues). Staff were to intervene as necessary to protect the rights and safety of others. Staff were to approach the resident and speak in a calm manner. Staff were to divert the resident's attention and remove the resident from a potential situation by taking the resident to an alternate location as needed. The resident had verbal and physical aggression triggers related to confusion and/or disorientation. The resident was able to de-escalate by talking with staff truthfully about the death of her family members and her placement in the facility. There was no pain evaluation assessment performed after the incident on 11/27/19. There was no skin - head to toe assessment performed after the incident on 11/27/19. The next skin assessment was performed two days after the event on 11/29/19. This assessment revealed the resident had a rash redness to both eyes. The occurrence report completed by the facility on 11/27/19 at 4:00 p.m., revealed Resident #7 had a history of paranoia. The resident had been verbally and physically aggressive towards staff. The incident between the two residents was witnessed and therefore substantiated. C. Staff interview The social services director (SSD) was interviewed on 12/19/19 at 8:50 a.m. He said this incident occurred on 11/27/19 after the dinner meal, in the smaller of the two dining areas. He said a male resident told him that he witnessed Resident #7 attempt to push Resident #103. The SSD said his investigation concluded that Resident #7 was telling Resident #103 that all of her family members were deceased . He said due to Resident #7's memory she relearned this information several times each day. Resident #103 told Resident #7 not to talk about that issue anymore. Resident #7 slapped Resident #103 on her left upper arm and then Resident #103 retaliated by slapping Resident #7 on her left upper arm. He said both residents were separated and he talked with Resident #103 regarding some residents were very sensitive about certain types of information and maybe she should try to keep her distance from Resident #7. He said Resident #103 had previously put in a request for a room change and she moved to the room she was in now. The facility failed to protect residents from resident-to-resident physical abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews; the facility failed to ensure all alleged violations for abuse were thoroughly investigated for one (#13) of five residents reviewed for abuse out of 40 sample residents. The facility failed to thoroughly investigate verbal abuse allegations and the staff person continued to work with residents. The facility failed to interview the appropriate staff proceeding the allegation of abuse. The facility failed to interview the appropriate residents under the care of certified nurse aide (CNA) #10. The facility failed to document an accurate array of events for the allegation of abuse for Resident #13. The facility failed to complete a thorough investigation of CNA #10's alleged verbal abuse which resulted in additional allegations of abuse made by multiple residents. Findings include: I. Facility policy and procedure The Abuse and Neglect Prohibition policy revised July 2018, provided by the nursing home administrator (NHA) on 12/18/19 at 11:30 a m. revealed, in part, Each resident has the right to be free from abuse .Facility supervisors will immediately investigate and correct reported or identified situations in which abuse .is at risk for occurring . Cross-reference: F600 Free from abuse II. Resident #13 status Resident #13, age [AGE], was admitted on [DATE]. According to the December 2019 computerized physician orders (CPO), diagnoses included muscle weakness, abnormalities of gait and mobility, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder and vascular dementia. The 12/8/19 minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS) score completed. No behaviors were marked. For functional status, the resident was extensive assistance for bed mobility, transfers, eating, toileting and personal hygiene. III. Observations The resident was observed from 12/16/19 through 12/18/19. She was in a wheelchair. She was observed in the dining room during meals and in front of the television at times. She was dependent on staff. She was limited in movement and was unable to engage in a conversation. She was able to nod her head yes or no. IV. Record review The care plan, revised 11/2/17, revealed, (Resident) has a history of emotional trauma. Interventions included: Watch for signs of distress while in a group setting and while conversation is going on around her .saff will refrain from asking details about (residents) past trauma but rather simply know that it exists. The care plan, revised 8/27/17, revealed, (Resident) has a communication problem related to vascular dementia. Interventions included: Anticipate and meet