**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure three (#279, #30 and #40) of six residents reviewed for accidents out of 39 sample residents remained free from accidents. RESIDENT #279 Resident #279, was admitted on [DATE] with diagnoses of hemiplegia (weakness on one side) after an intracerebral hemorrhage (stroke) and dementia with behaviors. The resident was identified to be at very high risk for falling. On 2/12/25 Resident #279 experienced a fall shortly after admission and the facility implemented a fall care plan with interventions which included ensuring the resident's call light was in reach and encouraging the resident to use the call light. However, the resident had severe cognitive impairments. Resident #279 sustained witnessed falls on 2/14/25 and 2/15/25. The resident was sent to the hospital following the 2/15/25 fall for evaluation of back pain and returned to the facility. The intervention the facility identified for both of these falls was a referral for behavioral health management as the resident was agitated at the time of the falls. The facility did not update the resident's care plan with the behavioral health management referral. The facility failed to identify any further fall interventions until 2/24/25, to include providing prompt response to all requests for assistance as the resident had fluctuating ability to utilize her call light and providing consistent rounding on the resident. However, on 2/26/25 Resident #279 sustained an unwitnessed fall in a common area of the facility which resulted in a right proximal femur fracture (thigh bone close to the hip) that required hospitalization and a right trochanteric fixation nail (TFN) surgical repair of the fracture. The facility failed to identify a root cause of the resident's fall. Upon Resident #279's readmission to the facility on 3/3/25, the facility failed to implement new fall interventions to prevent further falls for the resident. Due to the facility's failures to implement and document effective and timely person-centered interventions following falls on 2/12/25, 2/14/25 and 2/15/25, Resident #279 sustained a fall on 2/26/25 which resulted in a right femur fracture. RESIDENT #30: Resident #30, was admitted on [DATE] after hospitalization for a right femur fracture that required an IM (intermedullary nail, which is a rod that is inserted into the hollow portion of the femur to stabilize a fracture) hip nailing and was identified as a high fall risk. On 9/10/24, Resident #30 sustained an unwitnessed fall out of bed. The facility failed to implement new person-centered effective and timely fall interventions after the fall. On 9/20/24, Resident #30 experienced a second unwitnessed fall out of bed which resulted in a fracture around the right femur hardware that required hospitalization and further surgical repair. The facility failed to identify a root cause of the resident's fall. Upon Resident #30's readmission to the facility on 9/27/24, the facility failed to implement new fall interventions to prevent further falls for the resident. Due to the facility's failures to implement and document timely person-centered interventions following Resident #30's fall on 9/10/24, the resident sustained a fall on 9/20/24 which resulted in a right femur fracture around the hardware from her previous femur fracture. Additionally, Resident #30 sustained five additional witnessed and unwitnessed falls on 10/1/24, 11/16/24, 12/9/24, 2/6/25 and 2/13/25. The facility failed to update the resident's care plan with new person-centered fall interventions following the resident's falls on 10/1/24, 11/16/24, 2/6/25 and 2/13/25. The facility updated the resident's care plan with new fall interventions following the resident's 12/9/24 fall, however, the care plan was not updated until 12/16/24, seven days after the fall. RESIDENT #40: Resident #40, who was admitted on [DATE] with diagnoses of dementia and Alzheimer's disease, was identified as a fall risk. Resident #40 sustained falls on 4/11/24, 10/28/24, 1/10/25 and 1/18/25. The facility failed to update the resident's care plan with new person-centered fall interventions following each of the falls. On 1/21/25 Resident #40 sustained a fifth fall which resulted in a laceration to the resident's head that required transportation to the hospital emergency room to have the laceration glued to close it. According to the resident's progress notes, the facility implemented anti-tip devices on the resident's wheelchair following the fall on 1/21/25, however the resident's care plan was not updated with the intervention and observations during the survey revealed there were no anti-tip devices on the resident's wheelchair. Resident #40 sustained an additional fall on 3/6/25 and two additional falls on 3/9/25. Due to the facility's failures to implement and document timely person-centered interventions following falls on 4/11/24, 10/28/24, 1/10/25 and 1/18/25, Resident #40 sustained a fall on 1/21/25 which required treatment at the hospital for a head laceration. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, revised 2/29/24, was provided by the nursing home administrator (NHA) on 3/13/25 at 2:20 p.m. It read in pertinent part, The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. To be effective, a fall reduction program is characterized by four components: fall risk evaluation, care planning and implementation of interventions, ongoing evaluation process quality assurance performance improvement (QAPI), and a commitment by caregivers to make it work. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Interventions are to be re-evaluated when a resident falls for efficacy. II. Resident #279 A. Resident status Resident #279, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included right femur (thigh bone) fracture and hemiplegia after an intracerebral hemorrhage and dementia with behaviors. The 2/17/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. She was dependent on staff for toileting, required substantial/maximal assistance with personal hygiene, transfers, partial/moderate assistance with bed mobility and required set up assistance with eating. The assessment indicated Resident #279 had two falls without injury and one fall with injury since admission. B. Observations On 3/11/25 at 12:09 p.m. Resident #279 was sitting in a wheelchair at a table in the dining room with another resident. Nursing staff were not present in the dining room or in the nursing station adjacent to the dining room. On 3/12/25 at 9:40 a.m. Resident #279 was sitting with another resident at the table in the dining room. One unidentified dining staff member was in the dining room. Nursing staff were not present in the nursing station adjacent to the dining room. C. Record review The activities of daily living (ADL) care plan, initiated 2/12/25 and revised 3/9/25, indicated Resident #279 had impaired physical mobility related to a right femur fracture. Interventions included wheelchair for mobility (initiated 2/12/25), assistance with ambulation as indicated (initiated 2/12/25), transfers by staff (initiated 2/12/25), resident encouragement to use call light (initiated 2/12/25), weight bearing as tolerated to right lower extremity after a TFN (trochanteric fixation nail to fix a proximal femur fracture) (initiated 2/27/25) and physical therapy and occupational therapy (PT/OT) (initiated 3/9/25). The fall care plan, initiated 2/12/25 and revised 3/9/25, indicated Resident #279 was a high fall risk due to impulsive behavior, easily agitated, poor balance and safety awareness, on psychoactive and anticonvulsive medications and had experienced a right femur fracture on 2/26/25. Interventions included anticipating the resident's needs (initiated 2/12/25), assessing