**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the necessary mental health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for three (#19, #9 and #10) of four residents reviewed for mental health out of 29 sample residents. The facility failed to offer alternative mental health services when Resident #9 expressed wanting to die but refused counseling services. Resident #9 was admitted to the facility after a hip replacement and heart issues. Less than six months after she was admitted she was diagnosed with cancer. She did not have signs or symptoms of depression until she fell on 7/4/23 and broke her right arm. She lost her independence and said she felt disgusted with herself since she needed staff to help her with all activities of daily living (ADLs). During her interview, she was withdrawn and had been isolating herself in her room. She said she may never be able to use her right arm like she used to ever again and she was upset about it. She said every night she thought about dying and was ready to go. She did not understand why she had not died yet. The facility failed to identify, monitor and timely provide support to address the resident's newly developing depression, nor did the facility implement a person-centered care plan to include a timely referral for other types of mental health services after the resident refused formal therapy. Furthermore, the facility failed to evaluate Resident #10 on an ongoing basis and develop a comprehensive, person-centered plan of care to meet his psychosocial needs. The facility failed to make reasonable attempts to secure professional behavioral health services when a potential need was identified that Resident #10 was developing signs and symptoms of depression. The facility failed to assess, identify and implement person-centered interventions to maximize Resident #10 goals for care. Due to the facility's failures, the resident had several days of feeling down, depressed or hopeless according to the patient health questionnaire and expressed he was trying to exist and was bored with life. In addition, the facility failed to offer Resident #19 counseling services for her mental well-being. The facility failed to identify, monitor and timely provide support to address the resident's depression worsening after her family stopped visiting her, such as through the implementation of a person-centered care plan and timely referral for mental health services. Findings include: I. Facility policy The Behavioral Health Policy, effective 8/3/23, was provided by the director of nursing (DON) on 12/14/23 at 3:01 p.m. read in pertinent: Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, and/or accommodating a resident's distress or loss of abilities. Behavioral health care and services will: -Ensure that the necessary care and services are person-centered and reflect the resident's goal for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety, -Ensure that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being, -Provide meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents, and the community, -Provide an environment and atmosphere that is conducive to mental and psychosocial well-being, -Ensure that pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated, -Identify individual resident responses to stressors and utilize person-centered interventions developed by the interdisciplinary team (IDT), -Ensure care plans address the individualized needs of the resident and contain individualized interventions based on the diagnoses; and -Ensure that the IDT, which includes the resident, the resident's family, and/or representative, whenever possible, develops and implements approaches to care that are both clinically appropriate and person-centered. II. Resident #9 A. Resident status Resident #9, age over 65, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO) diagnoses, included transient cerebral ischemic attack (stroke), squamous cell carcinoma (cancer) and heart disease. According to the 11/1/23 minim data set (MDS) assessment Resident #9 had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS did not contain an assessment of the resident for depression. B. Resident interview Resident #9 was interviewed on 12/14/23 at 3:02 p.m. Resident #9 said she was getting on the bus to go out for the Fourth of July parade as a group activity and fell. She said she felt disgusted with herself and was angry that she fell. Resident #9 said she could only lift her arm about 90 degrees to her body and she may never get to lift it more. She said while she healed she could not participate in group activities. She said a physical therapist (PT) went to her room to work with her. She said activities were not offered to her in her bedroom. She said she was depressed and ready to die. Resident #9 said she was admitted to the hospital after the fall to treat her injuries but could not remember how long she was admitted for (record review showed she was admitted for 10 days). She said when she returned to the facility she was no longer independent and required staff assistance for almost everything. Resident #9 said she fell again on 10/23/23 when she tried to pick a card up off the floor and slid out of her wheelchair. Resident #9 said it was embarrassing and she scooted herself across the floor to get her call light for staff assistance. She said she was still depressed and was not sure if the facility offered her counseling services but she did not want to talk to someone. She said she did not know what else the facility could do to help her depression but every night she felt depressed and thought she was better off dead or was ready to die because of her age and she still could not walk or be independent. She said she felt like her bones were taking a long time to heal. C. Record review Resident #9's comprehensive care plan, revised 11/16/23, documented the resident had a decline in activity involvement due to her depression and her broken arm. An intervention for activities, revised on 8/3/23, was to explain to the resident the importance of social interaction and encourage the resident's participation by invitation and encouragement. It was also documented the resident had depression signs and symptoms due to her right broken humerus (arm) and subsequent decline in functional abilities. Interventions were documented as the following: -Discuss with the resident any concerns, fears, issues regarding health, or other subjects, -Monitor, document, and report any risk for harm to self as needed; and -Monitor, document, and report any signs or symptoms of depression. A progress note entered on 8/2/23 documented Resident #9's MDS assessment was completed. During the MDS assessment, the resident stated that had thoughts that she would be better off dead because her arm was not allowing her to do as much as she used to. She said she knew it was healing just not as fast as she wanted it to. The resident was asked if she wanted to speak to a therapist about her thoughts and she stated that she did not want to talk to anyone. The ADON and DON were notified of the findings and the ADON was going to talk to the resident.The resident was asked if she would like to attend her upcoming care plan meeting on 8/3/23. The resident stated that she did not want to attend. A progress note entered on 8/2/23 documented the ADON spoke with Resident #9. The resident said that she had feelings of depression due to the fact that her arm still had not healed and she needed a lot of assistance from staff. The resident said at times she felt she would be better off not being here. The ADON asked the resident to further elaborate on what she meant and if she had thoughts of harming herself. The resident denied thoughts of harming herself but said she felt like she could not care for herself without so much help from staff that she may have been better off not making it through the fall that resulted in her arm injury. The ADON consoled the resident and said he understood her feelings and that it was okay for her to feel a little down about not being as independent as she was previous to her fall. The ADON told the resident he was concerned about her being too depressed or her depression worsening. The resident said she did not want to talk to anyone about the situation but she agreed to the ADON informing her physician to see if medication was needed for her depression. A care conference held on 8/14/23. The notes documented Resident #9 had a positive outlook on life. She was not fond of being at the facility but was making the best of it. The note documented that the resident said it was hard getting old. Resident #9's patient health questionnaire (PHQ-9) was documented as a nine which indicated mild depression. Resident #9 said she did not want to talk to anyone at this time but agreed to the ADON informing her physician about possibly starting an antidepressant. The resident was having a hard time because she was not healing as fast as she wanted and was not independent like she used to be and it made her upset. A progress note entered on 8/21/23 documented the physician visited the resident on 8/17/23. The physician said the resident's appetite was good and she still attended desired activities. The resident declined therapy and medications during the visit and would inform the staff if her depression symptoms worsened. The facility continued with therapy and the resident's current plan of care. A progress note entered on 9/13/23 documented Resident #9's lungs had crackles in the bases. The resident denied being uncomfortable and admitted to a non-productive cough. The resident told the nurse that she did not want to go to the hospital and declined all tests. She said that she was ready to go (die) when it was her time. She allowed the nurse to give her oxygen to keep her oxygen within normal limits. A progress note entered on 9/13/23 documented Resident #9's oxygen saturation decreased to 86% (normal limits 90% and above) on room air. The resident refused to wear oxygen. The resident stated that she did not want to go to the hospital and declined all tests. She said if it was her time to go then she was ready. The resident's physician said she would visit the resident for an assessment. A progress note entered on 9/13/23 documented the nurse notified the resident's medical durable power of attorney (MDPOA) of Resident #9 refusing to wear her oxygen. The resident's oxygen saturation was at 77% on room air. The resident's MDPOA said he was on his way to the facility. The nurse ended the phone call and reapproached the resident to offer oxygen and the resident agreed. A progress note entered on 9/14/23 documented the resident tested positive for rhinovirus (type of head cold) and began antibiotics. D. Staff interviews The ADON was interviewed on 12/14/23 at 2:30 p.m. He said before Resident #9's accident she was independent with all activities of daily living (ADLs). He said she was very private and did not want any interventions in place for her depression. The ADON said she did not want to die but if she died then she was okay with it. He said the resident declined activities because she did not want to be seen by other residents being wheeled by staff to activities. The staff encouraged the resident to participate in activities and that the other residents would not think less of her if she needed help from staff. The staff made her comfortable to participate in activities. He said the resident did not like when staff checked on her too much and would not let staff come in and sit with her. The ADON said the staff documented that they checked on her. -However, the facility failed to document consistently when they checked on Resident #9. The activity director (AD) was interviewed on 12/14/23 at 9:24 a.m. She said she knew the resident became more depressed after the accident because she was no longer independent. She said the fall affected Resident #9 physically however it affected her mentally and she became more withdrawn than she used to be. The AD said when the resident returned from the hospital the resident said she was giving up on life because of her injury. The AD said she would not be surprised if Resident #9 still felt this way but she did talk to her a lot and the resident seemed okay. She said the facility was not doing anything for Resident #9's depression that she was aware of. III. Resident #10 A. Resident status Resident #10, over the age of 65, was admitted on [DATE]. According to the December 2023 CPO, diagnoses included traumatic subdural hemorrhage (bleeding in the brain post traumatic brain injury) with loss of consciousness status unknown, sequela (bleeding in the brain post traumatic brain injury), gastro-esophageal reflux disease without esophagitis, benign prostate hyperplasia without lower urinary tract symptoms (enlarged prostate gland that is not cancerous) and history of falling. According to the 10/29/23 MDS assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He did not exhibit disorganized thinking or inattention. He did not have behaviors, including rejections of care. The MDS assessment identified Resident #10 had several days of feeling down, depressed or hopeless. B. Resident interview and observations Resident #10 was interviewed on 12/11/23 at 1:11 p.m. He said she had a stroke and he needed a new brain. He said he had been in his current condition for almost ten years. Resident #10 said he was having one hell of a time just trying to exist. The resident said he was bored and bored with life. Observations throughout the survey between 12/11/23 and 12/14/23 between the hours of 8:00 p.m. and 6:00 p.m. identified Resident #10 did not get out of bed. He ate his meals in his room. When the resident was not eating, he spent his time sleeping or watching sports channels. C. Friend of the resident interview A friend of Resident #10 was interviewed on 12/13/23 at 12:0 p.m. She said she tried to come see Resident #10 almost everyday around lunch time so he had some company. The resident's friend said the resident's family member had not been available to visit Resident #10 as often as he used to. She said she really did not see too many staff check in with Resident #10. He said he told her he just wanted to go to sleep and pass. The friend said she wished staff would try to encourage him to spend less time in his bed. D. Record review -The review of Resident #10's comprehensive care plan identified the facility failed to develop a person-centered psychosocial wellness care plan to maintain the resident's highest practicable level of physical, mental and psychosocial well being. The resident's care plan did not identify individualized approaches of care/interventions that were part of a supportive mental and psychosocial environment which was directed towards understanding, preventing, relieving, and/or accommodating the resident's distress or loss of abilities. The 11/3/23 social service assessment read Resident #10 walked with a walker with two person assist and a gait belt for short distances. He needed help with most ADLs such as transferring, bed assist, dressing, toileting and bathing. He could eat independently in his room with set up help. Resident #10 was aware of self, family, friends, years, month, day and his surroundings. The resident did not have behaviors and his mood was pleasant. According to the social service assessment under the category of psychosocial, Resident #10 had a family member that visited and the resident was developing a good relationship with the staff. He had tried to use headphones that connected to the television so he was able to hear better but the resident could not tolerate the headphones. -There was no additional information or needs provided under psychosocial when the resident was assessed with social services. The 11/7/23 physical therapy evaluation documented Resident #10 refused to participate during the physical therapy evaluation. According to the evaluation, the resident said I am just going to die here in this bed and I will lie here the rest of my life until I die. The 11/7/23 occupational therapy evaluation documented Resident #10 liked sports and the outdoors. He felt he could not stand or walk and declined occupational therapy or attempts to get out of bed during the therapy evaluation. According to the evaluation, the occupational therapist offered a trip outside, modified bowling in a seated position, and offered bingo. The occupation evaluation indicated the resident declined and said What is the point, I can't do it, I am just going to die here and I wish it would be sooner rather than later. I have too much blood in my head and no one can drain it, I don't just have a zipper up there. -The review of the November 2023 and the December 2023 treatment administration record (TAR) and