**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for three (#46, #43 and #25) of six residents reviewed for falls out of 33 sample residents. The facility failed to timely and appropriately implement interventions including assistance with all activities of daily living. The facility failed to provide staff education and increase residents' supervision to prevent falls when all three residents could not ask for staff assistance by using the call light due to severely impaired cognition for Residents #46, #25 and #43. Furthermore, the facility failed to ensure adequate supervision and effective interventions were in place to prevent multiple falls for Resident #46, including falls that resulted in injuries requiring transfer to a hospital and one fall which resulted in a right hip fracture requiring surgical repair. Findings include: I. Facility policy The Falls and Fall Risk, Managing policy, undated, was provided by the nursing home administrator (NHA) on 3/7/24 at 10:55 a.m. It read in pertinent part: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-centered approaches to managing falls and fall risk included: -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. -Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. -If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. II. Resident #46 A. Resident status Resident #46, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included essential hypertension, fracture of unspecified part of neck of right femur, presence of right artificial hip joint, presence of left artificial hip joint, osteoporosis, acute respiratory failure with hypoxia (low blood oxygen) and Alzheimer's disease. The 1/15/24 minimum data set (MDS) assessment revealed the resident required supervision with transfers and walking (with a walker). He had one fall, no injury, since the prior assessment. The most recent MDS assessment dated [DATE] revealed severely impaired cognition with a brief interview for mental status (BIMS) score of two out of 15. He required moderate assistance with transfer sit to stand and bed to chair. He received scheduled pain medication for occasional mild pain. The resident had a fall prior to readmission, with a fracture, surgery and partial hip replacement. Medications included an anticoagulant and diuretic. B. Resident observation and representative interview Resident #46 was observed on 3/6/24 at 10:40 a.m. A large blue color bruise was around his right eye. The resident's representative said the resident fell when he lived at home and fractured his left hip. He said Resident #46 did not remember he was weak and unsteady on his feet and still tried to be independent in his room. C. Record review On 1/4/22 Fall Risk Assessment documented a score of five (at risk 10 or higher), indicating Resident #46 was not considered a high fall risk. -However, he had falls prior to admission with a fracture (see representative interview). On 1/23/24 the resident's Fall Risk Assessment score was 13, considered high risk for falls. A review of the resident's comprehensive care plan revealed: (Resident) has an ADL (activities of daily living) self-care performance deficit r/t hx (related to history) of fractures, weakness, hx (history) of falls, heart disease, tricuspid insufficiency (heart valve insufficiency), Alzheimer disease, spondylosis of cervical region (arthritis of the neck). Date initiated 1/4/22 and revised 3/2/22. Interventions included: Toilet use with limited, one person assistance. Encourage the resident to use call bell for assistance (understands use, does not consistently use). Revised 3/2/22. (Resident) is at risk for falls r/t (related to) unsteady on feet, potential side effects of medication, use of assistive devices, altered cardiac status, hx (history) of fx (fracture), left artificial hip, impaired cognition, impaired communication/hearing, incontinence. Date initiated: 1/4/22. Interventions included: Purposeful rounds. Tab alarm in wheelchair and recliner, pad alarm while in bed (initiated 2/7/24). Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 1/4/22. (Resident) has impaired cognitive function AEB (as evidenced by) BIMS (brief interview for mental status) score r/t (related to) Alzheimer's. Date initiated 1/4/22, revision 3/2/22. Interventions included: Call bell within reach, answer promptly. Assist with decision making by giving simple choices in daily cares. Keep the resident's routine consistent. -The facility failed to appropriately assess Resident #46's call light use ability. -After Resident #46's fall with major injury, hospitalization and surgery (see below), the only intervention added in the care plan to prevent falls was tab alarm in wheelchair and recliner, pad alarm while in bed. 1. Fall #1 On 1/12/24 a nurse documented: CNA (certified nurse aide) reported that resident is