the resident for adaptive devices (initiated 2/12/25), ensuring the call light was in reach and encouraging the resident to use the call light (initiated 2/12/25), encouraging adequate lighting and visual aids were in place and assessing for communication needs (initiated 2/12/25), ensuring appropriate footwear when ambulating or mobilizing in wheelchair (initiated 2/12/25), PT evaluation and treat as necessary (initiated 2/12/25), bed in lowest position while in bed (initiated 2/12/25), reviewing past falls and determining cause of falls, recording possible root causes for falls (2/12/25), medication review with consultant pharmacist (initiated 2/24/25), providing prompt response to all requests for assistance as resident had fluctuating ability to utilize call light and providing consistent rounding on resident (initiated 2/24/25). -The interventions initiated on 2/12/25 were not person-centered interventions specific to Resident #279. -Person-centered interventions were not identified after a witnessed fall on 2/14/25 when Resident #279 fell out of bed or after a witnessed fall on 2/15/25 when Resident #279 fell in the hallway without her walker and wheelchair (see below). -The care plan failed to identify and document a root cause with person-centered interventions after Resident #279 experienced an unwitnessed fall on 2/26/25 in a common area which resulted in a right femur fracture that required hospitalization and surgical intervention (see below). The 2/12/25 nursing progress notes documented Resident #279 was admitted at 2:00 p.m. Resident #279 was found on the floor in front of her wheelchair. The resident was assessed without injuries. The 2/12/25 nursing fall risk evaluation documented Resident #279 was a very high fall risk. The 2/13/25 interdisciplinary team (IDT) risk management note documented the root cause of Resident #279's fall was she was new to the facility and was disoriented and confused. Interventions that were put into place were a medical review and therapy services. The 2/14/25 nursing progress notes documented Resident #279 experienced a witnessed fall without head involvement. Resident #279 had attempted to get out of bed unassisted. The resident was assessed without injuries. The 2/14/25 IDT risk management note documented Resident #279 fell from the side of the bed to the floor. The root cause was identified as resident agitation, striking out at staff and lost her balance. Interventions that were put into place were behavioral health management to evaluate and treat. The 2/15/25 at 1:54 p.m. nursing progress notes documented Resident #279 had a fall at 1:00 p.m The ambulance was called at 1:15 p.m. and Resident #279 was transported to the hospital. The 2/15/25 at 9:24 p.m. nursing progress notes documented Resident #279 returned from the hospital. The 2/15/25 IDT risk management note documented a witnessed fall. Resident #279 was walking in the hallway without her walker or a wheelchair. The resident became agitated when staff attempted to assist and lost her balance. The root cause was identified as disorientation and agitation. The resident was transported to the hospital after complaining of back pain. The intervention identified was a referral to behavior health management. -However, personalized interventions for falls and behavioral health referral were not identified on the care plan after the 2/14/25 and 2/15/25 falls (see care plan above). The 2/19/25 behavioral health progress note documented for provider to consider adjusting Resident #279's psychoactive medications and monitor for side effects. The 2/26/25 at 5:15 a.m. nursing progress notes documented Resident #279 had an unwitnessed fall. It documented nursing staff at the nurse's station heard the sound of the couch in the lobby hitting the ground and Resident #279 crying and screaming. Resident #279 was observed on the ground with the couch on top of her. Resident #279 was assessed to have right lower extremity pain. Resident #279 was treated with diclofenac gel (an anti-inflammatory pain medication) and returned to her room. The physician was notified and an x-ray of the resident's right femur and hip were ordered. The 2/26/25 at 8:20 a.m. nursing progress noted documented Resident #279 had a right femoral fracture and was sent to the hospital for further evaluation. The 2/26/25 at 10:30 a.m. behavioral health note documented recommendations for adjusting medications with behavior interventions. Behavior interventions included actively monitoring the resident and surroundings to minimize known stressors, monitoring residents with poor safety awareness, avoid leaving the resident alone or with other residents unless staff were completing frequent, structured checks, maintaining visual supervision when in wheelchair, remaining as close as possible to intervene if necessary, anticipating resident's needs, providing resident with guided choices, if resident became upset, stepping back and engaging in conversation, setting clear boundaries with the resident regarding behavior of concern and remaining calm and neutral and redirecting resident with preferred activity. The 3/3/25 hospital discharge summary documented Resident #279 was admitted on [DATE] with a right femur fracture and orthopedic consult and underwent a right TFN hip nailing on 2/27/25. -However, a comprehensive review of the electronic medical record (EMR) failed to reveal an IDT risk management note of the 2/26/25 incident with a root cause analysis of the fall and interventions that needed to be implemented to prevent further falls. D. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 3/12/25 at 12:30 p.m. CNA #3 said Resident #279 was more calm since her medications were adjusted. She said when Resident #279 was first admitted to the facility, she became upset very easily and would not calm down. She said Resident #279 was very impulsive. She said the agitation and behaviors contributed to Resident #279's falls. She said Resident #279 now spent most of her time sitting in the dining room and staff did not do many activities with her. CNA #3 said she was not aware of any specific fall interventions for Resident #279. Registered nurse (RN) #3 was interviewed on 3/13/25 at 12:20 p.m. RN #3 said Resident #279 had a history of a traumatic brain injury and was independent prior to her admission to the facility. She said when Resident #279 was first admitted to the facility, she would thrash around and was a high fall risk. She said Resident #279 did not like too much stimulation and did not like to be pushed to do anything. She said Resident #279 did like a social environment and did well in the dining room with other people. She said she did not do well with male caregivers and tended to do better with younger female caregivers. She said during the day, staff kept her in the dining area so they could keep an eye on her. RN #3 said she thought Resident #279 had a fall mat and a low bed when she was in bed. The director of nursing (DON) was interviewed on 3/13/25 at 12:26 p.m. The DON said Resident #279 was a relatively new admission to the facility and staff were still getting to know her and what worked for her. She said Resident #279 admitted to the facility with behaviors and would refuse care. She said staff had to give her space or she would scream and accuse staff of harming her. The DON said the fall where Resident #279 experienced the fracture had occurred in the evening in the lobby. She said when staff reviewed the camera footage, Resident #279 had attempted to walk to the therapy room which was next to the lobby. She said Resident #279 was unable to open the door to the therapy room and attempted to walk behind the couch using the couch for balance. She said Resident #279 lost her balance and