progress notes did not identify Resident 10's mood and behavior was tracked and monitored after he made statements of wanting to die on 11/7/23. A list of residents receiving counseling supportive services was provided on 12/13/23 by the facility. The list did not identify Resident #10 received counseling supportive services even though the resident identified he had several days of feeling down, depressed or hopeless as identified by the MDS assessment and feelings of wanting to lie in bed and die as identified in the 11/7/23 physical and occupational therapy evaluations. E. Staff interviews The activity director (AD) was interviewed on 12/14/23 at 9:53 a.m. The AD identified Resident #10 did not participate in group or individualized activities other than watching sports on television. The AD said when she had asked him to do an activity, he told her he just needed a new brain. The AD said the resident was not part of a one-to-one program offering additional opportunities for engagement and socialization (cross-reference F679 for activity programming). The social service director (SSD) was interviewed on 12/14/23 at 10:47 a.m. The SSD said she helped residents with emotional needs by connecting residents to counseling services and other volunteers who helped provide additional support. The SSD said she checked in with Resident #10 but had not documented her check ins. The SSD said Resident #10 had not told her he was bored with life. She said Resident #10 had said he felt he could not do what he used to do since his stroke, but he did not seem too upset by it. She said he would talk to her about his past job and sports. She said a family member that he was close to use to visit more but he has not visited Resident #10 as much lately. The SSD said counseling services might help Resident #10 break out of his shell and encourage him to come out of his room. She said she thought a physician referral for the counseling service was made for Resident #10 but she was not sure what the status was. The SSD was interviewed again on 12/14/23 at 12:40 p.m. The SSD said she was thinking of another resident when she said she thought Resident #10 already had a physician referral for counseling services. She said a referral for counseling service was not made with the physician for Resident #10. The SSD said she was not aware Resident #10 told therapy on 11/7/23 that he wanted to remain in bed and die. She said the documented resident comments should have been communicated to her so she could have followed up sooner. The assistant director of nursing (ADON) was interviewed on 12/14/23 at 2:26 p.m. The ADON said he just made a counseling referral for Resident #10's physician. The nursing home administrator (NHA) was interviewed on 12/14/23 at 2:41 p.m. The NHA said the facility had some options within the community for behavioral health services including counseling services with a local hospice provider and telehealth. The NHA said she would reach out to the licensed social workers on the hospital campus and she would research other available resources with mental health services outside the community. The NHA said the facility should have identified and communicated the expressed feelings from Resident #10 so the facility could have provided him additional support. IV. Resident #19 A. Resident status Resident #19, age over 65, was admitted on [DATE]. According to the December 2023 CPO, diagnoses included dementia, recurrent major depressive disorder, left hip osteoarthritis, breast cancer and restless leg syndrome. According to the 11/1/23 MDS assessment Resident #19 had a severe cognitive impairment with a BIMS score of five out of 15. Her depression was not documented other than her diagnosis. B. Resident interview Resident #19 was interviewed on 12/11/23 at 11:53 a.m. She said she felt really depressed and the facility was not helping her with it. She said her family stopped visiting her but she did not know why. She said when her family did not visit it affected her mentally. Resident #19 said she was angry but did not know why. She said she knew she did not eat enough and had lost a lot of weight. During the interview, the resident was observed lying in her bed in the dark and she chewed on her nails constantly. C. Record review Review of the progress notes from January 2023 to December 2023 revealed the resident's depression signs and symptoms were not documented by the staff even though she had a diagnosis of major depression disorder and they discontinued her antidepressant on 5/22/23 and the facility restarted her antidepressant medication on 12/4/23 due to her losing weight. Resident #19's comprehensive care plan, revised 11/16/23, documented she was dependent on staff to meet her emotional, intellectual, physical, and social needs due to her cognitive deficits and physical limitations. The interventions for staff were to offer activities to Resident #19 and allow her to decline. She used Lexapro (antidepressant medication) for her depression. The interventions for the antidepressant were to monitor for negative side effects. She was documented as having a nutritional problem due to anorexia. The interventions documented were to monitor food intake and offer nutritional supplements when she refused to eat. -However, the facility failed to implement interventions for staff to provide support when the resident was depressed or guidance for staff to provide support for her major depressive disorder. D. Staff interviews The SSD was interviewed on 12/12/23 at 4:07 p.m. She said the facility had a few residents who had a hard time with depression and the facility worked with another organization to provide counseling services to the residents. She said the facility sent referrals if a resident needed counseling or therapy services and the organization provided the services once they accepted the referral. She said the facility completed pre-admission screening and resident review (PASRR) when residents were admitted . If the resident needed services the PASRR provided recommendations the facility followed. The SSD was interviewed again on 12/14/23 at 11:00 a.m. She said Resident #19 had a PASRR II completed and there were no recommendations needed for her major depressive disorder because dementia was her primary diagnosis. She said Resident #19 was not provided counseling services and she was not sure if the resident wanted to talk to anyone about her depression. Nurse aide (CNA) #1 was interviewed on 12/14/23 at 5:15 p.m. She said if a resident expressed depression or wanting to die she notified the nurse and made sure the resident did not have anything to harm themselves with. She said she would not leave the residents by themselves and used the call light to get help if possible. Licensed practical nurse (LPN) #1 was interviewed on 12/14/23 at 5:17 p.m. She said if a resident expressed depression or wanting to die she asked open-ended questions to get the resident to talk about what was going on and see if they were safe. She said she notified the resident's physician and the nurse supervisor. She said she did not experience a resident being depressed or heard of a resident saying they were ready to die. She said she checked the facility's policy to make sure she provided the correct amount of support to the resident and checked to see if the resident had anything to harm themselves. -The nursing staff interviewed had not worked at the facility for a long time and did not experience any residents showing signs of depression or expressing they wanted to die.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure one (#23) of two residents reviewed for skin and pressure injuries, out of 15 sample residents, received care consistent with professional standards of practice to prevent and heal pressure injuries. Specifically, Resident #23 developed two facility acquired avoidable pressure ulcers on his back, one of which was unstageable. Resident #23 required assistance with staff for activities of daily living (ADLs) such as dressing but staff did not identify skin concerns on the resident's back until the resident had an unstageable pressure injury with 100% necrotic tissue. The resident was identified at risk for pressure ulcers but had limited pressure ulcer preventive measures in place. The resident also had a decline in condition, food intake and mobility. He was not on a routine turning schedule when he required assistance of staff with bed mobility. Resident #23 preferred to sleep on his back. Resident #23 was not offered an air mattress to relieve pressure and help reduce pressure ulcer development until 8/24/22, two days after the resident developed two facility acquired pressure ulcers. Findings include: I. Professional reference A. The NPUAP Pressure Injury Stages, The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (undated) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable erythema. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. II. Facility policy The Pressure Ulcer Prevention policy, revised 5/15/2020, was provided by the interim director of nursing (IDON) on 8/30/22 via email. The policy read in pertinent part: All residents will be assessed using the Braden scale upon admission, quarterly, and with significant change in condition. Findings will be documented in the resident's chart. Skin will be assessed during personal care and weekly skin checks. Any findings are to be communicated to the nurse orally or via the skin check record and documented by the nurse in the resident chart. Preventative measures will be instituted as soon as the resident is determined to be at risk for developing a pressure ulcer, or if a pressure ulcer is already present . Residents who cannot sufficiently turn themselves to relieve the pressure must be turned every two hours. If the resident does not tolerate turning due to confusion and combativeness, place the resident on a pressure relieving mattress and turn at least every 4 hours. Document in the nurse's notes. According to the policy the facility may use a pressure-reducing chair cushion or air mattress. Staff also should use a single layer pink pad over pressure relief cushions. The policy read the facility should maintain the resident's head of the bed at or below 30 degrees or at the lowest degree of elevation consistent with the resident's medical condition. Staff should reposition chair-bound residents every hour if they cannot perform pressure-relieving exercises every 15 minutes. Staff should use pillows, foam wedges, sheepskin and heel and elbow protectors to prevent bony prominences from rubbing together. The PUP (Pressure Ulcer Prevention) packet, undated, was provided by the IDON on 8/30/22 via email. The packet outlined facility procedures to prevent pressure ulcers. According to the PUP, staff should: -Complete a new Braden score assessment for high risk triggers and new pressure sores; -Place the resident on a Q (every) two hour turning log; -Provide the resident a pressure relieving mattress; -Notify the director of nursing (DON) and the assistant director of nursing (ADON). The DON or the ADON would notify registered dietician (RD) for nutritional consultation; and, -Complete the care plan and place it in the folder to be scanned into the chart; According to the PUP, if the pressure ulcer was a new wound. Staff would complete a wound assessment that included: -Wound picture; -Wound consult requested from the physician; and, -Request vitamin C and zinc orders from the physician. III. Resident status Resident #23, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included cardiomegaly (enlarged heart), dementia without behavioral disturbances, and fracture of unspecified part of the neck of the left femur. The 7/31/22 minimum data set (MDS) assessment indicated Resident #23 was moderately cognitive impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident required limited assistance of one with bed mobility, dressing, personal hygiene, transfers, locomotion, and toileting. According to the MDS assessment, the resident was at risk for pressure ulcers. The MDS did not identify the resident had an actual pressure ulcer or interventions put in place to prevent the development of a pressure ulcer. IV. Observation and resident interview Resident #23 was sitting up in his lounge chair on 8/22/22 at 4:08 p.m. The resident was not observed to have a pressure relieving cushion or pad on his chair. He did not have a pressure relieving mattress or air mattress placed on his bed. He did not have positioning cushions or a wedge in place to assist the resident off his back. Resident #23 was observed in bed on 8/23/22 at 3:04 p.m. The resident was awake and laid flat on his back. He did not have a pressure relieving mattress or air mattress placed on his bed. He did not have positioning cushions or a wedge in place to assist the resident off his back. Resident #23 said he had some pain in his back. Resident #23 said he was not aware of any current wounds or injuries to his back. Resident #23 was observed sleeping flat on his back in bed on 8/24/22 at 10:24 a.m. The resident had a pillow/wedge positioned on his left side between him and the edge of the bed. The pillow/wedge did not provide the resident positioning support to relieve pressure off of the resident's back. A pressure relieving mattress or air mattress in place could not be determined at that time. -At 11:06 a.m. the resident was observed to be awake in bed. He had no changes to his position and continued to lay flat on his back. The resident said he was not in pain. -At 5:44 p.m. Resident #23 was observed sleeping in his bed. He did not have a positioning cushion, pillow or wedge in place and he laid flat on his back. Resident #23 was observed in bed sleeping 8/25/22 at 8:51 a.m. The resident laid flat on his back. He did not have a positioning device in place. -At 10:29 a.m. the resident remained sleeping in bed. There was no change in his position as he laid flat on his back. V. Record review The 11/14/19 CPO directed staff to conduct and skin check weekly and document the condition of skin every day shift every Monday. The 5/28/22 Braden scale for predicting pressure ulcer risk read Resident #22 was at moderate risk for pressure ulcer development. His sensory perception was very limited. His mobility was very limited but he walked occasionally. His skin was often moist. Resident #23 had probable inadequate food intake. The resident had a potential problem with friction and shearing. According to the Braden scale, the resident was able to move freely or required minimum assistance in movement. The 8/8/22 skin observation tool did not identify Resident #23 had skin concerns on his back. The 8/15/22 skin observation tool did not identify Resident #23 had skin concerns on his back. The 8/15/22 bath/skin check did not identify skin concerns. Review of Resident #23's medical record did not identify documented skin concerns prior to 8/22/22. The 8/22/22 Braden scale for predicting pressure ulcer risk read Resident #22 was at high risk for pressure ulcer development. His sensory perception was very limited. His mobility was very limited. Resident #23 had very poor food intake and had a problem with friction and shearing. According to the Braden scale, the resident required moderate to maximal assistance in moving. The 8/22/22 nurse note read Resident #23 was on alert charting for a pressure ulcer discovered on his back by the 8/22/22 day shift. According to the note, the wound nurse was scheduled to evaluate the resident on 8/23/22. The note read Resident #23 refused to lie on side despite encouragement. Pt. (patient) denies pain/needs, no s/sx (sign/symptoms) spreading infection at this time. Will continue to monitor. The 8/22/22 skin/wound note read Resident #23 was found to have two pressure wounds on his spine on the morning of 8/22/22. According to the note, the resident had a pressure ulcer on his lower spine that was 100% eschar (dead tissue). He had a second pressure ulcer on the middle of his spine that was non-blanchable erythema (redness). The note indicated the physician, the (interim) director of nursing, and the resident's family were notified, and pictures of the pressure ulcers were taken and measurements were completed. The facility obtained orders from the physician. The note revealed the resident was started on a turning schedule. The note read if the resident was not receptive to turning/repositioning, the facility would implement an air mattress to be the next step. The resident was on nutrition intervention and vitamin C and zinc was implemented. The note identified the resident had a significant decline and had not been eating well, taking his supplements or getting up and moving as much. According to the wound note, Resident #23 sat and slept