needs .Observe/document for physical/nonverbal indicators of discomfort or distress and follow up as needed . Review of the progress notes revealed the following: -11/21/19: Nursing note- Resident tearful, following reported verbal abuse in the dining area. Staff provided comfort measures and tender loving care (TLC) at night (HS) with some good effect. This was completed by registered nurse (RN) #3. The abuse investigation, provided by the facility, did not include an interview from RN #3. Review of the abuse investigation revealed the following: -Date of incident: 11/20/19. Time of incident: 5:00 p.m. -Date the investigation initiated: 11/21/19. Time investigation was initiated: 2:12 p.m. -Resident involved: Resident #13. Type of investigation: Verbal. -Suspected perpetrator: CNA #10 -Description: Staff indicated that a CNA was helping a resident to bed when he turned to another CNA and said, I can make her really upset. It was reported that he proceeded to say, Resident's name, I am going to the bank and I am going to take all of your money. Nursing has reported that this resident has been crying more recently. Investigation was initiated. Notably, the reporting party did not hear this first hand. CNA who witnessed this is being contacted. CNA accused of the incident has been suspended. -Staff interviewed: CNA #8, CNA #6 and licensed practical nurse (LPN) #1 (documented as RN) -Residents interviewed: four residents were listed including Resident #15 -Summary: There were conflicting stories about what happened. Therefore, the incident could not be substantiated. Residents interviewed denied witnessing event/behavior. RN (LPN) denied witnessing. CNA #6 denied any concerns of verbal abuse. CNA #8 expressed that assailant antagonizes residents at times. And tries to get responses out of them. -Conclusion: Due to conflicting stories, the incident could not be substantiated. -Action: CNA#10 was suspended for the duration of the investigation. Police were informed of the incident. Management will be watching the accused closely. CNA #10 educated on verbal abuse and reassigned to a different hall. The abuse investigation, provided by the facility, revealed the incident occurred in the dining room and not the residents room as documented in the investigation. Four residents and three staff members were interviewed. The LPN interviewed in the investigation was not the LPN on duty the day of the incident. The LPN on duty the day of the incident was not included in the investigation. CNA #10 was scheduled over two halls and only four residents were interviewed. Details of the interview specifics were not included in the investigation for both the staff and residents. The incident occurred at 5:00 p.m. on 11/20/19 and the investigation did not start until 2:12 p.m. on 11/21/19. V. Staff and resident interviews CNA #2 was interviewed on 12/18/19 at 8:37 a.m. She said she had heard of verbal abuse occurring. She said she did not witness it but it was dealt with that day by administration. She said this incident occurred about three weeks ago with CNA #10. She said CNA #10 was making inappropriate jokes to Resident #13 about stealing her identity. She said Resident #13 had spent the rest of that day crying and in her room. She said this resident did not want to come out of her room. She said nobody should have said that to her. CNA #2 was not included in the facilities investigation for staff interviews. The director of nurses (DON) was interviewed on 12/18/19 at 3:04 p.m She said she was unable to remember this incident. The NHA was interviewed on 12/18/19 at 4:25 p.m. He said they had an investigation completed for this allegation. He said he talked to CNA #10 but did not ask him about this particular incident. He said he asked this CNA if he had seen anything related to abuse. CNA #8 was interviewed on 12/18/19 at 5:07 p.m. She said this incident occurred at the dining room table. She said they were helping feed the residents at the dinner meal. She said CNA #10 looked at her and said You want to see me make her mad? She said he was teasing her about taking all of her money. She said she felt uncomfortable with the event. She said she had seen retaliation before. She said CNA #10 had picked on a couple of other residents. She said other residents had also witnessed him being rude. CNA #6 was interviewed on 12/18/19 at 5:11 p.m. She said they were helping feed the residents in the dining room. She said she was focused on her own financial difficulties. She said this resident did get agitated and tried to hit CNA #10. Resident #15 was interviewed on 12/19/19 at 11:19 a.m. She said she was usually focused on her own things. She was unable to provide any feedback related to the event in the dining room. Resident #9 was interviewed on 12/19/19 at 11:54 a.m. He said he had observed verbal abuse. He said it seemed to