grabbed onto the couch, which fell on top of her. She said the nursing staff were giving report at the nurses' station at the time, which was in the lobby. She said on the camera footage, the nurses were not in direct line of sight of the resident when the fall occurred. The DON said an intervention that was helpful in alleviating Resident #279's agitation and behaviors which contributed to her falls was calling Resident #279's son. She said too much stimulation and too many staff members attempting to assist the resident increased her agitation. She said Resident #279 did not want male caregivers and there were certain staff members that she preferred. She said one caregiver at a time should approach her. She said the staff also lowered her bed when she was in it. She said Resident #279 enjoyed social interaction with others in the dining room. The DON said staff were not using a fall mat as an intervention because of the tripping hazard. She said she did not know if a special lipped mattress was being used. She said there was an order for behavioral health to see her and talk of adjusting her psychoactive medications. The DON said Resident #279 was working with physical therapy now. -The personalized interventions described by RN #3 and the DON, such as one staff member approaching the resident, avoidance of male caregivers, using preferential female caregivers, keeping the resident in line of sight, calling the resident's son and enjoying social interactions in the dining room, were not included in the care plan. The nurse quality mentor (NQM) was interviewed on 3/13/25 at 12:35 p.m. The NQM said the facility was working on an action plan to address recently admitted residents who were a fall risk. -However, documentation of the facility's action plan was not provided during the survey. III. Resident #30 A. Resident status Resident #30, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 CPO, diagnoses included Alzheimer's disease, osteoporosis and right femur fracture. The 12/23/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of seven out of 15. She was dependent on staff for toileting, personal hygiene, required substantial/maximal assistance with bed mobility, transfer and required set up assistance with eating. The assessment indicated Resident #30 had two or more falls without injury and one fall with injury since admission. B. Observations On 3/12/25 at 9:05 a.m. Resident #30 was sleeping in her bed with the bed in the lowest position with a fall mat at the bedside. On 3/12/25 at 12:00 p.m. Resident #30 was sleeping in her bed with the bed in the lowest position with a fall mat at the bedside. C. Record review The ADL care plan, initiated 8/19/24 and revised 10/6/24, indicated Resident #30 had impaired physical mobility due to a previous history of a right femur fracture with IM hip nailing. Interventions included staff assistance with mobility (initiated 8/19/24), wheelchair for mobility (initiated 8/19/24) and weight bearing as tolerated to the right lower extremity (initiated 10/6/24). The fall care plan, initiated 8/19/24 and revised 12/16/24, indicated Resident #30 was at risk for falls due to poor balance and safety awareness, impulsivity and history of falls. It indicated Resident #30 had a history of crawling out of her bed and wheelchair. Interventions included anticipating the resident's needs (initiated 8/19/24), providing a grab bar in the bathroom with non skid strips (initiated 8/19/24), resident's call light within reach and encouraging use of the call light (initiated 8/19/24), providing prompt response to all requests for assistance (initiated 8/19/24), ensuring adequate lighting and visual aids and assessing for communication needs (initiated 8/19/24), PT evaluation and treatment with wheelchair adjustments as indicated (initiated 8/19/24), bed in lowest position with fall mat when resident was in bed (initiated 8/19/24), reviewing past falls and determining the cause of falls, recording possible root causes and assisting the resident up as resident was an early riser, as she allowed (initiated 8/19/24 and revised 12/16/24), encouraging rest periods when resident exhibited signs of fatigue (initiated 12/16/24), fall mat (initiated 12/16/24) and medication review with consultant pharmacist (initiated 12/16/24). -The interventions initiated on 8/19/24 were not person-centered interventions specific to Resident #30. -Person-centered fall interventions were not identified after the resident's unwitnessed 9/10/24 fall (see below). -The care plan failed to identify and document a root cause with person-centered interventions after Resident #30 experienced an unwitnessed fall on 9/20/24 which resulted in a periprosthetic (a fracture around the previous surgical hardware) right femur fracture that required hospitalization (see below). -The care plan failed to document person-centered interventions for Resident #30's witnessed and unwitnessed falls on 10/1/24, 11/16/24, 12/9/24, 2/6/25 and 2/13/25 (see below). The 9/10/24 nursing progress note documented Resident #30 had an unwitnessed fall. Resident #30 was on the floor by the bed, soiled, during 4:00 a.m. rounds. Resident #30 told the staff she had to go to the bathroom and fell down. Resident #30 was assessed without injury or pain. The 9/10/24 IDT risk management note documented an unwitnessed fall. The root cause was determined to be after Resident #30 had a sudden urge to use the bathroom and fell to the floor when attempting to transfer. Interventions included working with therapy on transfers, dressing, toileting, strengthening and balance and providing a beveled fall mat at the resident's bedside. -However, the interventions identified in the IDT note had already been initiated on 8/19/24 and were not new fall interventions (see care plan above). The 9/11/24 at 11:00 a.m. nursing progress note documented Resident #30 was complaining of severe pain in her right hip. The physician was notified and a right hip x-ray was ordered. The 9/11/24 at 4:00 p.m. nursing progress note documented Resident #30's x-ray was taken and the facility was awaiting results. -However, a review of Resident #30's EMR progress notes failed to reveal documentation of the hip x-ray results. The 9/20/24 nursing progress note documented Resident #30 had an unwitnessed fall. Resident #30 was found on the floor on a blanket by the side of her bed. Resident #30 was complaining of pain in the right hip. The physician was notified and the resident was sent to the hospital for evaluation and treatment. The 9/20/24 hospital progress notes documented Resident #30 had recent right hip surgery and now presented with a significant displaced fracture below the previous right hip hardware. She was admitted for orthopedic consultation. -A comprehensive review of the EMR failed to reveal an IDT risk management note of Resident #30's 9/20/24 fall with a root cause analysis and new person-centered fall interventions that needed to be implemented. The 9/27/24 nursing progress notes documented Resident #30 was readmitted to the facility from the hospital with a right femur fracture. The 10/11/24 IDT risk management progress note documented a witnessed incident on 10/1/24. Resident #30 slid or lowered herself from the edge of the wheelchair to the floor. The root cause was documented as Resident #30 had dementia and poor safety awareness with increased confusion after recent surgery. Interventions documented were a therapy evaluation for wheelchair positioning with the wheelchair seat lowered. -However, the IDT risk management progress note was documented ten days after the incident occurred on 10/1/24. -The facility failed to update the resident's fall care plan with the fall intervention following the 10/1/24 fall (see care plan