in the same position. Staff would be educated on the need for repositioning. The wound nurse was contacted and she would be available to see the resident on 8/24/22 for a wound consultation. The note read a new cushion for his back was requested from materials management (supply department). The 8/22/22 wound weekly observation tool read Resident #23's physician was contacted and responded to facility questions and requests. The 8/22/22 observation tool identified the pressure ulcer to the resident's lower spine was facility acquired and unstageable with necrotic tissue. The observation tool revealed the 8/22/22 observation was the first observation and did not have prior reference to refer to. The peri-tissue was red and the wound edges and shape were irregular. The unstageable pressure ulcer measured 15 millimeters (1.5 centimeters) in length and 25 milliliters (2.5 centimeters) in width. The tool indicated the presence of erythema. The observation tool indicated a pad located on his chair had to be thrown away because it was soiled. The 8/22/22 CPO provided orders for wound care for pressure ulcer #1 on the resident's lower spine, and pressure ulcer #2 on the resident's mid spine. According to the orders, staff were to cleanse the pressure ulcers with skintegrity wound cleanser, skin prep to intact skin, and apply mepilex every three days and prn (as needed). A second 8/22/22 CPO read the resident had orders for a wound consultation with the wound nurse. The 8/22/22 skin care plan read Resident #23 had a potential for pressure ulcer development related to immobility. According to the care plan, the resident should have intact skin, be free of redness, blisters or discoloration. The 8/22/22 care plan identified Resident #23 had a newly developed unstageable pressure sore on his back. Care plan interventions implemented on 8/22/22 included: -Administer treatments as ordered and monitor for effectiveness. -Educate the resident/family/caregivers on causations of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. -Inform the resident/family/caregivers of any new area of skin breakdown. -Monitor nutritional status. Serve diet as ordered, monitor intake and record. -Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), and stage. -The resident required supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Care planned interventions added after 8/22/22 included: -Pressure relieving was added to the back of the resident's recliner as of 8/23/22. -Pressure relieving air mattress added to the resident's bed as of 8/24/22. -Attempt to reposition the resident every two hours as of 8/24/22. The care plan noted on 8/24/22, the resident was resistant to repositioning therefore an air mattress was implemented to the resident's plan of care. The 8/23/22 nurse note read Resident #23 was on focused charting for pressure ulcers on his back. According to the note, the wound nurse was to round and evaluate the resident on 8/24/22. The note identified Resident #23 requested to remain in his bed the majority of shift. He allowed staff to assist with toileting and repositioning. Pillows were placed for additional comfort/pressure relief which the resident was not tolerating well. Routine pain medication was administered per orders. The note indicated the resident spent some time up and out of bed and in his recliner with two person staff assistance and was offered fluids during his visit with his daughter. The 8/24/22 note read Resident #23 was on alert charting for pressure ulceration at his back. The note identified the resident had a stage 1 pressure ulcer (mid spine) and an unstageable pressure ulcer (lower spine). According to the note, he was encouraged to sleep on his side but wiggles until he is on his back again and will not sleep anywhere but on his back. The resident was compliant with all his cares, was afebrile with no signs and symptoms of a spreading infection, and is currently sleeping with deep/rhythmic breathing. The August 2022 visual/bedside [NAME] report (certified nurse aide communication care guide) as of 8/24/22, was reviewed. According to the [NAME], the resident was able to move independently in his bed. -The [NAME] report did not direct staff to review Resident #23's skin during personal cares. The [NAME] did not direct staff to reposition the resident. VI. Staff interview The registered nurse clinical consultant (RNCC) was interviewed on 8/24/22 at 2:04 p.m. The RNCC said Resident #23 was at risk for pressure ulcer development but felt he was not on a pressure reducing mattress because he was on a turning schedule. She said there was no staff officially reviewing skin concerns prior to the IDON (interim director of nursing) who was placed in her position as of 8/22/22. The RNCC said a toileting schedule and a turning schedule could be one and the same. Registered nurse (RN) #1 was interviewed on 8/24/22 at 2:25 p.m. She said staff reviewed the resident's skin during baths/showers. The resident last was bathed on 8/15/22. The RNCC was interviewed on 8/24/22 at 5:31 p.m. She said a pressure relieving cushion was placed on the resident's chair as of 8/23/22. The RNCC said the facility was having difficulty with their air mattresses filling correctly with working air pumps. She said they have found an available air mattress and were in process of filling it and determining it was in good working order and holding air before placing it on the resident's bed. The RNCC said if the air mattress did not work, she assumed the IDON would order a new air mattress. She said she could not find a turning schedule for Resident #23. She said the IDON would hang a turning schedule in his room reminding staff to turn the resident every two hours. The RNCC said she could not find a wound consultant note so she would check if the wound nurse has seen the resident's pressure ulcer yet. Certified nurse aide (CNA) #1 was interviewed on 8/24/22 at 5:41 p.m. The CNA said staff were supposed to turn Resident #23 every two hours but he usually would not allow the staff to turn him because of his back and leg pain. CNA #2 was interviewed on 8/24/22 at 5:47 p.m. She said most residents should be turned every two hours if they were not able to turn themselves. She said she was not aware of having to do anything special for Resident #23. She said they would turn him more if he pushed his call light and requested. The IDON was interviewed with the RNCC on 8/25/22 at 5:21 p.m. They said the resident had a pressure relieving mattress on his bed as of 8/25/22. The RNCC said the wound nurse had not seen Resident #23 as ordered because she had a family emergency and did not inform the facility. The RNCC said the facility would work to improve communication with the wound nurse. She said the wound nurse would see the resident on the morning of 8/26/22. The IDON said she used to be wound care certified and would work on renewing her certification. The IDON said the resident's food intake has recently gone down. She said there was no documentation or reports that the staff had noticed concerns with Resident #23 before he was determined to have an unstageable pressure wound. Staff should be reviewing his skin weekly and then every time they perform cares such as dressing. The RNCC and the IDON said the resident has had a decline in condition and possibly at the end of life. They said they would inform staff during the new staff huddle to look at his skin daily. VII. Facility follow up The staff huddle minutes/agenda were provided by the IDON on 8/26/22 via email. According to the huddle minutes/agenda, the nurse practitioner saw Resident #23 on 8/26/22. He has had a significant change and was placed on comfort care as of 8/26/22. Resident #23 had a new turn/check/toilet log in place to have staff check off accordingly. The huddle minutes read staff were instructed to: -Turn Resident #23 every two hours and document on the turning log hung on the bathroom door. -Check his skin closely and make sure his dressing was intact and let the nurse know if his dressing was starting to come off his wound. The dressing should be changed every three days and as needed. -Monitor Resident #23 closely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** VII. Resident #14 A. Resident status Resident #14, age [AGE], was admitted on [DATE]. According to the admission computerized physician orders (CPO), diagnoses included age-related physical debility, repeated falls, and chronic atrial fibrillation. According to the 6/12/22 MDS assessment, the resident was cognitively impaired with a score of six out of 15 on the brief interview for mental status exam. The resident required extensive one person physical assistance with bed mobility, toileting, and transfers. It was noted the resident did not have any falls since admission. B. Record review The admission fall assessment completed on the day of admission 3/8/22 identified the resident was at high risk for falls. Fall #1 A fall note on 3/28/22 at 6:46 p.m. showed the resident fell. Neurological checks were within normal limits, no injuries were noted, and safety concerns were noted as the resident does not call for help and he is resistant to care assistance. A nursing note on 3/29/22 at 1:46 p.m. detailed the resident was on alert charting for a fall without injury on 3/28/22. The patient was noted to be very resistant to calling staff for help. A nursing note on 3/30/22 at 12:35 a.m. showed the resident was using his call light more often but the certified nurse aide (CNA) staff were still finding him attempting to transfer himself if staff did not get to his room quickly. -There was no description of the fall in the nursing progress notes/fall notes in the electronic medical record (EMR). A paper tracking record for improving patient safety (TRIPS) report on 3/28/22 at 3:30 p.m. noted the fall as the CNA heard a bang and went to check on the resident. He had lost his balance walking to the bathroom and fell over using his wheelchair as a walker. The resident had no complaints of pain with active range of motion and was assisted off the floor and back to his wheelchair and then to the bathroom. The resident stated he lost his balance. Immediate steps taken to prevent recurrence were to instruct the resident to call for help and increased staff monitoring. A care plan interventions to prevent falls form was completed on 3/28/22. It was noted the registered nurse clinical consultant (RNCC) reached out to the resident's family to discuss and determine the reasons for falls. Family stated the resident was self conscious with perineal care and rejected care at times. The resident's care plan was initiated on 3/8/22 and focused on risk for falls. It was reviewed and updated on 3/30/22 and referenced the fall on 3/28/22. A post fall facility incident report showed the resident stated he lost his balance and his knee went out. The resident was alert and oriented to person, place, time, and situation at the time of the fall. There were no injuries. The resident was noted to prefer to use his wheelchair as a walker. Fall #2 A paper TRIPS report on 7/4/22 at 9:00 a.m. showed the resident lifted the recliner all the way and slid out on the floor. The resident was fully assessed and assisted back into the recliner. The resident was reeducated on how to properly use the recliner. Immediate steps taken to prevent recurrence were noted as instructing residents to call for assistance and increased staff monitoring. No injuries were noted. The resident was wearing shoes at the time. A nursing note on 7/5/22 at 12:38 a.m. showed the resident was on alert charting for sliding out of his recliner after raising it all the way up. A care plan interventions to prevent falls form was completed on 7/4/22. It indicated appropriate footwear and anticipate resident needs. -The TRIPS report showed the resident was wearing shoes at the time of the fall. A post-fall incident report dated 7/4/22 at 9:50 a.m. did not reveal any new information about the fall or new interventions. -There were no new updates, revisions, or review of the resident's care plan after this fall. Fall #3 A TRIPS report dated 7/26/22 at 5:15 p.m. showed the resident was found on the floor in front of his recliner. The recliner was up as far as it could go and the resident was dumped out of the recliner onto the floor. No injuries were reported. A nursing incident note on 7/26/22 at 7:08 p.m. detailed the fall as the resident's recliner was in the highest position and the resident reported he was trying to raise his feet and pushed the wrong button causing him to slide out of the chair on the floor. Staff determined to switch out the recliner with one that did not lift him up since he was no longer standing on his own and using a hoyer (mechanical) lift for transfers. A nursing note the next day (7/27/22) confirmed the recliner was replaced the morning after the fall. A care plan intervention to prevent falls was completed on 7/26/22 and indicated an intervention to change the recliner as the resident had lifted the recliner so high it dumped him on the floor on more than one occasion. The post-fall investigation dated 7/26/22 showed the staff determined to remove the standing assist recliner from the resident's room. -The care plan was not updated to specify the resident should not have this type of recliner. Fall #4 A fall note on 8/12/22 at 5:43 a.m. showed the resident was found on the floor laying on his left side next to the bed. He was assessed by the nurse and no injuries were noted. The TRIPS form on 8/12/22 showed no injuries and the resident had slipped out of his bed thinking someone came into his room. Immediate steps taken to prevent recurrence were left blank on the form despite the form's instructions requiring at least one intervention be listed. A care plan intervention to prevent falls was completed on 8/12/22. It was signed by a licensed practical nurse with the resident's name and date of birth , but was left blank in the body of the form. The facility's post fall incident report showed the resident was found lying on the floor. The resident was noted to be very confused and was currently being treated for a urinary tract infection (UTI) and on antibiotic treatment for it. A nursing note on 8/12/22 at 4:44 p.m. showed a fall mat was placed bedside while the resident was at rest. -The fall mat was not documented in the care plan or anywhere else to alert staff of its need. Fall #5 A fall note on 8/18/22 at 5:36 a.m. showed the resident was found on the floor lying on his left side next to the bed. He was assessed and found to have no injuries and transferred back to bed. The fall mat was noted to not have been in place at the time of the fall. The CNA was noted to have been inserviced on the importance of making sure safety measures were in place before leaving after caring for residents. The TRIPS report on 8/18/22 showed the resident had stated he was ready to get up for the reason for the fall, and immediate steps taken to prevent recurrence was the CNA was inserviced concerning the use of the fall mat. A care plan intervention to prevent falls was completed on 8/18/22. It noted for a fall from bed to ensure a mat beside and to assess for need of pain medications. It also noted appropriate footwear. A post-fall incident report dated 8/18/22 did not reveal any new information related to the fall. However, under the notes section a follow up investigation performed by the IDON on 8/24/22 (six days after fall and during survey) showed the resident was started on a new drug, mirtazapine on 8/15/22, and started to showed increased confusion and had two falls on 8/18/22. The resident was taken to the ED (emergency department) on 8/19/22 and evaluated for altered mental status. He was started on IV (intravenous) antibiotics for three days and mirtazapine was discontinued on 8/18/22. On 8/24/22 it was noted the resident's confusion was continuing to slowly improve. -No updates or reviews to the care plan were completed. Fall #6 A TRIPS report dated 8/18/22 (same day as Fall #5) showed the resident experienced an unwitnessed fall. There was no description of the fall noted. The immediate steps taken to prevent recurrence were left blank. It was noted the resident had reopened a scab on his right forearm. No other injuries were noted. A care plan intervention to prevent falls was completed on 8/19/22. It was noted a wedge pillow was to be added to the residents' interventions. The post fall incident report dated 8/18/22 at 10:00 p.m. detailed the fall. Another resident used their call light to alert staff when they heard someone yelling for help. The nurse heard Resident #14 yelling for help and found him on the floor laying on his right side next to the bed on the fall mat. The resident had an abrasion to the right wrist and a