be more rampant. He said CNA #10 had been verbally abusive to some of the aides and the residents. He said Resident #102 was at the dining table one time being picky with her food and she had been missing her daughter. CNA #10 told her Either shut up and eat or go to your room. He said this CNA scared the residents. He said CNA #10 would go up behind them and whistle loudly in order to scare them. Resident #9 was not included in the facilities investigation for resident interviews. This resident resided on a hall covered by CNA #10's. The NHA was interviewed on 12/19/19 at 12:45 p.m. He said CNA #8 reported this incident to LPN #1 and then this LPN reported the incident to the NHA. He said they suspended CNA #10 pending investigation. He said he interviewed residents that were down the same hall as this CNA worked. He said they tried to interview six residents. LPN #1 was interviewed on 12/19/19 at 1:05 p.m. She said she was not the nurse on duty during the incident. She did not see or hear of any abuse. LPN #4 was not included in the facilities investigation for staff interviews. LPN #1 was included in the facilities investigation but was not present during the incident. LPN #4 was interviewed on 12/19/19 at 1:12 p.m. She said CNA #8 had told another CNA about the incident and that Resident #13 has been crying a lot. She said CNA#10 told another CNA, I know how to make her cry. She said he told her he was going to take all her money. She said this was not the first time she had heard this happening from CNA #10. She said the resident was unable to advocate for herself. She said residents had reported that CNA #10 had yelled at them. She said Resident #13 had been crying all day, the next day. The NHA was interviewed on 12/19/19 at 1:31 p.m. He said they focused on the hall this CNA worked for his investigation. He said they interviewed around six residents with higher cognition. He said he was not aware the LPN he interviewed was not on duty the time of the incident. He said Resident #13 always acted upset with this CNA. He said now that he was aware of a pattern, they would do a more thorough investigation. He said he had not initiated an investigation for the incident with Resident #102. He said he was going to lump the allegations together for one investigation involving this CNA. He said CNA #10 had been doing better since being moved to another hall. The CNA continued to provide care for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide treatment and services in a timely manner to prevent worsening of a pressure injury, for one (#99) of one resident reviewed for pressure injury out of 40 sample residents. Specifically the facility failed to: -Document a thorough assessment of a newly identified pressure injury to the resident's left heel upon discovery; -Ensure Resident #99 received timely treatment for a pressure injury to the left heel; -Implement timely pressure reduction interventions for a newly identified pressure injury to the left heel; and -Notify the physician and responsible party timely of the pressure injury. The facility's failures led to the worsening of a pressure injury from a blister to an unstageable wound covered with black eschar. Findings include: Cross-reference F657, failure to develop a comprehensive care plan. I. Facility policy and procedure The Skin Management policy, dated July 2017, was received from the director of nursing (DON) on 12/19/19 at 7:48 a.m. The policy documented in pertinent part, Management of tissue load through positioning, use positioning devices. Devices should be used to completely raise the pressure area, i.e. heel, completely off the support surface . Consider elevating the heels off the bed with pillow or use of heel protectors. Assess for risk of developing additional pressure ulcers. Totally relieve heel pressure by elevation of the heel completely off the bed surface. The resident, resident representative and the attending physician are notified. The care plan and care [NAME] are updated to reflect new interventions. II. Resident status Resident #99, age [AGE], was admitted on [DATE]. According to the December 2019 computerized physician's orders (CPO) diagnoses included dementia with behavioral disturbance, anxiety, post-traumatic stress disorder, obsessive compulsive disorder, and muscle weakness. The 12/2/19 minimum data set (MDS) assessment documented the resident was severely cognitively impaired and was unable to complete a brief interview for mental status (BIMS). The assessment documented he had short and long term memory loss and was cognitively moderately impaired for daily decision making. He required extensive two person assistance with bed mobility and transfers. He required extensive two person or more assistance with dressing, toileting, personal hygiene and bathing. He was at risk for developing pressure injury and had