above). The 11/18/24 IDT risk management progress note documented an unwitnessed incident on 11/16/24. The resident was sitting on the floor at the foot of her roommate's bed with her legs stretched out. The root cause was Resident #30 most likely needed to use the bathroom, was incontinent and was wanting to change. Interventions documented were to provide hygiene and care, environmental rounds for safety, low bed and fall mat in place. -The facility failed to update the resident's fall care plan with the fall interventions following the 11/16/24 fall (see care plan above). -Additionally, the interventions for the low bed and fall mat identified in the IDT note had already been initiated as interventions on 8/19/24 and were not new fall interventions (see care plan above). The 12/16/24 IDT risk management progress note documented an unwitnessed incident on 12/9/24. Resident #30 was seen sitting in the hallway and the roommate alerted staff. The root cause was documented as confusion and disorientation due to dementia and the resident had a history of scooting out of her wheelchair. Interventions documented were physician reviewed medications for possible fall risk and obtained laboratory work (labs). -However, the IDT risk management progress note was documented seven days after the incident occurred on 12/9/24. The 2/7/25 IDT risk management progress note documented a witnessed incident on 2/6/25. Resident #30 raised her legs and tipped her wheelchair backwards and hit her head on the floor. The root cause was poor safety awareness and impulsivity. Resident #30 did not have wheelchair pedals due to self propelling. Interventions documented were therapy working with resident on wheelchair positioning, mobility and core stabilization. -The facility failed to update the resident's fall care plan with the fall interventions following the 2/6/25 fall (see care plan above). -Additionally, the interventions for therapy to work with the resident identified in the IDT note had already been initiated as interventions on 8/19/24 and were not new fall interventions (see care plan above). The 2/17/25 IDT risk management progress note documented a witnessed incident on 2/13/25. Resident #30 was self propelling in her wheelchair and the wheelchair cushion slid off and the resident fell to the floor. The root cause was that the wheelchair cushion was not connected to the wheelchair. The intervention documented was for therapy to do a seating evaluation and connect the wheelchair cushion to the wheelchair with velcro straps. -However, the IDT risk management progress note was documented four days after the incident occurred on 2/13/25. -The facility failed to update the resident's fall care plan with the fall intervention following the 2/13/25 fall (see care plan above). D. Staff interviews CNA #4 was interviewed on 3/12/25 at 1:30 p.m. CNA #4 said Resident #30 would try to get up by herself in the past but did not try to get up by herself now. She said when Resident #30 was in bed, the bed was kept in the lowest position to the floor with a bed mat by the floor. Licensed practical nurse (LPN) #2 and RN #1 were interviewed together on 3/13/25 at 8:45 a.m. LPN #2 said when Resident #30 was first admitted to the facility she had experienced a fall prior to admission with a hip fracture that had been repaired. She said Resident #30 fell shortly after she arrived and fractured the same hip again . She said Resident #30 had poor safety awareness and would often try to transfer herself, usually on the way to the bathroom. RN #1 said Resident #30's most recent falls were not really falls. She said the resident would lower herself off the wheelchair seat onto the floor. She said this had been observed in the dining room. She said this behavior was on Resident #30's care plan. The DON was interviewed on 3/13/25 at 12:26 p.m. The DON said Resident #30's fall with fracture happened in September 2024 and she would have to check the resident's care plan to see what the current fall interventions were. She said the resident would not use the call light and tried to transfer on her own. She said Resident #30 had a low bed and fall mat in place for when she was in bed. She said Resident #30 was care planned for her crawling out of her wheelchair. She said the facility had evaluated her wheelchair to check her seating and her cushion. She said the facility had done a medication review, wheelchair cushion adjustment and the staff would get her up in the afternoon to help prevent this behavior. She said in the instances where the behavior was not observed and it was unclear if she had fallen they would do a risk management assessment and investigate it as a potential fall with a root cause analysis and review interventions that were in place. IV. Resident #40 A. Resident status Resident #40, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia, Alzheimer's disease and osteoporosis. The 1/13/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS assessment score of four out of 15. The resident was dependent on staff for toileting and bathing and required supervision to moderate assistance for most ADLs. B. Resident observations On 3/10/25 at 2:00 p.m. Resident #40 was self-propelling in her wheelchair in the dining room. Resident #40 was wearing non-skid socks and did not have any anti-tip devices applied to her wheelchair. On 3/11/25 at 12:39 p.m. Resident #40 was self-propelling in her wheelchair in the dining room. Resident #40 was wearing non-skid shoes and did not have any anti-tip devices applied to her wheelchair. C. Record review The fall care plan, initiated 5/24/23 and revised 3/10/25 (during the survey), revealed Resident #40 was at risk for falls due to her unsteady gait, cognitive deficits, weakness, impaired safety awareness and history of falls. Interventions implemented on 5/24/23 included anticipating and meeting Resident #40's needs, ensuring her call light was within reach, encouraging the resident to participate in activities that promoted exercise, ensuring adequate lighting, and ensuring she was wearing the appropriate footwear when ambulating in her wheelchair. An intervention to have Resident #40's bed in the lowest position at night, padding to furniture, and personal items within reach was added on 5/24/23 and revised on 1/22/25. On 1/22/25 an intervention was added to request a medication review with the pharmacist as indicated. Interventions implemented on 3/10/25 (during the survey) included having Resident #40's bed in the lowest position and adding padding to her furniture, moving the resident closer to the nurses' station, obtaining bloodwork and urinalysis when indicated, and assisting the resident with repositioning in her wheelchair. -However, the intervention of having the bed in the lowest position was already initiated as an intervention on 5/24/23. -The facility failed to update Resident #40's care plan with person-centered interventions following her falls on 4/11/24, 10/28/24 and 1/10/25 (see below). A fall risk evaluation, dated 8/16/23, revealed Resident #40 was at a high risk for falling. A fall risk evaluation, dated 12/21/23, revealed Resident #40 was not at high risk for falling. 