on the floor laying on a blanket. RN (registered nurse) assessed resident, H/T (head to toe) assessment with no injury noted. Staff showered resident and no red/bruised or open areas noted. Resident did not say if he fell or not. When asked by this nurse at breakfast he grinned and shrugged his shoulders. Resident resumed normal activities of the day. Denies any c/o (complain of) pain or discomfort. On 1/12/24 an incident description completed by a registered nurse revealed the following: staff reported that resident was laying on the floor on his blanket, saw resident on his right side with his blanket spread out under him, in no distress. No injuries, up and ambulating to the bath without change in gait, with walker. No injury noted in the bath. Call bell on the bed, not activated. On 1/12/24 a nurse documented: Resident complained that his shoulders and right leg are hurting. When LPN (licensed practical nurse) went in to reassess resident and asked about his pain, he denied pain. Family states that he doesn't like to complain. They are taking him to ER (emergency room) to be evaluated. Resident left facility via POV (private vehicle) in stable condition. On 1/14/24 a nurse documented: New complaints of pain and action taken: 7/10 (seven out of ten), given 2 (two) extra strength Tylenol at 12:00 a.m. with + (positive) effect. On 1/15/24 a restorative nurse aide (RNA) documented: Fall intervention: Resident found on floor next to bed. Fall intervention is low bed and fall mat. On 1/15/24 the interdisciplinary team (IDT) post fall review revealed: (Resident) has not fallen since April of 2023. He currently resides in a room by himself at the end of the hallway. Per his most recent MDS, he scored a 2/15 indicating severe cognitive impairment. He has communication difficulties with minimal difficulty hearing others, he does not use HA (hearing aids), understands others and is understood. He uses a FWW (front wheeled walker) with ambulation and needs some assistance with his ADLs. This fall occurred in his room as he was wrapped up in a blanket. He had gripper socks on at the time of the fall. Per the nursing notes, this fall occurred before 0700 (7:00 a.m.) that morning. No injuries were noted at the time of the fall and post fall. He did not use his call light, but it was within reach prior to the fall. This fall occurred likely due to him getting up for the morning. Staff assist him PRN (as needed) with bed mobility and dressing. Due to his significant cognitive impairment, he is not able to recall the reason for the fall. An electric low bed was implemented, and a fall mat was placed next to his bed for when he is in his bed, to prevent fall related injuries. Care plan reviewed. -However, according to progress notes (see above) the resident had new complaints of pain following the fall. -The resident's care plan was not updated with the new fall interventions. 2. Fall #2 On 1/16/24 RN documented: Date and time of fall 1/16/2024 at 1700 (5:00 p.m.). MD (physician) notified .New complaints of pain and action taken: c/o (complaints of) right hip pain, slight internal rotation noted. Resident roller chair noted in middle of room, appropriate nonskid shoes noted, floor dry free of other hazards, call light not within reach. On 1/16/24 a nurse documented: Contacted (hospital) ER (emergency room) to inquire of res. (resident's) status, res(ident) has been admitted to the hospital with dx (diagnosis) of rt. (right) femur fracture. The 1/16/24 orthopedic consultation report revealed the following: The patient is [AGE] years old. He is assessed through the ER (emergency room) on 1/16/24 with right hip pain following a fall at a nursing facility. He has a subcapital fracture with displacement and is a candidate for surgical management .Right hip procedure will include cemented endoprosthesis to bipolar arthroplasty. Resident #46 was hospitalized for seven days. On 1/18/24 a RNA documented: Fall intervention: resident had a fall on 1/16/23 he was found on floor with roller chair behind him. Fall intervention is room change to more visible room and had family take roller chairs out of room and replaced with regular chairs. On 1/19/24 IDT note revealed: (Resident) was admitted (to hospital) on 1/16/24 for right femur fx (fracture) with scheduled procedure for 1/17/24 and anticipated return within 3-5 days. (Resident's) room is currently located at the end of the 200 hallway and due to the recent falls, his poor safety awareness d/t (due to) progression of dementia it is the recommendation of the committee to relocate (Resident) to a room closer to nurses' station for closer monitoring. We will also ask the family to remove the kitchen roller chairs. (Resident) will be relocated to (room #) a highly visible room that is close proximity to 1/4 wing nurse station. Care plan will