reopened scab over the area above the right eye. The post fall investigation done by the IDON showed the resident was started on a new drug, mirtazapine on 8/15/22, and started to show increased confusion and had two falls on 8/18/22. The resident was taken to the ED on 8/19/22 and evaluated for altered mental status. He was started on IV antibiotics for three days and mirtazapine was discontinued on 8/18/22. On 8/24/22 it was noted the resident's confusion was continuing to slowly improve (the same information provided for Fall #5). Nursing notes showed resident was sent to the hospital for evaluation of altered mental status on 8/19/22 at 9:45 a.m. and returned the same day at 2:45 p.m. with an intravenous catheter (IV) and would receive IV antibiotics for three days for a UTI. -The wedge pillow was not added to the resident's care plan, nor was there a review or any updates to the care plan. The resident's kardex (CNA staff directive) as of 8/24/22 did not reference a fall mat or wedge pillow for safety. C. Observations On 8/23/22 at 10:28 a.m. Resident #14 was observed in bed with no fall mat in place. D. Interviews CNA #2 was interviewed on 8/24/22 at 2:40 p.m. She said if she were working with a resident she was unfamiliar with, she would reference the kardex and was where she would find out information about how the resident transfers or safety precautions in place. CNA #6 was interviewed on 8/25/22 at 9:18 a.m. She said she had not been on shift when Resident #14 had fallen. She said she could reference the care plan to find out fall interventions for residents and she thought she had done that once before for Resident #14. She said she could also ask her nurse about fall interventions and if the nurse did not know they would reference the care plan. CNA #4 was interviewed on 8/25/22 at 10:52 a.m. She said Resident #14 seemed to be doing better since she first started a few weeks previous and was pretty alert today and able to make his needs known. She said he was rolling out of bed and they were implementing a fall mat next to his bed. She said he would use his call light at times as well, and ensuring that was within reach was important. The IDON and RNCC were interviewed on 8/25/22 at 4:05 p.m. The RNCC said in the last two or three weeks Resident #14 went from limited assistance and eating independently to now requiring extensive assistance from staff, and she attributed this to an acute infection process related to his UTI. She said he was able to press his call light and make most of his needs known. The IDON said he was getting less confused and looking better but she was unaware of how alert he was. The RNCC staff mostly communicated fall interventions and safety awareness in handoff report (staff report about residents from shift to shift), but it should be care planned as well. She said staff did not utilize the kardex as a general rule as it was not maintained. The IDON said she would be implementing a huddle book that will have all updated information about residents' falls and safety interventions, and it would be available for all staff to review. They both acknowledged that fall interventions should be updated in the care plan and staff should be utilizing those interventions with residents. Based on record review, observations and interviews, the facility failed to ensure the facility provided adequate supervision and monitoring for four (#1, #14, #15 and #23) residents out of seven residents reviewed for falls and accidents out of 15 sample residents. Specifically, the facility failed to implement timely interventions and create effective approaches to prevent the recurrence of falls. The facility failed to create and implement a structured fall management program to help mitigate falls and fall recurrences. Resident #23 fell 12 times from 1/17/22 to 8/15/22. Many of the falls resulted in minor injuries. The resident sustained a fracture on 7/24/22, which was his eleventh fall. There were limited new interventions put in place after each of the falls. Interventions primarily included the staff monitoring and the reminder to the resident to use his call light for assistance. Resident #23 had impaired cognitive status and did not recall his falls as identified in both the 7/24/22 emergency department report and during an 8/24/22 resident interview. Almost all of the resident's falls were related to his need to use the bathroom. The resident would use his walker and wore shoes or non-skid socks to get up and attempt to take himself to and from the bathroom independently. The fall reports completed by the facility identified the resident was often not toileted an hour before the falls or it was unknown if the resident was toileted an hour before the falls. His interventions did not identify the toileting pattern or put specific toileting interventions in place. Resident #1 fell five times from 3/8/22 to 8/12/22. Most of her falls resulted in minor injuries such as skin tears. On her fourth fall that occurred on 4/17/22, the resident hit her head and face on a dresser and sustained lacerations requiring sutures. The resident had limited interventions put in place after each fall to prevent the recurrence of the falls. Resident #15 fell out of a bathing chair because the chair track was not secured on 5/23/22. The resident sustained minor injuries. The bathing chair securement/functional operation was not part of routine preventive maintenance checks before or after the incident on 5/23/22 to help ensure the bath chair was safe for use. The facility could not provide evidence that staff were educated on proper use of the bathing chair and what to look for when operating the bathing chair to prevent recurrence. Interviews with certified nurse aides (CNAs) that were responsible for bathing residents identified they were not educated by the facility of the potential malfunctions and actions to take when operating the bathing chair with a resident. Resident #14 fell six times since his 3/8/22 admission to 8/19/22. Resident #14's last four falls all occurred from 7/4/22 to 8/19/22. The facility failed to update the care plan with new interventions and consistently implement interventions such as a fall mat at the resident's bed side. Findings include: I. Facility policy and procedure The Fall Management Program policy, revised February 2021, was provided by the facility on 8/25/22. According to the Fall Management Program policy, the facility was to incorporate a fall management program. The policy read in pertinent part: The (facility) operates in a culture of safety. Staff, residents and family members are encouraged to report any problems or potential problems. A fall management team is responsible for information gathering and developing a plan of action to deal with falls, near misses and other safety concerns. Any resident at risk for falling is entered into the fall management program. The policy directed staff to take the follow preventive measures when resident safety concerns were identified: -Increase toileting frequency of the resident by staff; -Increase staff supervision and assistance for residents during specific high-risk times; -Increase monitoring using alarms; -Provide proper pain management; -Ensure the resident was using safe footwear; -Add a fall mat; -Provide specific behavioral management. The policy indicated the facility would complete an initial care plan, a TRIPS Report and an incident report, to ensure concerns were adequately addressed after a fall. The policy identified the director of nursing (DON) and the assistant director of nursing (ADON) were responsible for monitoring staff compliance and response to interventions. According to the policy, the interdisciplinary team (IDT) in efforts to prevent fall recurrence, would elevate and intervene as needed with: -Resident urinary needs that could potentially cause unsafe transfers; -Adequacy of resident monitoring; -Bed safety; -Wheelchair seating; -Environment; and -Underlying medical conditions and chronic conditions. II. Resident #23 A. Resident status Resident #23, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included cardiomegaly, dementia without behavioral disturbances, fracture of unspecified part of the neck of the left femur. The 7/31/22 minimum data set (MDS) assessment indicated Resident #23 was moderately cognitive impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident required limited assistance of one with bed mobility, dressing, personal hygiene, transfers, locomotion, and toileting. According to the MDS assessment, Resident #23 had two or more falls since his admission. He did not have rejections of care. B. Resident interview Resident #23 was interviewed on 8/24/22 at 11:06 a.m. He said he used his call bell regularly for assistance and they said staff answer the call light promptly. He said he did not remember if he had fallen or not. Resident #23 said he did not have current pain. C. Observations Resident #23 was sitting up in his lounge chair on 8/22/22 at 4:08 p.m. He said he was not in pain and did not have any concerns. His call light was placed near his reclining chair and was within reach. Resident #23 was observed in bed on 8/23/22 at 3:04 p.m. The resident was awake and laid flat on his back. Resident #23 said he had some pain in his back. Resident #23 said he was not aware of any current wounds or injuries. He did not have positioning cushions or a wedge between him and the edge of the bed. His bed was not in its lowest position. He did not have a fall mat next to his bed. His call light cord was next to him on his bed but the call button rested on the floor. Resident #23 was observed sleeping flat on his back in bed on 8/24/22 at 10:24 a.m. The resident had a pillow/wedge positioned on his left side between him and the edge of the bed. His call light was within reach. His bed was not in its lowest position. He did not have a fall mat next to his bed. -At 11:06 a.m. the resident had no changes to his position and continued to lay flat on his back. The resident still had a pillow/wedge positioned on his left side between him and the edge of the bed. His call light was still within reach. His bed was not in its lowest position. He did not have a fall mat next to his bed. -At 5:44 p.m. Resident #23 was observed sleeping in his bed. He did not have a cushion, pillow or wedge between him and the edge of the bed. His call light was in place. His bed was not in its lowest position. He did not have a fall mat next to his bed. Resident #23 was observed in bed sleeping on 8/25/22 at 8:51 a.m. He did not have a cushion, pillow or wedge between him and the edge of the bed. His call light was in place. His bed was not in its lowest position. He did not have a fall mat next to his bed. His bed was set at its lowest position. -At 10:29 a.m. the resident remained sleeping in bed. There was no change in his position. He did not have a cushion, pillow or wedge between him and the edge of the bed. His call light was in place. His bed was not in its lowest position. He did not have a fall mat next to his bed. His bed was set at its lowest position. D. Record review Fall #1 The 1/17/22 incident report read Resident #23 found on the floor next to his recliner at 1:45 p.m The resident stated he tripped coming back from the bathroom. The incident report indicated the fall was unwitnessed and he was ambulating without assistance but used his walker. The resident sustained minor injuries. He had a bruise to left elbow, a skin tear to back right hand, and a reddened area to left iliac crest (top of the pelvis.) The paper tracking record for improving patient safety (TRIPS) report indicated the resident was wearing shoes at the time of the fall. According to the report, it was unknown if the resident was toileted within an hour of the fall. He did not place his call light on to request assistance. Report identified the interventions put in place after the fall was: -The resident was instructed to call for help. -Increase staff monitoring. Fall #2 The 1/19/22 TRIPS report read Resident #23 was found on his bedroom floor at 9:30 p.m. He wore non-skid socks at the time of the fall and used his walker. The fall was not witnessed. According to the report, it was unknown if the resident was toileted within an hour of the fall. He did not place his call light on to request for assistance. The resident sustained minor injuries of two skin tears. The report identified the intervention put in place after the fall was: -The resident was instructed to call for help. An incident report for the 1/19/22 fall was not provided. Fall #3 The 1/23/22 incident report read Resident #23 found on his bedroom floor at 6:25 p.m. Resident #23 said he was attempting to move over his bedside table from in front of him so he could go to the bathroom. The incident report indicated the fall was unwitnessed and he was ambulating without assistance but used his walker. The resident did not sustain injuries. According to the incident report, the resident agreed to use his call light. The call was provided and secured to his blanket. The incident report indicated a sign was placed at the resident's bedside, reminding him to call for staff assistance before ambulating. The 1/23/22 TRIPS report indicated the resident was wearing non-skid socks at the time of the fall. According to the report, it was unknown if the resident was toileted within an hour of the fall. The TRIPS report identified the resident did use his call light for help but the report did not clarify if he did not wait for staff assistance after placing his call light on. He did not place his call light on to request for assistance.The report identified the intervention put in place after the was: -The resident was instructed to call for help. Fall #4 The 1/29/22 incident report read Resident #23 was found sitting on the floor in front of his reclining chair at 5:15 p.m. Resident #23 said he was attempting to move his bedside table from in front of him so he could go to the bathroom. The incident report indicated the fall was unwitnessed. The resident did not sustain injuries. The 1/29/22 TRIPS report indicated the resident was wearing shoes at the time of the fall. According to the report, it was unknown if the resident was toileted within an hour of the fall. The TRIPS report identified the resident did not use his call light for help. The report identified the interventions put in place after the fall were: -The resident was instructed to call for help. -Use his walker. The care plan for falls, last revised on 2/23/22, read Resident #23 was at high risk for falls. Interventions initiated on 8/7/19 were: -Ensure the resident's call light was in reach. -Provide prompt response to all requests of assistance. -Follow the fall protocol. -The resident uses a walker to ambulate. Fall #5 The 3/2/22 incident report read Resident #23 was found sitting on his floor at 6:10 a.m. According to the incident report he tripped over his feet while walking to his recliner. The resident sustained a skin tear to his right elbow and skin tear to the back of his right hand as a result of the unwitnessed fall. The resident complained of chest pain. X-rays were conducted and there were no fractures found to his chest. He wore non-skid socks and used his walker at the time of the fall. The 3/2/22 TRIPS report indicated the resident was going either to or from the bathroom at the time of the fall which contradicted the incident report. He wore non-skid socks and used his walker at the time of the fall. According to the report, it was unknown if the resident was toileted within an hour of the fall. The TRIPS report identified the resident did not use his call light for help.The report identified the interventions put in place after the fall were: -The resident was instructed to call for help. -Increase staff monitoring. Fall #6 The 3/14/22 incident report read Resident #23 was found on the floor near his bed. His shoes were on and his walker was next to him. He was found laying on his right side with a blanket under his head. He denied pain, however he had an abrasion to his right shoulder and a bruise to his right thigh as a result of his unwitnessed fall. The resident stated that he came back from the bathroom and his knees went out from him. The 3/14/22 TRIPS report identified the resident was found on the floor at 9:15 p.m. The TRIPS indicated the resident wore shoes and used his walker at the time of the fall. According to the report, Resident #23 was toileted within an hour of the fall. The TRIPS report identified the resident did not use his call light for help. The report identified the intervention put in place after the fall was: -The resident was instructed to call for help. Fall #7 The 4/5/22 incident report read Resident #23 was found on the floor near his bed at 