1. Fall incident on 4/11/24 - unwitnessed The facility fall report, dated 4/11/24 at 11:48 a.m., revealed Resident #40 was found on the floor between her bed and her wheelchair. Resident #40 said she was changing her incontinence brief and fell. Resident #40 was assessed by two nurses and her cognition was at baseline. Resident #40 had a bruise on her right elbow. Resident #40 was reminded to call for assistance using her call light. The report documented situational factors, including ambulating without assistance. The report docu[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure three (#44, #59 and #13) of six residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being out of 39 sample residents. Resident #44 was admitted to the facility for long term care on 9/2/22. It was identified that Resident #44 was at risk for weight loss and nutritional decline due to Alzheimer's disease, previous history of weight loss and hyperthyroidism (increased metabolism due to an overactive thyroid gland). On 10/8/24, Resident #44 weighed 146.5 pounds (lbs). On 12/5/24, Resident #44 weighed 136 lbs, which indicated the resident had lost 10.5 lbs in two months. In December 2024 the facility increased the resident's Med Pass (oral nutritional supplement). The resident was evaluated by speech therapy (ST) and it was recommended to downgrade the resident's diet to pureed on 12/25/24. The resident's comprehensive care plan indicated the resident needed to be weighed weekly to monitor the resident's nutritional status since she was at risk for weight loss. The facility failed to consistently weigh the resident weekly as directed on the care plan. On 1/8/25 the resident weighed 134.8 lbs, which indicated the resident had lost 8 percent (%) (11.7 lbs) in three months, which was considered severe. The facility failed to implement further person centered nutrition interventions after the resident's weight began trending down again on 1/21/25 and the resident lost an additional 5.7% (7.6 lbs) in two months, from 1/21/25 to 3/6/25. Due to the facilities failures to change or implement new nutritional interventions after Resident #44's weight started to trend downward for a second time on 1/21/25 the resident sustained 14.5% (21.3 lbs) weight loss in six months, from 10/8/24 to 3/6/25, which was considered severe. Additionally, Resident #59 was admitted to the facility for long-term care on 10/2/23 with a diagnosis of schizoaffective disorder (mental illness) and vascular dementia. The resident's weight fluctuated and on 11/12/24 he weighed 160 lbs. On 12/10/24, the resident weighed 162.4 lbs. The resident was admitted to the hospital from [DATE] to 12/13/24 for an elective knee surgery. The facility failed to reweigh Resident #59 after he was readmitted to the facility. The resident was not weighed until 1/2/25, which indicated he had lost 18 lbs (11%) in one month, from 12/10/24 to 1/2/25, which was considered severe. The facility implemented Juven (protein supplement, Magic cup (frozen nutritional supplement), Boost (oral nutritional supplement) and Liquid protein to combat the resident's weight loss and assist with wound healing. The facility frequently ran out the Magic cup and did not provide an alternative to supplement the resident's calories and nutrition. The resident was admitted to the hospital from [DATE] to 2/17/25 for a gastrointestinal bleed. Upon readmission, the resident weighed 144 lbs. The resident lost 8.4 lbs (5.8%) in one month, from 2/19/25 to 3/13/25, which was considered severe. The facility continued to fail to consistently offer the Magic cup or an alternative to provide the resident with additional calories to meet his nutritional needs. Additionally, the facility failed to consistently monitor and document the resident's meal intake to aid in an accurate and thorough nutritional assessment when the resident was experiencing weight loss. Furthermore, the facility failed to consistently monitor and document Resident #13's meal intakes. Findings include: I. Facility policy and procedure The Weight Management policy and procedure, revised 2/29/24, was provided by the nursing home administrator (NHA) on 3/13/25 at 2:20 p.m. It read in pertinent part, Residents identified with weight change will be assessed by the interdisciplinary team (IDT) and further interventions will be implemented to minimize the risk for further weight change where possible and to promote weight stability. Residents identified at risk for weight change will have interventions implemented to minimize the risk for additional weight change included in their plan of care. This may include supplements, registered dietitian (RD) evaluation and assisted dining. Residents with weight variance (loss or gain) are reweighed. Significant/severe weight variance is defined as 5% in one month, 7.5% in three months or 10% in six months. II. Resident #44 A. Resident status Resident #44, age [AGE], was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dysphagia (difficulty swallowing) and hyperthyroidism. The 2/26/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with deficits in long and short term memory, per staff assessment. It indicated that a brief interview for mental status (BIMS) was not attempted because she was rarely to never understood. She was dependent with eating, toileting, personal hygiene, bed mobility and transfers. The assessment documented the resident was 64 inches (five foot, four inches) tall and weighed 130 lbs. The MDS assessment indicated the resident had gained 5% or more in the last month or 10% or more in the last six months. -However, the resident had not gained weight (see record review below). B. Record review The activities of daily living (ADL) care plan, initiated 9/5/22 and revised 9/15/24, indicated Resident #44 had deficits related to Alzheimer's disease and behaviors. Interventions included Resident #44 required cueing by staff for eating (initiated 8/6/22) and was dependent on staff for all care (initiated 12/8/24). The nutrition care plan, initiated 9/8/22 and revised 7/26/24, indicated Resident #44 was at nutritional risk due to dementia and previous history of weight loss. Interventions included monitoring weights as ordered (initiated 9/8/22), offering food alternatives of equal nutritional value (initiated 9/8/22), serving the diet as ordered and monitoring intake and recording every meal (initiated 9/8/22), RD to evaluate and make diet recommendations as necessary (initiated 9/8/22), providing and serving supplements as ordered - Med Pass or alternative oral supplement three times a day (initiated 9/15/22), providing a sack lunch for when the resident's husband took the resident out of the facility (initiated 10/31/22), obtaining the resident's weight every Sunday and monitoring for weight loss with Lamictal (initiated 9/28/23). -However, the facility failed to weigh the resident every Sunday as indicated on the care plan (see record review below). A review of the comprehensive care plan failed to include the resident's need for one-on-one assistance for meals after Resident #44 triggered for severe weight loss on 12/12/24 and again triggered for significant weight loss on 2/27/25. Review of Resident #44's electronic medical record (EMR) revealed the resident was prescribed Lamotrigine (medication to treat hyperthyroidism) from 5/5/23 to 10/13/23. -The facility failed to update the resident's care plan when the medication was discontinued. The March 2025 CPO revealed a physician's order for weekly weights for monitoring of weight loss with Lamictal initiation and a history of hyperthyroidism, ordered 5/28/23 and discontinued 12/7/23. -A comprehensive review of the Resident #44's electronic medical record (EMR) did not reveal a current order for a weekly weight for weight loss, although the care plan specified to weigh the resident every Sunday. The resident's weights were documented in the resident's EMR as follows: -On 10/8/24, the resident weighed 146.5 lbs; -On 10/22/24, the resident weighed 144 lbs; -On 10/30/24, the resident weighed 142.5 lbs; -On 11/5/24, the resident weighed 143 lbs; -On 12/5/24, the resident weighed 136 lbs; -On 12/12/24, the resident weighed 126 lbs; -On 12/18/24, the resident weighed 126.8 lbs; -On 12/26/24, the resident weighed 126.6 lbs; -On 1/8/25, the resident weighed 134.8 lbs; -On 1/21/25, the