be reviewed and updated at time of readmission. Family was in agreement with recommendations and have taken the chairs home. On 1/23/24 a Nursing admission Assessment revealed Resident #46 had right femoral fracture repaired. On 2/5/24 social worker documented: Following RCC (resident care conference) with daughter, (name) and son (name), a communication board was hung in (Resident) room, WBing (weight bearing) status, reminders of no ice with water and use of tab alarm in chair and pad alarm in bed for tracking patterns of movement and to help protect the integrity of hip frx (fracture) repair. (name) DON (director of nursing) also is performing an in-service with the 100 (unit) nurses. On 2/6/24 a nurse documented: POA (power of attorney) called and asked if any family could come to help with resident. He wanted to go to his room, but he transfers himself and if he falls and breaks his hip, it won't be good. On 2/12/24 a nurse documented: Alarm on wc (wheelchair), recliner, and bed for resident's safety. He forgets he needs assistance with transfers. The alarm does help resident to hesitate before actually continuing to transfer self. 3. Fall #3 On 2/14/24 a nurse documented: Date and time of fall: 2/14/24 at 1715 (5:15 p.m.) No newly observed injuries. -The details of the fall were not indicated. On 2/15/24 a RNA documented: Fall Intervention: Resident found on the floor on 2/14/24. Intervention is staff education on purposeful rounds. On 2/15/24 IDT post fall review revealed: (Resident) has not fallen this month until this fall. He has poor safety awareness and requires staff assistance with his ADLs due to recent hip fracture. He has been moved to a room closer to the nurses' station within the past month and family has removed his rolling chairs out of his room with his most recent fall. He has severely impaired cognition with a BIMS score of 2/15 per his most recent MDS. He has minimal difficulty hearing, usually is able to make his needs known and to understand others and usually understood by others. His vision is adequate with glasses. He is WBAT (weight bearing as tolerated) and is working with therapy. He was wearing proper footwear at the time of the fall. He does not consistently use his call light. Due to significant cognitive impairment and communication deficits, he does not recall the reason why he was up by his table and the cause of the fall. However, he tested positive for RSV (respiratory synctial virus) and is now under precautions. Deconditioning could also be a potential cause of the fall due to recent surgery and now testing positive for RSV. Restorative has done education with staff for purposeful rounds. He remains in a high traffic hallway where staff are aware to observe him in his room and to monitor for unassisted transfers, and his activity while he is in his room. Continue to work with therapy to maintain strength. Care plan reviewed. 4. Fall #4 On 2/28/24 a nurse documented: (name) in activities came and told this nurse, '(Resident) is on the floor, it looks like it's been awhile because there is dried blood all over the floor.' Grabbed vs (vital signs) equipment while calling (number), asked (name) to send an RN to (Resident #46's) room. Attempted to print paperwork to ship resident out . (name) trying to dress wounds on R (right) head and R (right) arm and hand. Resident c/o (complained of) R (right) hip pain. (name) was helping to hold resident back up, (name) was attempting to keep right leg still. Resident was getting tired of sitting on the floor. I walked EMTs to room while giving report. They left at 1530 (3:30 p.m.). Room is without clutter. Appeared resident walked toward closet and fell then scooted himself back to recliner where he was found. 1455 (2:55 p.m.) (name), CNA and this nurse had redirected resident from another room and since he was going into restroom we took him back to his room and was going to set him on the toilet. Resident refused and wanted in recliner. As I left I reminded (name) to put his alarm on. She said she would and had already picked it up to apply alarm. It appears resident took alarm off and stuck it in his drawer that is beside his recliner. (POA), (name) and (physician) are aware of resident's fall and injuries. ER was given report and EMT's took resident from building at 1530 (3:30 p.m.). The 2/28/24 emergency department report revealed the following: BIBA (brought in by ambulance) from (facility) after fall with head injury over right eye. Does not remember what happened. Skin tear to right elbow. On 2/28/24 a nurse documented: Returned at 1730 (5:30 p.m.). Changed dressing and approximated R (right) elbow. On 2/29/24 a nurse documented: Bruising to eyebrow is now around eye and onto cheek. On 2/29/24 the IDT review revealed: (Resident) has poor safety awareness and requires staff