8:00 a.m. The resident said he lost his balance while he tried to get back in bed after using the bathroom. According to the report, Resident #23 was not toileted within an hour of the fall. The resident did not sustain injuries as a result of his unwitnessed fall. The 4/5/22 TRIPS report indicated the resident wore non-skid socks and used his walker at the time of the fall. According to the report, Resident #23 was not toileted within an hour of the fall. The TRIPS report identified the resident did not use his call light for help. The report identified the interventions put in place after the fall were: -The resident was instructed to call for help. -Increase staff monitoring. Fall #8 The 4/30/22 incident report read Resident #23 was found on his bedroom floor. The resident said he lost his balance when he tried to get up from the toilet. He then crawled into his bedroom. The resident sustained a skin tear to his right elbow and a skin tear to his right upper arm as a result of his unwitnessed fall. The identified intervention was to remove a cane from his room and place the call light within his reach. The 4/30/22 TRIPS report identified the resident fell at 12:45 p.m. The TRIPS report read he wore non-skid socks and used a cane at the time of the fall. According to the report, Resident #23 was toileted within an hour of the fall. The TRIPS report identified the resident did use his call light for assistance. The report did not clarify he used his call light before or after his fall, to call for assistance. The report did not identify additional interventions. The fall care plan intervention initiated on 6/2/22, after the resident had eight falls in 2022, read: -Ensure the resident was wearing appropriate footwear when ambulating. According to the intervention, the resident wears black tennis shoes. The 6/22/22 minutes for the all-staff meeting were provided by the interim director of nursing (IDON) on 8/24/22 at 5:27 p.m. According to the minutes, staff were informed that they needed to be aware of the various interventions that have been established for the fall risk residents. The minutes read a fall subcommittee would be implemented in the near future to look carefully at the residents who were at risk for falls and had history of falls. The subcommittee would review and brainstorm to see if new interventions needed to be incorporated. The minutes identified that the former director of nursing would ask staff for their input on resident falls. Fall #9 The 6/23/22 incident report read Resident #23 was found on his bedroom floor. He was trying to go to the bathroom. The resident did not sustain injuries from his unwitnessed fall. The 6/23/22 TRIPS report identified the resident fell at 2:30 p.m. The TRIPS report read he wore shoes at the time of his fall. According to the report, Resident #23 was not toileted within an hour of the fall. The TRIPS report identified the resident did use his call light for assistance. The report did not clarify he used his call light before or after his fall, to call for assistance. The report did not identify interventions put in place after the fall. Fall #10 The 7/8/22 incident report read Resident #23 was found on his bedroom floor laying supine in front of his bed. The call light was activated after he fell. He said he was coming from the bathroom and slipped. He was trying to go to the bathroom. The resident sustained a skin tear to his left elbow from his unwitnessed fall. According to the incident report, interventions included increased staff monitoring and education to use the call light when needing assistance and ambulating. The 7/8/22 TRIPS report identified the resident fell at 1:30 p.m. The TRIPS report read he wore shoes and used a walker at the time of his fall. According to the report, it was unknown if Resident #23 was toileted within an hour of the fall. The TRIPS report indicated an additional intervention of a physical and occupational therapy referral. The 7/8/22 Morse fall scale for Resident #23 was conducted. According to the Morse scale scoring key, a resident with a score of 45 or greater was at high risk for falling. Resident #23 was assessed to have a high fall risk score of 90. Fall #11 The 7/24/22 incident report read Resident #23 was found on his bedroom floor laying on his right side at 10:43 a.m. He said he was heading back from the bathroom when his feet came out from under him. The resident sustained a skin tear to his left hand and a bruise to his right elbow from his unwitnessed fall. The resident was able to move all of his extremities and denied pain. The incident report noted no other injuries were observed. The resident was assisted off the floor and placed in his recliner. The incident report indicated new orders for a chair alarm were put in place due to his frequent falls and refusal to use his call light. The 7/24/22 TRIPS report identified the resident fell at 1:30 p.m. The TRIPS report his feet were bare other than TED hose (compression stockings) but he used his walker at the time of his fall. According to the report, Resident #23 was toileted within an hour of the fall. The TRIPS report did not indicate additional interventions were put in place other than the chair alarm. The 7/24/22 at 3:00 p.m. hospital emergency department (ED) report revealed Resident #23 was brought to the emergency room related to groin pain. According to the ED report, the resident fell the morning on 7/24/22, was assessed by the facility staff who identified skin tears but otherwise seemed fine. The ER report read the afternoon of 7/24/22, the resident started to complain of right side groin pain and was limping so he was brought to the ER for an evaluation. The ED report indicated the resident denied pain at the time of the ER evaluation and did not recall the fall. The 7/24/22 x-ray findings were provided by the facility on 8/25/22. The resident had images of his bilateral hips. The images did not reveal acute fr[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to ensure one (#1) of three residents reviewed for nutrition/hydration, out of 15 sample residents, maintained acceptable parameters of nutritional status to avoid unintended weight loss. The facility failed to identify and implement timely interventions to maintain the resident's weight. The facility failed to timely respond to Resident #1's significant weight loss. Resident #1 lost 15 pounds (lbs) in one week, resulting in 11.6% total weight loss between 7/10/22 and 7/17/22. The facility did not timely consult with the registered dietitian (RD) after the resident lost 15 lbs. The facility did not incorporate new interventions in response to the weight loss. The resident lost an additional 7 lbs between 7/17/22 and 8/21/22, revealing a total weight loss of 22 lbs at 17.1%. The facility and RD did not attempt to identify the causation of the weight loss or follow physician's orders to check the resident's albumin levels to determine if there was a medically related concern. The review of the July 2022 and August 2022 meal intake records identified the resident frequently ate less than 25% of her meal, most prominently at breakfast. The facility did attempt to identify the potential root cause to her low meal intake. The facility failed to consistently document snacks and additional fluids to determine if the resident was receptive and receiving the snacks and fluids. The facility failed to create a care plan identifying Resident #1's risk for significant weight loss and provide care plan directive interventions in attempt to maintain the resident's weight, promote weight gain once the weight had become significant, and to prevent further weight loss. Findings include: I. Facility policy and procedure The Resident Nutrition and Weights policy, revised March 2021, was provided by the facility on 8/25/22. The policy identified the purpose of the nutrition policy was to establish a method of systematically monitoring the residents nutritional status, providing proper nutrition for residents and monitoring the effects of nutritional intake. The policy read in pertinent part: Those residents with significant weight changes will be discussed mostly during the Weight, Skin and Nutrition meeting. Residents with the following clinical conditions will be considered at risk for weight loss: Medication usage such as diuretics, laxatives or cardiovascular agents; also poor oral health status, depression, dementia, therapeutic are mechanically altered diet, lack access to culturally accepted foods, slow eating pace, cancer, refusal to eat, open wounds, radiation, chemotherapy, kidney disease, COPD (chronic obstructive pulmonary disease), altered bowel elimination and gastrointestinal surgery. According to the policy, weights will be obtained for scheduled order. If a resident weighing over 100 lbs has been identified to have a five pound weight change, the staff should reweigh the resident with charge nurse or assistant director (ADON). The charge nurse or the ADON would enter the weights in the resident's medical record and review for weight gain or loss. The policy identified weight changes at or above 5% in one month, 7.5% in three months, or 10% in six months were considered to be significant. According to the policy, if significant weight loss was identified, staff should complete the following actions within 48 hours of weight loss identification: -Order in an albumin in level as per standing order. -Consult the registered dietitian. -Notify the physician. The policy indicated all residents with significant weight change would have a care plan addressing the residents needs with measurable objectives to be done in the appropriate time frame. According to the policy, food percentage intakes were monitored by dietary and certified nurse aides (CNAs) and charted in the medical record by the CNAs. Documentation/charting should also include snack and supplement intake. II. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included dementia, acute gastroenteropathy (a disease of stomach and intestines) due to Norwalk (Norovirus) agent, cardiomegaly (heart enlargement), osteoarthritis, atrial fibrillation, glaucoma and anxiety. The 5/22/22 minimum data set (MDS) assessment identified a brief interview for mental status (BIMS) could not be completed. According to the MDS the resident's cognition was moderately impaired. She exhibited short and long term memory impairment. The MDS also indicated the resident had inattention and disorganized thinking. Resident #1 required extensive physical assistance of one person with eating, bed mobility, dressing, toileting, and personal hygiene. She needed extensive physical assistance from more than two persons for transfers. The MDS assessment indicated Resident #1 did not have a weight loss of 5% or more in a month in the MDS look back period and did not have a 10% weight loss or more in the six months. The resident was not on a physician prescribed weight gain regimen. The resident did not have rejections of care behaviors. The MDS assessment identified the resident had possible signs and symptoms of swallowing difficulty with foods and liquids. There were no identified concerns with the resident's oral/dental status. III. Observations Resident #1 was observed in the dining room on 8/23/22 at 9:53 a.m. with her eyes closed. The resident was provided assistance with her breakfast. She accepted the assistance, opening her eyes for short periods at a time and making a small amount of incoherent verbalizations. Resident #1 was in the dining room on 8/24/22 at 5:47 p.m. drinking an Ensure with a straw. The resident was able to drink the Ensure independently. IV. Record review The weight record identified the following: -2/27/22, Resident #1 weighed 126 lbs; -5/1/22, Resident #1 weighed 133 lbs; -5/29/22, Resident #1 weighed 124.5 lbs; -6/26/22, resident #1 weighed 128 lbs; -7/10/22, Resident #1 weighed 129 lbs; -7/17/22, Resident #1 weighed 114 lbs; -7/25/22, Resident #1 weighed 112 lbs; -8/14/22, Resident #1 weighed 111.3 lbs; and, -8/21/22, Resident #1 weighed 107.2 lbs. The weight record identified Resident #1 lost 15 lbs in seven days, resulting in 11.6% total weight loss between 7/10/22 and 7/17/22, which was considered significant weight loss. The weight record identified Resident #1 lost 22 lbs between 7/10/22 and 8/21/22, revealing a total weight loss of 17.1%, which was considered significant weight loss. The CPO for Resident #1 was reviewed. The CPO indicated the last CPO intervention for weight loss was on 8/25/21. The CPO did not identify the resident had new orders or changes in her orders when the resident presented significant weight loss between 7/10/22 and 8/21/22. The CPO identified the following pertinent orders: -The 9/18/19 CPO read the resident had an order for weekly weights. -The 9/18/19 read the resident had an order for a dietary consultant for significant weight loss. -The 9/18/19 CPO read the resident had an order for albumin levels to be checked PRN (as needed) with significant weight loss. -The 12/11/19 CPO read the resident had an order for a mechanical soft diet. -The 1/30/21 CPO read the resident had an order for Ensure (nutrition supplement) offered twice a day between meals for weight loss. -The 8/25/21 CPO read the resident had an order for protein powder three times a day for skin integrity. -The review of the medical record did not identify the resident's albumin levels were checked as ordered when significant weight loss was identified in July 2022. The 4/13/22 mini nutritional assessment identified Resident #1 was malnourished. The 7/13/22 dehydration risk screener assessment read Resident #1 required extensive physical assistance with eating and was at risk for dehydration. The July 2022 weight review report, sent to the facility from the RD on 7/27/22, was provided by the facility on 8/25/22. The July 2022 weight report identified the resident weighed 112 lbs in July 2022. The report indicated Resident #1 lost 12.5% total weight within 30 days and 9.68% weight loss between 90 days of the review. -The report did not identify the day of the weight review or the dates for the 30 day and 90 day review. According to the July 2022 weight review report the resident had a liquid multi-vitamin started on 7/30/21, protein power and Juven (protein mix) added to her diet on 8/25/21. She consumed 50% of her Ensure and accepted a homemade shake 75% of the time. According to the report, the resident had progressive dementia and a history of refusing her adaptive sippy cup. -The weight report did not identify new interventions. The July 2022 intake record identified Resident #1 ate less than 25% of her meals on the following days in July: -7/1/22 for breakfast and lunch; -7/3/22 lunch; -7/5/22 lunch; -7/6/22 lunch; -7/8/22 dinner; -7/9/22 breakfast; -7/11/22 dinner; -7/12/22 dinner; -7/13/22 breakfast and lunch; -7/14/22 lunch; -7/16/22 dinner; -7/20/22 breakfast; -7/21/22 breakfast; -7/22/22 breakfast and dinner; -7/24/22 breakfast; -7/25/22 lunch; -7/27/22 breakfast; and, -7/28/22 breakfast. The record identified the resident only refused two meals in July 2022. The resident refused dinner on 7/14/22 and dinner on 7/20/22. The record showed the resident was not available for breakfast on 7/16/22. The record read Resident #1 meals were not applicable on: -7/4/22 for breakfast; -7/11/22 for breakfast; -7/27/22 for dinner; and, -7/30/22 for breakfast. -The intake record did not identify why the meals were not applicable to the resident. According to the July 2022 intake record, the resident only was offered and received snacks and additional fluids on 7/6/22 and 7/25/22. The August 2022 intake record identified Resident #1 ate less than 25% of her meals on the following days between 8/1/22 and 8/24/22: -8/3/22 dinner; -8/4/22 breakfast, lunch and dinner; -8/5/22 lunch; -8/7/22 breakfast; -8/9/22 dinner; -8/10/22 breakfast; -8/11/22 breakfast; -8/12/22 breakfast; -8/13/22 breakfast; -8/20/22 breakfast; -8/22/22 breakfast and lunch ; -8/23/22 breakfast; and, -8/24/22 breakfast. The record identified the resident refused four meals in August 2022. The resident refused breakfast on: -8/6/22; -8/8/22; -8/18/22; and -8/21/22. The record showed the resident was not available for breakfast on 8/2/22. The record for meal on 8/22/22 was left blank. According to the August 2022 intake record, the resident only was offered and received snacks and additional fluids on 8/2/22. The 8/30/19 activities of daily living (ADL) care plan identified the resident had a self-care performance deficit related to dementia. The intervention for eating, initiated 7/6/21, read Resident #1 required extensive assistance from one staff member to eat. -The August 2022 care plan did not document that Resident #1 was at risk for significant weight loss