resident weighed 132.8 lbs; -On 1/29/25, the resident weighed 130 lbs; -On 2/12/25, the resident weighed 130 lbs; -On 2/19/25, the resident weighed 131.4 lbs; -On 2/27/25, the resident weighed 128.2 lbs; and, -On 3/6/25, the resident weighed 125.2 lbs. -A review of Resident #44's electronic medical record (EMR) revealed the resident was not consistently weighed weekly as directed on the resident's comprehensive care plan (see care plan above). The resident did not have a weekly weight obtained in the month between 11/5/24 to 12/5/24. -A review of Resident #44's EMR revealed the resident did not have a weekly weight obtained between 12/26/24 to 1/8/25, 1/8/25 to 1/21/25 and 1/29/25 to 2/12/25. The resident sustained an 8% weight loss (11.7 lbs), which was considered severed from 10/8/24 to 1/8/25, in three months. The resident sustained a 14.54% (21.3 lbs) weight loss, which was considered severe, from 10/8/24 to 3/6/25 in less than six months. The March 2025 CPO revealed the following diet and nutritional supplementation orders: -Regular diet, pureed texture, regular/thin consistency, ordered 12/25/24; -Med Pass two times a day ordered 9/5/24 and discontinued 12/5/24; and, -Med Pass three times a day for weight loss, may provide alternate oral supplement as needed, ordered 12/5/24. The 12/2/24 quarterly nutrition assessment documented Resident #44 was on a regular diet with regular texture and was receiving Med Pass 120 milliliters (ml) four times a day for weight loss. The note indicated an alternate oral supplement could be provided as needed. It documented the resident's oral intakes were variable and the resident was independent with set-up assistance with eating. The 12/6/24 nutrition progress note documented Resident #44's weight was trending downward. The resident currently weighed 136 lbs, which was down from 146 lbs on 10/8/24. It documented the resident was having a poor acceptance of solids but was drinking fluids well. The resident's weight was discussed with the IDT. The IDT considered interventions that included a referral to ST, trial downgrade in diet texture and increased oral supplementation to three times a day. -However, the 12/2/24 quarterly nutrition assessment documented Resident #44 was receiving Med Pass four times a day. The 12/12/24 nutrition progress note documented Resident #44 triggered for severe weight loss and was reviewed in the weight meeting. The resident's diet was changed to pureed texture and oral supplementation was increased to three times a day on 12/5/24. -However, the 12/2/24 quarterly nutrition assessment documented Resident #44 was receiving Med Pass four times a day. The 12/19/24 nutrition progress note, documented as follow-up, indicated the resident had no further weight loss over the last week. The staff reported the resident's intake had improved with a pureed diet. She was being evaluated by ST. The 1/23/25 nutrition progress note documented Resident #44's weight was still down but stable and the resident was accepting routine oral supplements. Interventions were to continue with the current plan and monitor. The 2/26/25 quarterly nutrition assessment documented Resident #44 was on a regular diet with regular texture and was independent with meal assistance. Resident #44 was receiving Med Pass three times a day with variable oral intakes. -However, Resident #44 was changed to a regular diet with pureed texture on 12/25/24 and required one-on-one meal assistance. The 2/28/25 nutrition progress note documented Resident #44 triggered for significant weight loss in the past six months. Resident #44 was seen by ST, remained on a pureed diet and continued to receive one-on-one assistance at meals with varied intakes and varied acceptance of Med Pass three times a day. Interventions included adjusting the time of oral supplementation to earlier in day to promote acceptance. -Resident #44's weight began trending down again on 1/21/25 and the facility did not assess the resident until 2/28/25, when she triggered for severe weight loss. The January 2025 medication administration record (MAR) documented Resident #44 was provided 120 ml of Med Pass three times a day. -However, the January 2025 MAR failed to document an alternate oral supplement was provided as indicated on the resident's care plan after Resident #44 did not consume the Med Pass after a meal on 1/1/25, 1/3/25, 1/5/25, 1/9/25, 1/11/25, 1/12/25, 1/17/25 and 1/19/25 (see care plan above). The February 2025 MAR documented Resident #44 was provided 120 ml of Med Pass three times a day. -However, the February 2025 MAR failed to document an alternate oral supplement was provided as indicated on the resident's care plan after Resident #44 did not consume the Med Pass after a meal on 2/1/25, 2/3/25, 2/5/25, 2/9/25, 2/11/25, 2/12/25, 2/17/25 and 2/19/25. The March 2025 MAR (reviewed from 3/1/25 to 3/13/25) documented Resident #44 was provided 120 ml of Med Pass three times a day. -However, the March 2025 MAR failed to document an alternate oral supplement was provided as indicated on the resident's care plan after Resident #44 did not consume the Med Pass after a meal on 3/9/25. A review of the meal intakes for Resident #44 from 2/10/25 to 3/10/25 revealed the following: -Out of 27 opportunities for breakfast, the resident ate 50% or less three times, 25% or less one time and was not documented three times; -Out of 27 opportunities for lunch, the resident ate 50% or less five times, 25% or less one time and was not documented three times; and, -Out of 27 opportunities for dinner, the resident ate 50% or less two times, 25% or less three times and was not documented ten times. A review of the feeding assistance documentation revealed inconsistent documentation for Resident #44 from 2/17/25 to 3/9/25. The documentation indicated Resident #44 received no help one time, set-up help one time, partial to moderate help two times and substantial or maximal assistance three times. C. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 3/12/25 at 1:30 p.m. CNA #4 said Resident #44 was a good eater and usually ate most of her meals. She said Resident #44 was good with fluid intakes and she liked her supplement beverages. She said Resident #44 would not eat on her own, was dependent with eating and required assistance from staff. The RD was interviewed on 3/13/25 at 8:35 a.m. The RD said the weight team met weekly. She said since Resident #44's dementia was progressing, they had been discussing whether she needed hospice services. She said ST evaluated Resident #44. She said Resident #44's diet had been switched to pureed and that had been easier for her to swallow. She said there had been timing issues on what times Resident #44 was more likely to accept her supplement and they had adjusted the times. The RD said Resident #44's weights had been stable the last three months. She said she did not have any other ideas for nutritional interventions to prevent further weight loss. She said she would continue to evaluate what interventions would be appropriate for Resident #44. She said in the past, Resident #44 had been on Med Pass four times a day. She said there was room for interventions to be tried to help combat the resident's weight loss. She said examples of interventions could include increasing supplements, trying larger portions of items the resident liked, getting feedback from staff and trying snacks. -However, in the last three months Resident #44's weight was trending down and the facility failed to implement new person-centered nutritional interventions to address the resident's severe weight loss. Registered nurse (RN) #1 was interviewed on 3/13/25 at 8:45 a.m. RN #1 said Resident #44's dementia had been progressing. She said she had a period of time when she would not