assistance with his ADLs due to recent hip fracture. He has been moved to a room closer to the nurses' station within the past month and family has removed his rolling chairs out of his room with his most recent fall. He has severely impaired cognition with a BIMS score of 2/15 per his most recent MDS. He has minimal difficulty hearing, usually is able to make his needs known and to understand others and usually understood by others. His vision is adequate with glasses. He is WBAT and is working with therapy. He does not consistently use his call light. Due to significant cognitive impairment and communication deficits, he does not recall the reason why he was up by his table and the cause of the fall. However, he tested positive for RSV within the past two weeks and potential deconditioning due to recent hip fracture, and recent RSV. He was sent to the hospital due to c/o hip pain and abrasion to head. Due to significant cognitive impairment, he is not able to recall the cause of the fall. He is on skilled therapy. Restorative placed hipsters on him to prevent fall related injuries due to hx of fracture and repeated falls due to his poor safety awareness. Staff to continue with purposeful rounds to monitor his in-room activities and to help mitigate falls, as he will wear them. Care plan reviewed. C. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 3/6/24 at 1:30 p.m. She said the staff were to check on the resident within hour increments. She said to prevent further falls the resident should not be left alone in his room because he would try to get up from his recliner. She said the resident could not use the call light. She said the staff frequently brought Resident #46 by the nurses' office and placed him in his wheelchair in front of the television to keep an eye on him. CNA #2 was interviewed on 3/6/24 at 1:40 p.m. She said before the fall with hip fracture, the resident was independent in his room. The staff interventions were to help him to the bathroom before he tried to go without assistance. She said he should call for staff assistance but he did not remember to use the call bell. She said the resident should be checked by staff more frequently, like every 15 minutes, but this intervention was not in the care plan. She said the purposeful rounds intervention did not have a time attached and when staff was busy they did not check on the resident for a couple of hours. The RNA was interviewed on 3/7/24 at 8:07 a.m. She said after a fall, a registered nurse assessed the resident for injuries and let the RNA know of the accident. She said she reviewed the care plan, added new approaches and wrote a note. She said the IDT reviewed each fall once a week. III. Resident #25 A. Resident status Resident #25, age [AGE], was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), the diagnoses included Parkinson's disease with dyskinesia (involuntary movement of the face, arms, legs or trunk), muscle weakness, right artificial hip joint, restless leg syndrome, hypertension and hyperlipidemia. The 1/15/24 minimum data set (MDS) assessment documented the resident was moderately cognitively intact with a brief interview for mental score (BIMS) of 10 out of 15. He required substantial assistance with showering, dressing, toileting and transfers. The resident fell two or more times since he was admitted and since the last assessment. B. Resident interview Resident #25 was interviewed on 3/4/24 at 4:39 p.m. He said he slipped out of his reclining chair when he transferred himself to or from his wheelchair. He thought he slipped because of the bed sheet on the reclining chair. He slept in his chair instead of a hospital bed. He did not know what the facility was doing to prevent him from slipping or falling. He felt like falling was one of those things in life that would happen. C. Observations On 3/4/24 at 1:11 p.m., the resident transferred himself from the wheelchair to the reclining chair. An unidentified housekeeper entered the room as the resident transferred himself. She did not ask if he needed help and no staff entered the room. The housekeeper was in the room until 1:26 p.m. A continuous observation occurred on 3/6/24 from 9:25 a.m. until 11:01 a.m. The resident was sleeping in his bed with his door open. The resident's room was the second to last room in the hallway and according to previous interventions he was supposed to be moved closer to the nursing station. A staff member looked in the resident's room at 9:33 a.m. The staff member did not walk into the resident's room. An unknown dietary aide walked in and out of the resident's room at 9:47 a.m. At 9:58 a.m. an unidentified nurse walked in the resident's room and closed the door. The nurse left the room at 10:01 a.m. and kept the door open approximately 30 degrees. The resident was not visible with the door