or had actual significant weight loss. The August 2022 care did not identify the resident had a nutritional care plan. The care did not identify interventions to maintain the resident's weight other than the type of assistance she needed to eat. The care plan did not identify interventions to prevent weight loss or interventions to take once significant weight loss was identified. The care plan identified there were no new interventions pertaining to the resident's nutritional needs. V. Staff interview The interim director of nursing (IDON) was interviewed with the registered nurse clinical consultant (RNCC) on 8/25/22 at 4:44 p.m. The IDON said she started in her position as the IDON on 8/22/22 and did not know the former director of nursing's weight loss processes. The IDON said she would have expected that after identification of significant weight loss, staff would look at what would have potentially caused the weight loss and contributing factors such as poor intake and reason for poor intake. The physician would be notified and the weight loss and interventions would be discussed in the monthly weight review meeting. The RNCC said the RD reviewed residents in her monthly weight review and emailed staff with her concerns. They said a weight review report was completed and passed to the former DON but she was not sure where it was placed. The IDON said the resident was already offered protein powder and Ensure and did not believe new interventions were implemented after the identification of significant weight loss. She said the resident liked the apple Ensure. The IDON said she was not aware the resident did not have a nutritional care plan but should have. The IDON and the RNCC said moving forward, the facility was now under new nursing management and she would make sure nurses notify her of weight changes. The IDON said Resident #1 weights would be checked weekly and a nutrition care plan would be added with new interventions. The RD was interviewed on 8/30/22 at 9:24 a.m. The RD said she was aware of Resident #1's significant weight loss as identified in the July 2022 weight review report but did not incorporate new interventions. She said she was not aware that resident dropped to 107 lbs in August 2022. She said the resident was already on a multivitamin, protein powder, and Ensure. She said it was normal protocol to try to incorporate new interventions and try different approaches to promote weight gain when a resident had experienced a significant loss in weight. She said she conducted a weight review in August 2022 with the former DON, also identifying significant weight loss, but did not incorporate new weight interventions. She said she provided her August 2022 weight report to the former DON but was not sure where the information went from there. The RD said she had not reviewed resident weights since her last review on 8/10/22. During the interview, the RD reviewed the 107 lbs weight for Resident #1. She said staff should have contacted her with the weight change and conducted a weight to determine it was accurate. The RD said as of 8/30/22, the resident's current weight is at 112 lbs, still indicating a significant weight loss. She said she was not sure why the resident had a significant weight loss in such a short time but believed it could be because the staff was not providing enough attention and assistance as a potential contributing factor. The RD said she was not aware Resident #1 did not have a nutrition care plan, providing staff directives and communication. The RD said she was not responsible for resident care plans. She said she has not observed the resident eat recently but according to her meal intake record, the resident ate 76% to 100% of her meals, 50% to 60% of the time. The RD said she had not requested the resident's labs or albumin to be checked to determine if there were other medically related contributing factors related to her weight loss. The RD said moving forward she would work with the facility to improve communication and instruct staff to increase attention and encouragement during meals. She said she would order Magic Cups (high calorie ice cream nutritional supplement) to have staff offer to the resident. VI. Facility follow up An 8/26/22 staff huddle update (conducted after survey exit) was provided by the IDON on 8/29/22 via email. According to the huddle, staff was instructed to offer Resident #1 ice cream and apple juice flavored Ensure. The huddle update indicated staff should document the additional food and fluid interventions under the snack (intake) record. The huddle update reminded staff to document snacks provided. A 8/29/22 email sent by the IDON read the IDON completed a weight review on 8/29/22 and would review the findings with staff on 8/30/22 during a staff huddle. The IDON said identified concerns would be directed to the RD and the physician as needed. A 8/29/22 handwritten nurse note identified as the weight review was provided by the IDON on 8/29/22 via email. The weight review for Resident #1 read she had a 10% weight loss within 180 days. The identified weights to determine the loss were 126 lbs to 112 lbs. The review did not identify the dates of the weights. The review identified the prior interventions of Juven, protein powder and Ensure between meals. The 8/29/22 did not identify new interventions. The 8/29/22 nutrition care plan was provided by the IDON on 8/30/22 via email. The care plan indicated the resident has nutritional problem(s) or potential nutritional problem(s) related to anorexia. The 8/29/22 intervention included: -Monitor, document and report as needed any signs and symptoms of dysphagia such a pocketing/holding food in mouth, choking, coughing, drooling, and making several attempts at swallowing. The care plan directed staff to document and report refusals to eat and any other concerns during meals. -Monitor, document and report to the physician and signs of of malnutrition, emaciation (cachexia),muscle wasting, and significant weight loss of 3 lbs in one week, 5% weight loss or greater in one month, 7.5% weight loss in three months, and 10% or greater in 6 months. -Obtain and monitor lab/diagnostic work as ordered. Report results to the physician and follow up as indicated. -Provide and serve supplements as ordered to include Ensure BID (twice a day), protein powder TID (three times daily.) -Provide, serve diet as ordered, monitor intake, and record quality of meal (intake). -RD to evaluate and make diet change recommendations PRN (as needed).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#17) of two residents reviewed for pressure ulcers out of 18 sample residents did not acquire an unstageable pressure ulcer. Resident #17, who was at risk for pressure ulcers and had no pressure ulcers as of 4/11/21, spent virtually all of his time lying in bed on his back. The facility failed to implement a turning and repositioning schedule, failed to implement a proper pressure relieving mattress to keep weight off the resident's heels, failed to acquire a timely wound nurse consultation, failed to revise the care plan to reflect actual skin breakdown, and failed to consistently document weekly wound assessments. These facility failures contributed to Resident #17 developing an unstageable pressure ulcer on 5/6/21 to his left heel which was Stage 4 on 5/17/21 when the wound had slough and necrotic tissue present. The left heel wounds became infected requiring two courses of antibiotic treatment. Findings include: I. Facility policies and procedures A. The Pressure Ulcer Prevention policy, provided by the assistant director of nursing (ADON) on the afternoon of 5/27/21, documented the purpose was to promote healthy, intact skin through risk assessment and preventative measures. Preventative measures were to be instituted as soon as the resident was determined to be at risk for developing a pressure ulcer, or if a pressure ulcer was present. -Residents who cannot sufficiently turn themselves to relieve pressure must be turned every two hours. If a resident did not tolerate turning due to confusion and combativeness, place the resident on an air mattress overlay and turn at least every four hours. Document in nurses' notes. -May use a pressure reducing air mattress; refer to the interdisciplinary team to order appropriate surfaces for beds. -Relieve pressure under heels by using heel elevating pillows or other devices. B. The Pressure Ulcer Management policy, provided by the ADON on the afternoon of 5/27/21, documented in part the following: -Preventative measures will be initiated if not already in place. Staff will be instructed to avoid positioning the resident on the pressure ulcer. -Ensure air mattress overlay in place, and institute turning every two hours if not already being done. The policies did not instruct the use of air overlays versus alternating air mattresses for pressure relief for residents at high risk. II. Professional reference regarding air mattresses According to Direct Supply (2018) Air Overlays vs. Mattresses, retrieved from https://www.directsupply.com/blog/air-overlays-vs-mattresses-which-is-best-for-my-resident: Most air overlays only measure three inches thick, and are not nearly large enough to prevent a typical resident bottoming out. When this happens, all benefits of immersion are lost as the body's peak points of pressure will rest on the surface underneath, providing the ideal condition for pressure ulcers. III. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the May 2021 computerized physician orders, diagnoses included chronic obstructive pulmonary disease, anemia, unspecified dementia without behavioral disturbance, depressive disorder, and diabetes mellitus. According to the 4/11/21 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. No behavioral symptoms or care rejection were documented. He required extensive assistance with activities of daily living except eating. He had a suprapubic catheter and was occasionally incontinent of bowel. He was 72 inches tall and weighed 164 pounds. He had no pressure ulcers, but was at risk for pressure ulcers, and had moisture associated skin damage. IV. Resident interview and observations The resident was interviewed on 5/24/21 at 4:00 p.m. He said he had a pressure ulcer on his left heel, and that they changed his dressing every afternoon. He said he had previously had pain to his left heel but they changed medicines and it has a deadening effect. Observation revealed he had an plastic overlay mattress on his bed and a foam device to float his heels. He said he had sores on both heels but one had healed; however he thought the right one was coming back because it's sore. Further observations of Resident #17 on 5/24/21, and throughout the days of 5/25, 5/26 and 5/27/21, revealed he did not leave his room or sit up in his chair. He was on his back in bed during subsequent observations, and his heels were resting directly on his bed, not floated. On 5/25/21 he was observed lying diagonally in bed with his ankles crossed, putting pressure on both his heels. V. Record review A. Care plan The care plan, initiated 9/13/16 and revised 2/2/21, identified potential for pressure ulcer development related to disease process, diabetes, history of ulcers and immobility. The goal was for intact skin. Interventions included: -Air mattress overlay placed on resident's bed 2/2/21; -Follow facility policies for prevention/treatment of skin breakdown 9/13/16; -Monitor nutritional status; -Resident had hard callous on right heel upon admission, no tenderness, skin intact 3/23/2020; -The resident requires pressure relieving/reducing device on bed/chair 3/23/2020. -The resident did not have a care plan for actual skin breakdown. B. Physician orders Pertinent May 2021 physician orders were documented as follows: Wound care orders for left heel: cleanse with wound cleanser, apply barrier ointment or skin prep to protect intact peri-wound skin, apply collagenase, cover with gauze, wrap with kerlex gauze daily. No Coban, use tape to secure, every day shift for pressure ulcer, ordered 5/6 and started 5/7/21. Cephalexin (antibiotic) capsule, 500 mg, give two capsules four times a day for infection, left heel for 10 days, starting 5/24 and ending 6/3/21. Protein powder with meals three times daily, ordered 5/19/21. C. Nurses' notes and wound assessments On 5/6/21 at 1:44 p.m., the first nurses' note about the resident's pressure ulcer documented, Resident complaining of more increased pain to the left heel decubitus (pressure ulcer) . notifying (physician) of increased pain of description of wound. The physician ordered Ultram for pain and zinc with vitamin C for healing. On 5/10/21 at 2:43 a.m., a nurse documented the resident had a non healing left heel wound. Left foot wrapped as ordered and floating as tolerated. Foul odor noted in room, becoming stronger at left heel. Denies any pain at this time. On 5/10/21 at 5:41 p.m., a nurse documented the wound has s/s (signs and symptoms) of infection. (Physician) ordered Keflex (antibiotic) 500mg (by mouth four times daily for) 10 days. On 5/15/21 at 4:29 p.m., Resident continues on Keflex for wound on heel. Heel appears to have developed a hard shell over wound. Discharge is not noted today but strong odor is still present. On 5/17/21 at 11:51 a.m., a weekly wound observation note (wound assessment) documented a stage 4 pressure ulcer to the resident's left heel with slough and necrotic tissue present. The extent of necrosis to the wound bed was 100%. A small amount of serosanguinous drainage was documented with foul odor present. The wound measures 4 mm long by 2 mm wide. The peri-wound tissue was pink and sloughy, edges are rolled, and infection was suspected due to drainage, foul odor and inflammation. Interventions were documented as leg pillow to keep heels off bed. On 5/21/21 at 2:03 p.m., Resident completed Keflex today; he still has s/s of infection (odor, redness, tenderness, mod amt drainage). RN contacted (physician) and he ordered Bactrim DS (one by mouth twice daily for) 10 days. He requested a wound culture which was done and sent to the lab. He also asked (wound nurse) to eval - she is a wound nurse that works in surgery (at the hospital). On 5/22/21 at 4:20 p.m., Resident is on Bactrim . awaiting results of culture . He says that his left heel wound is tender to touch but doesn't require pain medication. On 5/24/21 at 7:24 a.m., This nurse made a phone call to surgery services to request resident left heel evaluation by (wound nurse); voice message left in her phone answer machine. -The wound assessment dated [DATE]was blank, indicating the most recent weekly assessment was not completed. On 5/25/21 at 6:41 p.m., Infection care plan has been done. On 5/27/21 at 8:24 a.m., nursing notes documented, Changed dressing on resident's heel this morning, wound continues to have a strong odor. Area was cleaned with wound cleanser, area has a soft green covering, eschar is noted. Santyl ointment applied, covered with gauze pad and curlex wrapped around foot. Resident slept through process. On 5/27/21 at 5:54 a.m., Wound care nurse came to resident and looked at his wound, and will get back with us on new wound care orders. D. Pain assessments Review of May 2021 medication administration records was reviewed for pain levels 1-10, it revealed the resident requested Acetaminophen on 5/5 and 5/6/21 for 6/10 pain, 5/9/21 for 5/10 pain, and twice on 5/16/21 and 7/10 and 9/10 pain. He requested Tramadol on 5/25/21 for 8/10 pain. VI. Wound observation On 5/27/21 at 11:10 a.m., Resident #17's wound care was observed with the wound registered nurse (RN), licensed practical nurse (LPN) #3 and RN #3 present. LPN #3 unwrapped the Kerlix dressing to the resident's left heel. There was no drainage observed on the small non-adhesive dressing which was over the wound. The wound was then exposed. The wound was measured by the wound nurse, and measured 2.5 cm x 3.5 cm. There was an area of necrotic (eschar) tissue within the wound bed. The remaining wound contained yellow slough. The peri-wound was intact with slight redness to the edges. The right heel was observed and there was no wound; the skin was intact with only a small hard callous in the middle. The wound nurse identified the left heel wound as unstageable. She recommended autolytic (medicated) debridement (no scalpel/sharp debridement at this time). VII. Staff interviews The registered dietitian (RD) was interviewed on 5/26/21 at 4:15 p.m. She said for wound healing, Resident #17 was getting a multivitamin, Ensure once or twice daily depending on acceptance, protein powder twice a day, which they were increasing to three times as of today, and as of today they would add Juven (supplement for wound healing) as well. He was also taking zinc and vitamin