eat for a week or two and would not even open her mouth. She said she thought this was related to the resident's dementia that was progressing. She said Resident #44 had lost weight during that period. She said she was dependent on staff for eating. -However, review of Resident #44's EMR did not reveal documentation regarding Resident #44 refusing to eat for a week or interventions the facility attempted to address the residents' refusals. RN #1 said currently Resident #44 seemed to be eating. She said because of her overall decline staff had been discussing hospice services but was not currently on hospice services. III. Resident #59 A. Resident status Resident #59, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 CPO, diagnoses included schizoaffective disorder, vascular dementia, and gastrointestinal hemorrhage. The 1/7/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent with eating and was dependent on staff for most other ADL. The assessment documented the resident was 65 inches (5 foot, 5 inches) tall and weighed 144 lbs. The assessment documented the resident had experienced a weight loss of 5% or more in the month prior or 10% or more in the six months prior and was not on a physician-prescribed weight-loss regime. The assessment documented the resident did not have any rejections of care. B. Record review The nutrition care plan, initiated 2/28/25, revealed Resident #59 was at risk for nutritional problems due to pressure wounds, weight loss, being bed-bound and inadequate oral intakes. Pertinent interventions included monitoring weights as ordered, providing and serving supplements as ordered, providing and serving his diet as ordered and recording intakes. The March 2025 CPO revealed the following physician's orders: Juven nutritional supplement, mix one packet with eight ounces of water two times a day for wound healing, ordered 2/28/25. Magic cup nutritional supplement, give one four ounce cup twice a day for wound healing, ordered 1/24/25. Boost nutritional supplement, one bottle three times daily for wound healing. Resident may choose what supplement he wants, he has liked Magic Cup in the past, ordered 1/24/25. Liquid protein supplement, give 30 milliliters (ml) three times a day for wound healing, ordered 1/2/25. Resident #59's weights were documented in the EMR as follows: -On 11/12/24, the resident weighed 160.4 lbs; -On 11/27/24, the resident weighed 161.6 lbs; -On 12/10/24, the resident weighed 162.4 lbs; -On 1/2/25, the resident weighed 144.4 lbs; -On 1/9/25, the resident weighed 146.0 lbs; -On 1/21/25, the resident weighed 145.6 lbs; -On 1/29/25, the resident weighed 144.8 lbs; -On 2/6/25, the resident weighed 146.0 lbs; -On 2/19/25, the resident weighed 144.0 lbs; -On 2/27/25, the resident weighed 135.0 lbs; -On 3/6/25, the resident weighed 135.5 lbs; and, -On 3/13/25, the resident weighed 135.6 lbs. -The resident sustained an 11% (18 lbs) weight loss, from 12/10/24 to 1/2/25, in one month, which was considered severe. -The resident sustained a 5.8% (8.4 lbs) weight loss, from 2/19/25 to 3/13/25, in one month, which was considered severe. A nutrition progress note, dated 10/11/24 at 4:46 p.m., revealed Resident #59 had a significant weight gain. Resident #59 had good food intakes and had off and on issues with edema. A physician progress note, dated 12/16/24 at 11:57 a.m., revealed Resident #59 had a scheduled right total knee replacement on 12/12/24. The nutritional assessment, dated 1/2/25, revealed Resident #59 was at an increased nutritional risk due to a decline in meal intakes since his surgical procedure. Resident #59 had had some refusals for breakfast, ate 50% to 75% for breakfast and lunch and had 76% to 100% intakes for dinner. Interventions put in place included continuing his regular diet, honoring food preferences, offering alternatives and snacks and encouraging intakes. A nutrition progress note, dated 1/2/25 at 5:16 p.m., revealed Resident #59 had significant weight loss following an elective knee surgery. Resident #59 had an increase in his time spent in bed and poor intakes since his readmission. Resident #59's physician had initiated some routine oral supplements, including Boost three times daily, the week prior with varied acceptance. Resident #59's weight loss was reviewed with the IDT and the RD recommended liquid protein three times daily. -The facility failed to weigh the resident until 1/2/25, 20 days after he was readmitted post-knee surgery to determine a baseline weight. A nutrition progress note, dated 1/9/25, revealed Resident #59's weight had been stable for one week but continued to have concerns with his wounds. The facility staff reported Resident #59 showed some overall improvement but was still eating some lighter meals. The RD recommended the staff continue to offer Resident #59 the oral supplements as ordered and accepted. Resident #59's weight was reviewed with the IDT. A nutrition progress note, dated 1/24/25, revealed Resident #59 had ongoing concerns with inadequate intakes for wound healing. Resident #59's weight had been stable over the last week. Resident #59 had orders for liquid protein three times daily and Boost three times daily. Resident #59 had enjoyed Magic Cup supplements in the past, so the RD recommended the staff offer the supplement at lunch and dinner meals as he would accept. Review of Resident #59's progress notes revealed the resident was not administered the Magic Cup as ordered twice on 1/28/25, once on 1/29/25, once on 2/3/25, twice on 2/5/25, once on 2/7/25, once on 2/10/25, once on 2/11/25, twice on 2/12/25, once on 2/17/25 and twice on 2/19/25. -The progress notes did not reveal any alternative supplement or snack was offered when the Magic Cup was not administered. A physician's progress note, dated 2/18/25 at 11:05 a.m., revealed Resident #59 had undergone a procedure on 2/6/25 to manipulate his knee under anesthesia following his knee replacement. Resident #59 had coffee-ground emesis on 2/14/25 and was rehospitalized . Resident #59 was found to have septicemia likely related to the knee manipulation and was started on a 21-day course of antibiotics. A nutrition progress note, dated 2/20/25, revealed Resident #59 continued to have inadequate oral intakes and his weight remained down significantly but was stable over the month prior. Resident #59 had a recent hospitalization for a gastrointestinal bleed and wound infection and chose to remain in bed. Resident #59 expressed he preferred to eat soups. Resident #59 had variable meal intakes and varied acceptance of oral supplements including Boost three times daily, Magic Cup twice daily, and liquid protein three times daily. The RD encouraged intakes, especially of high protein sources, and recommended the staff continue to offer Resident #59's preferred foods as they were able to. Review of Resident #59's progress notes revealed the resident was not administered the Magic Cup as ordered once on 2/20/25, twice on 2/24/25, twice on 2/25/25, twice on 2/26/25 and twice on 2/27/25. -The progress notes did not reveal any alternative supplement or snack was offered when the Magic Cup was not administered. A nutrition progress note, dated 2/28/25 at 3:37 p.m., revealed Resident #59 continued to have significant weight loss and pressure wounds. Resident #59 elected to remain in his bed and continued to have varied meal and nutritional supplement intakes. Resident #59 was educated on diet and the facility staff worked to honor his food preferences as they were able to. The RD recommended continued efforts to offer and encourage meals and snacks for Resident #59 and encourage the nutritional supplements. The RD recommended Juven twice daily to help with wound healing. Review of Resident #59's progress notes revealed the resident