one unstageable pressure injury. III. Record review The resident's skin assessments were reviewed. On 11/16/19 the nurse documented on the skin assessment the resident had a new skin issue, a blister to the left heel. There was no further description of the blister. The nurses' notes were reviewed. There was no documentation on 11/16/19 that any interventions were put into place for the blister to the left heel. There was no documentation that the physician or responsible party were notified. A communication form/progress note dated 11/18/19 was reviewed. The note documented the resident had an area on the left heel that was discolored and soft. He had redness extending in the instep of the foot and upper foot. The note documented it appeared to be due to his feet being clamped together. There were no measurements of the blister.The physician, resident's wife, and hospice were notified. The note documented the wound occured on 11/18/19. However, the wound was noted two days prior on 11/16/19. The resident's orders were reviewed. The resident did not have orders to treat the wound until two days after it was initially observed on 11/16/19. On 11/18/19 skin prep (protective film) was ordered to the heel every shift and the resident was to be placed on an unspecified type of air mattress. The care plan was reviewed. The care plan dated 11/27/19 addressed the pressure ulcer developed to the left heel. However, there was no care plan that addressed the resident's risk for skin breakdown prior to the development of the left heel wound or a current care plan that addressed the resident's risk for skin breakdown. The resident had a Braden skin risk assessment dated [DATE]. The skin risk assessment indicated the resident scored a 13 out of 18 (highest risk) and was at moderate risk for developing skin breakdown. The assessment documented he had limited sensory perception, skin was occasionally moist, he was chairfast, his mobility was very limited, nutrition was probably inadequate, and friction and shearing was a potential problem. The facility failed to develop a care plan after this assessment and the resident developed a pressure ulcer to his left heel on 11/16/19. On 11/20/19, four days after the wound was observed, a boot was ordered to the left lower leg to offload the pressure to the heel. On 11/23/19 the weekly pressure ulcer record documented the blister was a 14.88 cm blood-filled blister. The plan was to offload the heels. Use an offloading boot and pillows. The wound was being treated with skin prep. On 11/25/19 the nurse's note documented the resident had eschar (dead tissue) to the heel. IV. Observation and interviews The resident's left heel was observed with registered nurse (RN) #2 on 12/17/19 at 9:40 a.m. The wound covered the entire left heel and was black. The RN said the wound was caused because he would move all over the bed and with his contractures, they could not float his heels. She said he now wore a boot to keep pressure off the heel. She could not explain why there had been a delay in treatment of the wound from 11/16/19 through 11/20/19. Licensed practical nurse (LPN) #5 was interviewed on 12/18/19 at 1:33 p.m. He said when a new wound was discovered the physician and family were notified immediately. He said the nurse should measure the wound and obtain treatment orders for the wound and notify the director of nursing (DON) and the wound care nurse. The wound care nurse was interviewed on 12/18/19 at 3:01 p.m. She said she does wound rounds one time a week with a wound care physician. She said if a nurse finds a wound they should notify the physician for treatment orders right away and not wait for her. She said this has been our process for a long time, but I have to keep educating the nurses because they do not always call for orders right away. She reviewed the documentation of the wound occurring on 11/16/19 and the physician and family not being notified until 11/18/19 and the boot was not ordered until 11/20/19. She said I see where this is a problem. She further stated, I have educated the nurses regarding this multiple times. The DON was interviewed on 12/18/19 at 3:43 p.m. She said the nurse who finds a new wound or worsening wound should notify the physician for orders immediately. She reviewed the documentation of the wound occurring on 11/16/19 and the physician and family not being notified until 11/18/19 and the boot was not ordered until 11/20/19. She said timely notification and treatment was an area for improvement. The DON further said after reviewing the care plan that she did not see a care plan for the resident prior to the wound that describes interventions to prevent skin breakdown. She said he should have had a care plan in place for skin integrity to prevent skin breakdown prior to the left heel wound because he was at risk. She was unable to locate one.