C. Following his blood glucose (BG) levels, they're in appropriate range, so I don't think his BG is contributing to his non-healing right now. The medical director was interviewed on the afternoon of 5/27/21. After discussing overlay versus alternating air mattresses (see professional reference above), she said she would order an alternating air mattress for Resident #17. The assistant director of nursing (ADON) was interviewed on 5/27/21 at 4:37 p.m. She said Resident #17's pressure ulcer was unstageable and she was surprised it was assessed as a Stage 4 on the 5/17/21 wound assessment. She said that during the COVID-19 outbreak Resident #17 was in his room, then became resistant to coming out of his room. She said he actively kicked off the heels up pillow the staff had been using for him for a long time. And because he was in his room a significant amount of time, his dietary and fluids decreased, his foot was always on the bed, and he was not taking in the appropriate amount of nutrition to help his body heal the pressure ulcer. The wound started as a blister and they started treating it right away, but no matter what treatment they used, he would not keep his feet off the bed (however, there was no documentation of the resident refused repositioning or heel floating) His feet are dependent and that makes it hard. He kicked off the foam heel cups, as well as pillows. -The facility failed to implement increase monitoring of his feet with the resident would not keep his feet off the bed nor was it care planned the resident would not keep his feet off the bed. The ADON said they had an overlay on his bed, added Ensure, zinc, vitamin C, a multivitamin, protein powder, and the infection control nurse reviewed his wound regularly and gave direction. She said the resident's doctor looked at the wound numerous times, and just this week the facility had a wound nurse assess it. She said he was at risk before the pressure ulcer developed, and it would behoove them to have an alternating air mattress and he doesn't because we don't have one. She said she planned to pick one up herself that weekend. She said they could get one delivered but they were expensive and the former DON had declined to purchase one. The ADON said if only they had that professional reference (see above) three months ago, the resident's pressure ulcer might have been avoided. She said she agreed wholeheartedly that Resident #17 should have had an alternating air mattress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to consistently and thoroughly assess, manage and alleviate severe, constant pain for one (#10) of two residents reviewed out of 18 sample residents. Resident #10, who was diagnosed with end stage multiple sclerosis and multiple contractures, said in interviews on 5/24/21 and 5/25/21 that she experienced constant pain, at an 8/10 (eight out of 10) level, and that pain medications helped for a while but the pain returned as soon as her medications wore off. She said she had been in pain all her life, and palliative/hospice care had not been discussed with her. Nursing staff and the resident's physicians were aware and documented her pain was uncontrolled, that she requested comfort care and pain relief. Although pain medications were added and adjusted, the resident continued to experience severe breakthrough pain several times daily. Pain assessments prior to medication administration were frequently not documented, nor was the quality and location of pain, and effectiveness of pain medications after administration. The resident's pain contributed to loss of appetite, weight loss, depression, cognitive loss; and four Stage 2 pressure ulcers (three to her sacrum and one to her left heel) because movement, repositioning and bathing were too painful. Pain assessments revealed her pain interfered with her sleep and her daily life. Non-pharmacological methods for pain relief such as heat, cold packs, massage, physical therapy transcutaneous electrical nerve stimulation (TENS) treatments and aromatherapy had not been care planned or documented as recently attempted. The resident's inadequate pain management contributed to physical and psychosocial harm, as the resident regularly stated her pain was 8/10 and stated she wanted to fall asleep and not wake up anymore, and that she was tired of suffering and wanted to be kept comfortable at the end of her life. Although she opted for comfort care, said goodbye to her family, and began giving away her personal possessions, the facility failed to acknowledge the resident's end of life choices and provide adequate pain relief. Findings include: I. Facility policies and procedures A. The Pain Management policy, revised March 2021, was provided by the assistant director of nursing (ADON) on the afternoon of 5/25/21. The policy/procedure documented in pertinent part, that pain, both acute and chronic, has a significant effect on quality of life for long term care residents. In an effort to prevent negative outcomes related to pain, this policy outlines a systemic approach for addressing residents' pain. Each resident will receive a comprehensive pain assessment quarterly and for change in condition such as persistent or worsening pain. Interim assessments would be done by nursing staff each shift, and documented on the medication administration record (MAR) in the appropriate spot. For the cognitively intact resident, the nurse may use the numerical one-to-ten scale or visual scales such as the Faces scale or pain thermometer scale. The nurse may question the resident about their ability to perform activities of daily living (ADLs) and/or use clinical observations. The nurse will report pain to the attending physician if the pain has worsened from a previous screen despite treatment. If a resident has increased requests for pain medication, the nurse will report the change to the attending physician in a timely fashion. Urgent requests for pain management will be directed to the on-call physician if the attending physician is unavailable. Scheduled dosing will be used in an effort to consistently control pain. Non-pharmacological methods of pain control may be used first, with resident consent. Such methods may include, but are not limited to, TENS units, music, massage, heat/cold application, therapeutic activities, repositioning, distraction, cushions, aroma therapy, relaxation techniques, humor, and exercises. The nurse administering the medication will document date, time, medication, route given, pain rating, and type of pain. Within one hour of pain medication administration, nursing will follow up with the resident and document results. If the pain medication is unsuccessful, the nurse may add non-pharmacologic relief, or a different medication according to the resident's MAR, taking resident preference into account. Monitoring pain data will be part of the facility's ongoing quality improvement program. B. The Comfort Care policy, revised February 2021, was provided by the ADON on the afternoon of 5/25/21. The documented purpose was to provide comfort care measures for residents who have reached the final stage of their lives and their goal is a peaceful death with dignity. Appropriate care is provided to alleviate pain. When comfort care is desired, the resident's plan of care will outline measures to be implemented to ensure: the resident's right to die with dignity and respect; promotion of quality of life; conserving the resident's energy, preserving emotional and physical well-being and providing adequate pain relief. -The ADON said the facility did not have policies regarding palliative care or hospice, as requested, as these services were not offered by the facility due to lack of resources and funding. II. Resident status Resident #10, age [AGE], was admitted on [DATE]. Diagnoses per May 2021 physician progress notes and computerized physician orders (CPO) included multiple sclerosis (MS); multiple contractures; major depressive disorder, single episode; and hypo-osmolality (low sodium blood levels) and hyponatremia (high sodium blood levels). According to the 5/9/21 minimum data set (MDS) assessment, the resident was her own decision maker. She had modified cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. There was no documentation of delirium or behavioral symptoms, and no rejection of care. She was totally dependent for ADLs, and had range of motion impairments to her upper and lower extremities. She had an indwelling catheter and was always incontinent of bowel. She had medically complex conditions including MS, hyponatremia and depression. She had moderate pain during the assessment, almost constantly, and no numerical pain level was documented, although she was able to numerically rate her pain (see interview and pain assessment findings below). Her pain made it difficult to sleep at night and limited her day to day activities. She had weight loss, was 64 inches tall and weighed 100 pounds. She had one Stage 2 pressure ulcer. She took antidepressant and opioid medications daily and received oxygen therapy. She had a life expectancy of less than six months. -Review of the resident's 2/14/21 MDS assessment revealed she was cognitively intact with a BIMS score of 15 out of 15, three months earlier. II. Resident/staff interviews and observations Resident #10 was interviewed on 5/24/21 at 1:00 p.m. She said, I have pain all the time. She rated her pain at 8/10, and said the location was My butt. That's where it always is. There's not much they can do. She said she had been in pain all her life. The resident said she had lost weight, approximately eight or nine pounds, but said she was not concerned about that. The resident was observed lying on her right side in her bed, with her neck bent forward and her chin to her chest. Her neck was contracted and supported with pillows, but she was able to raise her head. She said she stayed in bed because it was more comfortable for her. She had an alternating air mattress on her bed. On 5/25/21 at approximately 8:30 a.m., the resident said her pain level was 8/10. Her registered nurse (RN) #1 said she had given her morphine but she could give her Norco which usually helps, and did so. On 5/25/21 after lunch, the resident again rated her pain at 8/10. RN #1 and licensed practical nurse (LPN) #3 were notified and LPN #3 said she had just given Resident #10 Norco 10 minutes ago, and it needed time to take effect. Review with RN #1 of Resident #10's medications revealed she had orders for Norco, Morphine Sulfate, and Fentanyl patches. Upon checking back with Resident #10 approximately 30 minutes later, she said her pain was 8/10. Her pain medication (Norco) had been ineffective. RN #1 checked Resident #10's orders and said she was able to give her sublingual morphine, and prepared it to administer to Resident #10. Upon checking back with RN #1 a few minutes later, she said Resident #10's pain was improved at 3/10. -Per interview with RN #1 and LPN #3, the facility had no palliative care or hospice available. They said they did not know why and LPN #3 said she wondered why palliative care was unavailable to residents at the facility. At 4:00 p.m., RN #1 said Resident #10 could have her regularly scheduled pain medications and she would prepare her medication and give them to her. She said Resident #10 always gives high numbers when describing her pain: 7, 8, 9 out of 10. On 5/25/21 at 4:58 p.m., the resident was sleeping, leaning forward in her bed, grimacing. On 5/25/21 at 6:15 p.m. Resident #10 said she was in pain, 8/10 and they had told her they could not give her anything else for pain. Her face was red and sweaty, and the front of her T-shirt was wet with drool. This was reported to a certified nurse aide (CNA) coming on duty, who said she would notify Resident #10's nurse. She said the nurses were in a shift change meeting and currently unavailable. On 5/26/21 at 8:02 a.m., the resident was sleeping, with her head down and her face not visible. Review of the resident's MAR on the morning of 5/26/21 revealed the resident was not given a pain medication until an hour and 45 minutes later and effectiveness was not documented (see below). There were no nursing notes to indicate why, or that the resident's pain level of 8/10 was reported on 5/25/21 at 6:15 p.m. On 5/26/21 at 10:22 a.m. Resident #10 was sleeping with her head down, grimacing. On 5/26/21 at 2:53 p.m., Resident #10 was asleep with her head down, grimacing. On 5/26/21 at 6:00 p.m., Resident #10 said she was okay, and her pain level was okay. III. Record review A. Care plans The resident's care plan, initiated 2/3/19 and revised 11/27/2020, identified chronic pain related to MS. The goal was adequate relief of pain or ability to cope with incompletely relieved pain. Interventions included: -Pain is alleviated/relieved by Norco PRN (as needed) and Fentanyl patch, scheduled Valium, PRN compound suppositories, PRN lidocaine cream, PRN Ultram for breakthrough pain. -Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. -Notify physician if interventions are unsuccessful or if current complaint is a significant change from the resident's past experience of pain. The care plan further documented (under ADLs) that Resident #10 was exclusively staying in bed and requested the facility stop weekly weights, as being lifted in the Hoyer (mechanical) lift was very painful for her. She was placed on comfort care on 5/14/21 and all care was focused on her comfort. She received bed baths only as she could not tolerate sitting up in the shower chair. She was transferred via Hoyer lift only and requested that the Hoyer lift be used as little as possible. On 11/27/2020 she was not getting out of bed. Her physician declined gradual dose reduction of her Lexapro antidepressant in January 2020 due to increased signs and symptoms of depression. She had a lack of appetite identified on 3/23/2020, and was eating less than 25% of all meals, stating she just was not hungry. She was refusing all supplements, Ensure, protein shakes. On 3/7/21 she would drink Juven in water daily to supplement protein intake. She had a healing Stage 2 pressure ulcer on her coccyx on 3/7/21. She had an indwelling catheter due to a pressure ulcer on her coccyx on 11/27/2020. -The resident's care plan was not revised to include comfort care, current pain medications, non-pharmacological pain interventions, her reports of unrelieved pain, instructions to medicate for pain prior to care provision, or current skin breakdown. The resident had four Stage 2 pressure ulcers as of 5/27/21. B. Pain assessments Resident #10's most recent 3/21/21 Pain Interview assessment documented she had pain or hurting almost constantly over the last five days, which made it hard for her to sleep at night. Pain interference with daily activities was not assessed. Her numeric rating scale was 7/10. She had Fentanyl patches, scheduled pain medication, PRN pain medication. Is effective for pain at patch change, when the patch is on 3rd day, requests more PRN pain medication. The assessment further documented, Resident does not ask for pain medication PRN, and has voiced effectiveness. -A status change pain assessment was not conducted when Resident #10 began requesting PRN pain medications and stated her pain medications were often ineffective (see observations/interviews above and pain level documentation below). C. Pain medication orders Review of May 2021 physician orders and medication administration records revealed the following pertinent pain medications: Review of May 2021 physician orders and medication administration records revealed the following pertinent pain medications: -Tegretol XR tablet extended release 12 hour 100 mg (milligrams), 100 mg once daily for MS (started 11/17/19). -Tegretol tablet 200 mg, 200 mg twice daily for pain (started 11/16/19). -Morphine Sulfate (concentrate) solution 100 mg/5ml (milliliters), give 8 mg by mouth every 4 hours for comfort care related to MS, hold medication if respirations under 12 (started 5/27/21). -Acetaminophen tablet 325 mg, give 2 tablets every 4 hours PRN for pain (no pain level parameters documented in order, started 2/28/21). -Fentanyl Patch 72 hour 12 mcg/hr, apply 1 patch transdermally every 72 hours for pain with 50 mcg (micrograms) patch to equal 62mcg and remove per schedule (started 11/19/2020). -Fentanyl Patch 72 hour 50 mcg/hr, apply 50 mcg transdermally every 72 hours for pain with 12 mcg to equal 62 mcg (started 11/19/2020). -Hydrocodone-Acetaminophen tablet 10-325 mg, give 1 tablet every 4 hours as needed for pain, APAP from all sources not to exceed 3 gm/24hr. (started 2/28/21) -Morphine Sulfate (concentrate) solution 20 mg/ml, give 8 mg every 2 hours as needed for shortness of breath or pain related to MS. If respirations are below 12 hold medication (started 5/26/21). -Suppository blend pellet (suppository base), insert 1 suppository rectally every 12 hours as needed for pain: Diazepam 5mg, Amitriptyline 5mg, Lidocaine 2mg. May be given vaginally (started 6/9/2020). D. Failure to adequately address pain levels of 7/10 and above Review of the resident's May 2021 MAR revealed her pain levels, when assessed prior to administration of PRN pain medications, were 7/10 or above (up to 9/10) several times per day, a total of 72 times from 5/1-5/26/21. Instead of numeric pain levels, check marks were often documented above nurses' initials. Effectiveness of the PRN medications were often not documented as assessed, and pain medications were often documented as ineffective. The location and quality/description of the resident's pain was rarely documented. On the night of 5/25/21, Resident #10 reported 8/10 pain at 6:15 p.m. (see interview above). However, review of the MAR on 5/26/21 revealed she did not receive anything for pain on 5/25/21 until her regularly scheduled dose of Morphine Sulfate at 8:00 p.m., one hour and 45 minutes later, and after she had been told she could not have anything else for pain. Instead of a numerical pain level, the nurse documented a check mark. There were no nursing notes regarding this administration or its effectiveness. There was no documentation that the resident reported 8/10 pain at or before 6:15 p.m. that night and had been denied pain medication, or that the resident's pain was reported to the nurse (after this was reported to a CNA, see above). Nursing notes documented scheduled Voltaren Gel 1% was applied at 9:34 p.m. and Morphine Sulfate PRN was given at 11:38 p.m. No numerical pain assessments were documented on the night of 5/25/21. No non-pharmacological pain interventions were documented, and physician notification was not documented. E. Interdisciplinary (IDT) and physician notes Review of IDT notes for the past six months revealed the documentation was predominantly related to Resident #10's pain, which was ongoing and typically at 8/10 to her buttocks, lower back and neck, when the location was assessed. IDT notes included the following pertinent documentation: -On 1/19/21 the resident's physician documented in a visit note Resident #10 was receiving transdermal 50mc/hr fentanyl patch for pain but without adequate control. Repositioning strategies have been discussed with the patient but she is uninterested due to comfort concerns . She expresses constant 8/10 pain in her buttocks that is poorly managed with her current regimen. She is interested in exploring other options to help get better pain control. She is not interested in anything else and has no interest in doing things other than watch TV (television) in her room. Her main goal is improved pain control. -On 1/28/21 a nutrition/dietary note documented in part, Patient with no new weight recorded since November (2020). Of note, patient has been refusing many things, including weight checks and nutrition interventions. Per report, she has developed a stage 2 to her coccyx. 17 lb weight loss noted in 4 months (from July-November 2020 weights). This is 16%, which is significant . -On 2/4/21 a medical director note documented in part, End stage MS and accompanying debility, immobility, contractures and chronic pain. Depressive disorder due to condition. Exacerbated by uncontrolled pain . Low back pain is not adequately controlled. She is amenable to increasing the frequency of hydrocodone. (Primary care physician) and I have been discussing and considering other options including Methadone or Morphine. The liquid morphine concentration would be effective more rapidly than her Hydrocodone. Long acting morphine may be more effective than her Fentanyl patches given that the latter are not well absorbed when people have low body fat . Pain into legs that is sometimes relieved with PRN Hydrocodone. Sometimes not. Does not like waiting for so many hours between doses of breakthrough medicine when she is having pain. Wonders about starting Morphine instead. The medical director changed her Hydrocodone from 1 tablet every 6 hours PRN to 1 tablet every 4 hours PRN for 30 days due to pain in the coccyx as above. -On 2/5/21 at 2:47 a.m., a nurse documented, Pt (patient) yelling out HELP and CNA went to see what was wrong. Pt could not find call light and needed pain medication. Norco provided. At 3:27 a.m. the pain medication was documented as effective and the resident was sleeping. -On 2/10/21, the registered dietitian (RD) documented, Patient with new weight on 1/29 of 99.5#, has refused suppositories in the past. Weight loss of 5.2% in last 180 days. Stage 2 to coccyx reported. Juven was ordered. -On 2/18/21 a social services note documented, Significant pain. It has been reviewed numerous times by MD . She is bed bound . Healing stage 2 on her coccyx. -On 2/19/21 a medical director note documented in part, pain in the coccyx. We discussed potential switch to liquid Methadone from her Fentanyl patch, since she is likely not absorbing much of it due to lack of body fat . Contracture of multiple joints (muscle relaxer) not helpful . I wanted to talk to her about other pain med modalities/options as well. Her pain is sometimes overwhelming and meds don't work. Usually in her groin or pelvis. -On 2/19/21 a social services note documented in part, (Resident) is bent over far, she has been this way for years and is not under any stress at this time. She does not work with PT anymore because it causes too much pain for her. She states she does not have as much pain when she is bent over, that it relieves some of the pain. She can lift her head for a short amount of time . says she hasn't been sleeping as well due to pain. -On 4/8/21, the medical director documented, She has too much pain in her body to allow transfer to the shower or bath, so she gets only bed baths . She reports that her pain is at 5, which is good for her, she says. -On 4/14/21, a nurse note documented the resident's physician visited and was informed, she had refused to order breakfast or lunch today . staff reported resident has been declining food last few days. (Physician) reports resident saying she wanted to go to sleep and not wake up. Resident has been more withdrawn this last week. Will continue to monitor. -On 4/16/21 the medical director documented, Chronic neck pain from her MS and severe chronic deformity. Depressive disorder due to condition. Exacerbated by uncontrolled pain. Pain in the coccyx . Palliative care . (Resident) would like to be made as comfortable as possible. She understands that she has a poor prognosis. There is nothing in particular that motivates her to live longer. She does not want aggressive medical interventions to prolong her life. She does want pain control . Consider something stronger than tramadol or hydrocodone for her breakthrough pain . Once we have a reliable medicine for breakthrough pain I think it would be safer (from a pain point of view) to make plans to change her long acting med to Methadone or something else . Will cont(inue) to discuss with (resident's physician) and RN. (Resident) has been saying that she just wants to sleep. She would rather sleep all day and not be aware of what is going on around her. She cannot bathe because of pain with movement and her deformities. Her pain is out of control with any movement . -On 5/4/21 at 8:11 p.m., a nurse documented in part, Resident continues to appear stuporous (lethargic) although does wake to request pain medications. Norco given PRN at 6:00 p.m. Effective results, resident asleep. -On 5/5/21 at 3:00 p.m. the resident's physician documented, Severe hyponatremia with sodium 120. Patient has requested end of life care: 'I want to fall asleep and not wake up anymore.' -On 5/5/21 at 3:28 p.m. a nurse documented, Resident also showed relief when I spoke to her about comfort measures. From this nurse's perspective, you could see a weight being released from resident on the new comfort measures. -On 5/8/21 at 12:36 a.m., a nurse documented, Resident continues on comfort measures. Reports pain during HS (hour of sleep) med pass. Offered PRN morphine as she had recently had Norco at (5:30 p.m.). Resident states that she doesn't want to take morphine until her sister visits. Explained that morphine was not ordered to end life, but to provide comfort for pain. Resident did not respond to this nurse. Resident requested Tramadol and APAP for pain. No further complaints of pain voiced. Resting comfortably. -On 5/8/21 at 4:43 a.m., Resident requested pain medication at (4:20 a.m.) Norco administered at (1:40 a.m.). Tramadol/APAP brought to resident's room. Explained what was being given. Resident asked why morphine wasn't brought. Reminded resident of earlier conversation. Resident reports that her sister did come (she did have visitors yesterday although this nurse not certain if sister present) and that she wanted morphine. Education provided again to resident. Explained that medication is provided for pain but that she still has other medications as previously ordered, that medication can cause sedation and can depress the respiratory system. Also explained that she is receiving a low dose at this time, that medication is not long acting and that as a PRN, she must request it. Resident states she understands and would like morphine dose at this time. Morphine administered at 0.1ml/2mg at (4:30 a.m.). -On 5/8/21 at 5:57 p.m., a nurse documented, Resident spoke with (medical director) today and they agreed to having morphine scheduled and PRN. Resident is tired of 'suffering' and wants to be kept comfortable at end of life. She has requested comfort measures. Ultram DCd (discontinued). Resident has had a lot of family members visit in the past week and she is telling them that she does not want to live anymore. (The resident's physician) was here on the 5th and he initiated comfort care orders. He discontinued weights, vitals, meds (medications) that aren't for comfort. -On 5/10/21 at 5:36 p.m., Resident requesting pain medication frequently. RN spoke with (resident's physician) and he increased morphine dose. Very poor PO (oral) intake today. Wound on sacral area is closed. -On 5/11/21 at 2:34 a.m., Resident was sleeping and she could not be woken up enough to take her (8:00 p.m.) medications. Gave morphine at (11:30 p.m.) for pain. VS (vital signs) at (11:40 p.m.) BP (blood pressure) 86/55, P (pulse) 67, 02 (oxygen saturation) 98. -On 5/13/21, a social services note documented, Resident is on comfort care. She is on scheduled morphine with a PRN order for breakthrough, and she also is able to take her oral pain medication and fentanyl patches . Has a stage 2 pressure sore that has healed and then re-opened . Not interested in anything except some music but refused to have music set up in her room . Would like to donate some of her glass figures to staff, with work with (family) for this. -On 5/19/21 at 3:20 a.m., a nurse documented, During routine cares new pressure area noted to (left) lateral heel and two new areas noted below chronic sacral wound. Skin assessment updated . Resident continues to call frequently asking for additional pain medications. Resident reports minimal relief after morphine administrations. -On 5/23/21 at 9:55 p.m., a nurse documented, Resident morphine has been increased in dose, no adverse effects, resident verbalizes she has pain all the time, at this time it is tolerable, verbalizes the morphine is effective at times. -On 5/25/21 at 1:31 p.m., a nurse documented giving a Norco tablet, which she documented as ineffective at 2:40 p.m., with the resident reporting 8/10 pain. At 2:44 p.m. she gave 8 mg of morphine which she noted at 3:30 p.m. was effective with a reported pain level of 2/10. No other pain medications were documented in nursing notes until 9:34 p.m. Voltaren gel and 11:38 p.m. scheduled morphine. The pain level and effectiveness were not documented. (See observation above where the resident reported 8/10 pain at 6:15 p.m. which was not addressed.) -On 5/26/21 at 2:25 p.m., the resident was given PRN Norco with no pain level or effectiveness documented until 7:23 a.m. when effectiveness was documented as unknown. The resident continued to report level 7/10 or 8/10 pain when she was awake, and was documented to have every two hour checks per physician orders beginning at 1:30 p.m. on 5/26/21. (See physician interviews below.) Review of the resident's every-two-hour check documentation revealed nursing staff were to document the date, time, their initials, Resident #10's pain level, and pain medication administered. The resident reported 8/10 pain on 5/26/21 at 1:30 p.m. and was given 8mg morphine and Norco. At 2:55 p.m. she had 7/10 pain and received PRN morphine. At 3:55 p.m. she had 4/10 pain and received no medication; at 4:15 p.m. she had 4/10 pain and received 8 mg morphine. At 6:00 p.m. she was sleeping, received no medication, and respirations were not counted. At 8:00 p.m. she had 8/10 pain and received morphine. At 10:00 p.m. she was sleeping and her respirations were 12. On 5/27/21 at 12:00 a.m. she was sleeping with 12 respirations. At 2:00 a.m. and 4:00 a.m. she was sleeping and unresponsive with 14 respirations. At 5:30 a.m. she had 7/10 pain, was given morphine and respirations were 14. At 6:32 a.m. her pain was 2/10 and no morphine was requested. At 7:30 a.m. she had 8/10 pain, was sleepy and reported pain but treatment postponed with no respiration count. At 7:35 a.m. and 8:00 a.m. she had 8/10 pain and was due for scheduled morphine but her meds were held because her respirations were eight and she was not able to swallow and lethargic. At 10:35 a.m. her pain was 2/10 and no morphine was requested. At 12:20 p.m. her medications were held because her respiration rate was 9, stupor, and no pain medication was given. At 1:00 p.m. she was very somnolent, non-responsive, cares given, resident responded at very end, and no pain level or medications were documented as given. At 2:35 p.m., her pain was 8/10, respiration was 8, she was unable to keep her head up, and gave no response when asked again, no medications were given. At 3:10 p.m. her respirations were 9, no medications were given and no pain level was documented. At 5:08 p.m., the medical director said to give morphine scheduled & Valium. Review of weights for the previous year revealed Resident #10 weighed 115 pounds on 4/16/2020 and her most current weight was 100 pounds. Her weight had been down to 88 pounds on 11/5/2020. -Nurses were not consistently documenting whether the resident was asleep or awake, number of respirations per minute, pain levels, or follow-up on pain medication requests per resident and physician request (see physician interviews below). IV. Failures in facility response to Resident #10's pain Review of IDT notes and MARs revealed the facility failed to develop a step-by-step protocol to assess and relieve Resident #10's pain. The medical record further revealed the resident did not receive pain medication as often as she could have them, and that nursing staff did not check with her often enough to assess her pain levels. Even when the resident requested pain medications and said her pain was 8/10 or higher, she frequently did not receive pain medications as requested and nurses did not consistently check back with the resident to ensure her pain medications were effective, to assess whether they needed to take further measures or notify the physicians if medications were ineffective. These failures continued until the medical director got involved and specifically directed nursing staff to honor the resident's wishes for pain relief and comfort. V. Staff interviews The assistant director of nursing (ADON) was interviewed on 5/25/21 at 4:30 p.m. She said she was concerned about Resident #10's pain, acknowledged it was severe, and said her tolerance was high and opioids were less effective for her. She also found Resident #10 was sleeping in between doses but she was ready to go. She said they had not sought a pain clinic consult, or discussed Resident #10 in quality assurance meetings. She said they had discussed comfort care with Resident #10, who really wanted them to help her go, but they could not do that. She said they did not have palliative or hospice care available at the facility, but the resident was now on comfort care. She acknowledged, however that Resident #10 was not comfortable. She said their medical director worked for a hospice agency in a city about two hours away, and planned to see Resident #10 on 5/27/21. She said she did not know what they would do if the opioids stopped working for Resident #10. She said the medical director had discussed initiating methadone, but that would require weaning her from opioids and then sta[TRUNCATED]