opened at 30 degrees. At 10:33 a.m., an unidentified staff member walked from an office at the end of the hallway. The staff member did not enter the resident's room. At 10:36 a.m. the same unidentified nurse walked by all rooms in the hallway. She did not enter Resident #25's room. At 10:54 a.m. laundry entered the resident's room and woke the resident up. She put the resident's clothes away and closed the door at 30 degrees. She did not ask the resident if he needed anything. D. Record review The fall care plan, revised 5/10/23, revealed the resident had a care plan for falls. The resident was at risk for falls related to his history of falls, muscle weakness, potential medication side effects, potential vision impairment, cognitive impairment, Parkinson's, psychotropic medication use, potential vision impairment, history of furniture walking, incontinence, increase in tremors, decrease range of motion to bilateral lower extremities (hips), does not consistent call for assistance, refuses the use of slideboard, arthropathy of right hip, benign prostate hyperplasia, right artificial hip, refusal to let staff assist with transfer, potential medication side effects and refusal to use sit to stand lift. Interventions included anti-roll brakes placed on wheelchair (initiated 6/30/21), call do not fall sign placed at bedside (initiated 10/9/19), extra grab bar placed in bathroom to facilitate easier and safer transitions between toilet and wheelchair (initiated 4/12/23), high back wheelchair for proper positioning (initiated 10/20/22), offer and encourage a room closer to the nurse's desk or a high visible room (initiated 11/4/23), purposeful rounds (9/2/18), sign to alert staff of high fall risk on outside of resident's door (initated 10/20/23), extensive two assist and use gait belt (initiated 11/20/23). -The fall risk care plan did not consistently include interventions added after he fell (see below). The 1/19/24 fall risk assessment revealed the resident had intermittent confusion, had one to two falls in the past three months, was chair bound, had a change in medication and had Parkinson's disease. The resident scored a 19 which indicated the resident was a high fall risk. 1. Fall incident on 2/19/24 The 2/19/24 nurse initial fall note revealed the resident was found on the floor between his recliner and his wheelchair. The resident tried to transfer himself from his wheelchair into his recliner to take a nap and slipped between the chairs. The new intervention was resident education on call for staff assistance. -The root cause was not identified. -The physical assessment of the resident was not documented. -The fall care plan did not reveal new interventions. 2. Fall incident on 1/5/24 The 1/5/24 nurse's initial fall note revealed the resident was found on the floor. The resident tried to transfer from his recliner to his wheelchair. The new intervention was staff training to offer toileting after meals. -The root cause was not identified. -The fall care plan did not reveal new interventions. 3. Fall incident on 11/29/23 The 11/29/23 nurse's progress note revealed the resident was found on the floor in front of the recliner. The resident tried to transfer to his wheelchair. The intervention was to call for assistance when toileting. -The root cause was not identified. -The fall care plan did not reveal new interventions. 4. Fall incident on 11/13/23 The 11/13/23 nurse's progress note revealed the resident was found on the floor. The resident tried to transfer to his recliner because he was uncomfortable in his wheelchair for a long period of time. The intervention was to call for assistance when he wanted to transfer to and from his wheelchair. -The root cause was not identified. -The fall care plan revealed there was a call don't fall sign at the bedside initiated on 10/9/19. The care plan revealed to offer and encourage a room closer to the nurse's station or a high visible room initiated on 11/14/23. 5. Fall incident on 9/29/23 The 9/29/23 nurse's fall progress not revealed the resident was found on the floor. The resident had to transfer from his recliner to the wheelchair and slid to the floor. -The root cause was not identified. -There was no intervention documented. -The fall care plan did not reveal new interventions. E. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 3/7/24 at 11:14 a.m. The CNA said she knew a resident was a high fall risk because therapy told her and when she rounded. She said if a resident fell, she would turn the call light on, ensure the resident was safe and notify the charge nurse. She said typical interventions included to check on residents frequently to see if they had to use the bathroom, if they were thirsty or if they were hungry. She said purposeful rounding was walking up and down the hallway and look in the resident's room. She said Resident #25 was a high fall risk. His interventions were to help him to the bathroom before he tried to go without assistance. Registered nurse (RN) #1 was interviewed on 3/7/24 at 9:52 a.m. She said she knew a resident was a high fall risk based on the resident's cognition and gait. If the resident was restless or their gait was unsteady, she told the CNAs to keep an eye on the resident and keep the resident close to the nurse's station. She said if a resident fell, the registered nurse would do an initial assessment. The assessment included a cognition check and a physical check to see how their gait was and if they had fractures, bruising and skin tears. If the fall was not witnessed, she would monitor for 72 hours with a neurological check. She would notify the provider and the family. She said Resident #25 was a high fall risk because he felt confident to transfer himself. She said CNAs knew he was not compliant with his call light so purposeful rounding was important for his safety. The director of nursing (DON) was interviewed on 3/7/24. The DON said if a resident fell, the nurse responded to do an assessment. The fall assessment was documented in the electronic medical record. After an unwitnessed resident fall, neurological checks started, the provider and family were notified, the care plan was updated to include new interventions and the interdisciplinary team reviewed the fall. She said a nurse knew a resident was a high fall risk based on the fall risk assessment and a CNA knew a resident was a high fall risk based on Kardex (care instructions for CNA). She said one typical intervention was purposeful rounding. She said purposeful rounding was walking into the resident's room to ask if the resident needed something to drink, if the resident was in pain, if the resident needed to go to the bathroom. She said if the resident was asleep, the staff should to go in the room to see if the resident was restless. She said she did not have a frequency for purposeful rounding because the staff were going up and down the hallway to help residents. She said the ideal frequency was an hour. She said Resident #25 was a high fall risk. She said a room closer to the nurse's station opened yesterday and the resident was moving. She said staff that went up and down the hallway should have went into Resident #25's room with the door closed and if he was sleeping. -Resident 25's Kardex did not reveal purposeful rounding to prevent falls. IV. Resident #43 A. Resident status Resident #43, age [AGE], was admitted on [DATE]. According to March 2024 CPO, diagnoses included nonexudative age-related macular degeneration, bilateral, intermediate dry stage, osteoarthropathy, saddle embolus of pulmonary artery without acute cor pulmonale, history of falling, age-related osteoporosis, insomnia and dementia. The 1/19/24 MDS assessment revealed severely impaired cognition with a BIMS score two out of 15. She required supervision with bed mobility and transfers. She had one fall, no injury. B. Record review The fall risk assessments review revealed: On 10/20/23 Fall Risk Assessment score 14, which indicated high fall risk. On 1/19/24 Fall Risk Assessment score 14, which indicated high fall risk. The comprehensive care plan revealed: (Resident) has an ADL (activities of daily living) self-care performance deficit r/t (related to) external devices, impaired balance, limited mobility, limited ROM (range of motion), musculoskeletal impairment. Date initiated 7/17/22 Resident) is at high risk for falls r/t (related to) confusion, gait/balance problems, hx (history) of falls, right femur fx (fracture). Date initiated 7/17/22. Interventions included: Apply tape to floor bedside bed to aide in unassisted transfers out of bed. Fall leaf to door frame alerting staff high fall risk. Date initiated 2/10/24. Keep w/c (wheelchair) positioned close to bed with wheels lock for unassisted transfers out of bed. Date initiated 2/10/24. Move to a room where she is more visible. Purposeful rounds. Sign to alert staff of high fall risk placed on outside of resident's door. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Ensure that the resident is wearing appropriate nonskid footwear when ambulating or mobilizing in w/c (wheelchair). Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. -The facility failed to define a time frame for purposeful rounds. -The facility failed to appropriately assess severely cognitively impaired Resident #43 for the use of a call light. 