was not administered the Magic Cup as ordered twice on 3/3/25 and twice on 3/5/25. -The progress notes did not reveal any alternative supplement or snack was offered when the Magic Cup was not administered. A nutrition progress note, dated 3/6/25 at 8:27 p.m., revealed Resident #59 had no further weight loss over the past week and had some improvements with his heel wound despite poor meal intakes, poor acceptance of the Magic Cup and Juven supplements, and varied acceptance of the Boost supplement. The RD's plan was to continue with the interventions as ordered and as Resident #59 would accept. Review of the amount eaten CNA task from 2/17/25 to 3/12/25 revealed the following: -One meal was documented on 2/20/25 at 9:09 a.m. and one meal was documented at 1:11 p.m.; -One meal was documented on 2/27/25 at 9:14 a.m. and one meal was documented at 1:09 p.m.; -One meal was documented on 3/3/25 at 6:54 p.m.; -One meal was documented on 3/5/25 at 7:07 p.m.; -No meals were documented on 3/9/25; -Two meals were documented on 3/10/25 at 1:13 p.m.; and, -One meal was documented on 3/11/25 at 9:25 a.m. and one meal was documented at 1:24 p.m. C. Staff interviews RN #1 was interviewed on 3/13/25 at 9:45 a.m. RN #1 said Resident #59's nutrition was better and he had been eating more recently. RN #1 said Resident #59 went on a self-imposed hunger strike for one week. RN #1 said Resident #59 was on protein supplements, including Magic Cup and Juven. RN #1 said Resident #59 was not picky about what foods he ate when he chose to eat. RN #1 said the facility had issues with running out of the Magic Cup supplement. RN #1 said when the facility ran out of Magic Cup, she would offer Resident #59 a snack or something equivalent. -However, review of Resident #59's progress notes did not reveal any documented alternatives being offered when the Magic Cup was not administered (see record review above). The RD was interviewed on 3/13/25 at 8:45 a.m. The RD said Resident #59 was very particular about what he ate when he first admitted to the facility, so the facility did their best to meet his preferences. The RD said Resident #59 became more willing to try to eat different foods and started overeating a lot, snacking, and taking nutritional supplements on his own. The RD said Resident #59 was doing very well before his elective knee surgery (12/12/24), but since the procedure, he had not been himself. The RD said the facility saw a significant change in Resident #59's eating as far as interest in eating and willingness to eat. The RD said Resident #59 only wanted to eat soups for a period of time. The RD said she had tried implementing different supplements but Resident #59 varied with his acceptance. The RD said she had tried to educate Resident #59 and figure out his food preferences to offer what they could. The RD said it was difficult to maximize Resident #59's nutrition with him controlling his own care. -However, review of the resident's care plan did not reveal documentation indicating the resident was particular with foods or his preferences. The RD said there had been vendor issues with keeping Magic Cup in stock at the facility. The RD said she generally tried to ensure the physician's order for nutritional supplements indicated to offer a different supplement similar in nutritional value if the supplement was out of stock. The RD said she thought the Magic Cup supplement was in stock near the nurse's station so the nursing staff did not have to leave the floor to offer it to the residents. The RD said Resident #59's order did not state they could offer an alternative. The director of nursing (DON) was interviewed on 3/13/25 at 12:45 p.m. The DON said the documentation in Resident #59's amount eaten CNA task was not missing a lot of information. The DON there were some meals missing due to Resident #59 being in the hospital. -However, there were multiple meals not documented when Resident #59 was in the facility (see record review above). IV. Resident #13 A. Resident status Resident #13, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 CPO, diagnoses included generalized muscle weakness, dysphagia, Alzheimer's disease, dementia, vitamin D deficiency, prediabetes and severe protein-calorie malnutrition. The 2/21/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of three out of 15. The resident required set-up or clean-up assistance while eating and was dependent on staff for assistance with most other ADL. The MDS assessment documented the resident was 55 inches (4 foot, 7 inches) tall and was 97 lbs. The MDS assessment documented the resident had not experienced any weight loss or weight gain. The assessment documented the resident was prescribed a mechanically altered diet. B. Record review The nutrition care plan, initiated 1/20/17 and revised 3/6/25, revealed Resident #13 was a nutrition risk due to her eating habits and preferences, eating less than 50% at meals, and having trouble chewing regular textured foods with altered dental status. Pertinent interventions included monitoring weights as ordered, monitoring intake and recording each meal and offering snacks twice a day and as needed. -However, review of the amount eaten CNA task revealed the facility failed to consistently monitor and document the amount that Resident #13 consumed at meals. Review of the amount eaten CNA task from 2/13/25 to 3/12/25 revealed the following: -Two meals were documented on 2/13/25 at 1:26 p.m.; -One meal was documented as 76% to 100% eaten and one meal was documented as 26% to 50% eaten on 2/14/25 at 1:23 p.m.; -One meal was documented on 2/18/25 at 1:40 p.m.; -No meals were documented on 2/19/25; -Two meals were documented on 2/20/25 at 1:05 p.m.; -Two meals were documented on 2/21/25 at 8:00 a.m. and 12:00 p.m.; -Two meals were documented on 2/23/25 at 9:45 a.m. and 1:10 p.m.; -One meal was documented on 3/1/25 at 9:23 p.m.; -No meals were documented on 3/2/25; -One meal was documented on 3/3/25 at 8:29 p.m.; -One meal was documented on 3/5/25 at 6:29 p.m.; -One meal was documented on 3/6/25 at 7:33 p.m.; -One meal was documented on 3/8/25 at 7:09 p.m.; and, -No meals were documented on 3/9/25. C. Staff interviews CNA #7 was interviewed on 3/12/25 at 3:41 p.m. CNA #7 said she wrote down how much the residents ate and drank at each meal and recorded it in the resident's EMR at the end of her shift. CNA #4 was interviewed on 3/12/25 at 3:52 p.m. CNA #4 said she recorded the percentage eaten of each meal in the resident's EMR. CNA #4 said each CNA was responsible for recording their residents' meal intakes after each meal. CNA #6 was interviewed on 3/13/25 at 9:21 a.m. CNA #6 said she marked how much each resident ate of each meal after each meal took place. CNA #6 said any unmarked meals in the EMR could be due to the resident refusing to eat. The RD was interviewed on 3/13/25 at 8:31 a.m. The RD said she and the facility administrators met weekly as a team to discuss the residents' nutrition. The RD said the facility had noted more difficulty in encouraging and redirecting Resident #13 with eating. The RD said Resident #13 disliked being told what to do but could use redirection and refocusing when eating. The RD said she had made an adjustment in interventions the week prior to maximize Resident #13's calorie intake between meals. The RD said she reviewed the CNAs meal intake documentation, but did not rely on them. The RD said she worked with the restorative dining aide. She said she would observe the residents herself prior to the nutrition meetings. The RD said there were missing meals in Resident #13's EMR, but she did not know why they were missing. The DON was interviewed on 3/13/25 at 12:45 p.m. The DON said meal intake percentages were documented in the task [TRUNCATED]