1. Fall #1 On 12/17/24 a nurse documented: Resident was resting in bed, was trying to get up into w/c (wheelchair) and sustained unwitnessed fall. Resident w/c was at bedside and locked. Resident was sitting on floor with back towards the frame of her bed, feet facing the opposite side of the room. Call light within reach, lying next to resident in bed. 2. Fall #2 On 1/27/24 a nurse documented: CNA reported (Resident) had to be lowered to the floor in her room by her bed. When entering the room this nurse observed (Resident) sitting on her buttock with her back resting against the bed with legs straight and hands at her side. Wheelchair is sitting at bedside with brakes engaged, floor is clean/dry and clutter free. She had her slippers on. C/O (complained of) slight right shoulder pain 1/10. She reports she had just come from the bathroom and was transferring to the bed when she got dizzy. When asked what happened she stated 'I'm keeping the floor warm' and laughed. ROM WNL (range of motion within normal limits), mentation is at baseline. She was assisted up by this nurse and CNA. (Resident) was able to help in getting herself up and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews; the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, as evidenced by severe or significant weight loss for three (#76, #68, and #34) of four residents reviewed for nutrition of 35 sample residents. Resident #76 with a diagnosis of dementia exhibited behaviors of putting his (G-tube) down his shirt on 10/1/19. No immediate interventions were put into place to distract or prevent the resident from subsequently pulling out is own G-tube on 10/2/19. After this occurred the failed to; initiate additional interventions to prevent weight loss which contributed to severe weight loss; and implement the registered dietician (RD) recommended interventions to increase caloric intake and prevent severe weight loss. Based on observations, the facility consistently failed to assist and encourage the resident in the dining room which resulted in low meal intakes. The resident received a frozen nutritional supplement orally twice a day upon admission, however, the supplement was frequently refused. No new nutritional interventions were initiated. The resident's significant weight loss occurred on 10/23/19 and his severe weight loss occurred on 10/30/19. Additionally, the most recent nutritional assessment was completed on 9/6/19. There were no current nutritional assessments completed after the resident removed his G-tube and began oral intakes. The most recent nutrition progress note was completed on 10/9/19, which revealed the RD suggested an additional nutrition supplement three times a day. This intervention was not implemented by the facility. There were no additional nursing or interdisciplinary team (IDT) notes evaluating the resident's current oral intake following the removal of his G-tube. The facility failed to assess Resident #68's nutritional status; provide adequate meal assistance in the dining room; evaluate the effectiveness of past nutritional interventions; and implement the RD recommended interventions to prevent significant weight loss. The most recent nutritional assessment was completed on 9/17/19. The resident went to the hospital on [DATE] and experienced a rapid decline in his cognitive function. The facility failed to reassess the resident's nutritional status after his hospitalization which resulted in significant weight loss. In addition, the facility failed to act upon the RD's recommendations to prevent significant weight loss. The facility failed to consistently provide meal assistance and implement care planned interventions to prevent weight loss for Resident #34. The resident was assessed as dependent with activities of daily living (ADLs) which included eating. Observations revealed the facility consistently failed to provide the assistance needed for adequate nutritional status which resulted in significant weight loss. The resident had an open area on his coccyx in addition to his poor nutritional status. Findings include: I. Facility policy and procedure The Nutrition and Unplanned Weight Loss policy, revised September 2017, was provided by the director of nursing (DON) on 10/31/19 at 1:00 p.m. It read, in pertinent part, The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. Treatment decision should consider all pertinent evidence and relevant issues (e.g., food intake, resident/patient wishes, overall condition and prognosis, etc.), and should not be based solely on lab or diagnostic test results. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting). The Medication Orders policy, revised November 2014, was provided by the DON on 10/31/19 at 1:00 p.m. It read, in pertinent part, The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. When recording orders for commercial dietary supplements, specify the type, amount, and frequency. The Acute Condition Changes clinical protocol, revised December 2015, was provided by the DON on 10/31/19 at 1:00 p.m. It read, in pertinent part, Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the nurse. II. Resident #76 A. Resident status Resident #76, age above 80, was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO) diagnoses included dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, nutritional anemia, aphasia, and dementia. The 9/18/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. He required supervision and set up help only with eating and extensive assistance with other activities of daily living (ADLs). Documented was the resident's height: 66 inches and weight: 166 pounds. He experienced a loss of liquids/solids from his mouth when eating or drinking and had no known significant weight loss. He received nutrition through a feeding tube and accepted 51% (percent) or more of total calories through tube feeding. B. Observations Lunch observations on 10/29/19 at 12:19 p.m. revealed the resident received his meal in the assisted dining room. The resident was observed to take a few bites of food then said he was not hungry and left the dining room. The facility failed to offer the resident an alternative option for food. Dinner observations on 10/29/19 at 5:34 p.m. revealed the resident received his meal in the assisted dining room, and again took a few bites of food before he left the dining room. Staff did not approach the resident to encourage eating. Breakfast observations on 10/30/19 at 8:30 a.m. revealed the resident received his meal in the assisted dining room. He did not consume any food before he left the dining room and staff did not encourage the resident to eat his breakfast. Lunch observations on 10/30/19 at 12:15 p.m. revealed the resident received his meal in the assisted dining room. He ate a few bites of his food before he left the dining room. He was asked if he wanted anything else to eat, but was not offered specific items of his liking (to communicate more effectively with a resident who has dementia). Staff did not further encourage him to eat his lunch. Breakfast observations on 10/31/19 at 8:50 a.m. revealed the resident received his breakfast in the assisted dining room. He did not receive prompting or assistance with eating. He left the dining abruptly room and did not eat any of his food. C. Record review The comprehensive care plan, revised 9/19/19, revealed Resident #76 had an activities of daily living (ADL) self-care performance deficit and required supervision and set up assistance with eating. Interventions included, to provide finger foods when the resident had difficulty with utensils, eat in the assisted dining room, and provide milkshakes or liquid food supplements when the resident refused or has difficulty with solid food, or provide nutritious foods that can be taken from a cup or a mug. The Nutrition admission Assessment, completed on 9/6/19 by the Registered Dietician (RD), revealed Resident #76's weight as 169 pounds upon admission on [DATE]. It documented his usual body weight as 190 pounds and he experienced a 20 pound loss prior to admission, from his usual body weight. His comprehension was documented as alert and aphasic. The resident's intake was through enteral feeding and he received 2,004 calories per 24 hours with 85.2 grams of protein per day. Review of the weights and vitals summary revealed the following: -9/5/19: 169.0 pounds; -9/18/19: 166.0 pounds; -9/25/19: 167 pounds; -10/2/19: 166.0 pounds (the resident removed his own G-tube on 10/1/19); -10/9/19: 162.0 pounds; -10/16/19: 162.0 pounds; -10/23/19: 156.0 pounds (6.59% weight loss in one month); and -10/30/19: 149.0 pounds (10.24% weight loss in one month). The September 2019 CPO revealed the following pertinent orders: -Magic cup ice cream after lunch and after dinner two times per day for weight loss started on 9/6/19; -Jevity 1.5 calorie liquid nutritional supplement, 334 milliliter via G-tube three times per day for nutrition ordered on 9/6/19; The Jevity was decreased from three times per day to two times per day on 9/13/19. Staff were to provide assistance with oral intake meals at lunch time. The 9/20/19 speech therapy progress note revealed the resident's tube feeding was decreased due to an increase in the resident's oral intake. It was then discontinued on 10/2/19 when the resident removed his G-tube. The September 2019 medication administration record (MAR) revealed the resident accepted 100% of his ordered calories through tube feeding. He refused the magic cup supplementation 18 times, he consumed 50% or less 25 times, and consumed 75-100% 8 times during the month of September. Additional meal intakes for September 2019 were unavailable. The October 2019 CPO revealed the following pertinent orders: -Magic cup ice cream after lunch and after dinner two times per day for weight loss started on 9/6/19; -Jevity 1.5 calorie liquid nutritional supplement, 334 milliliter via G-tube at bed time for nutrition ordered on 9/6/19 and discontinued on 10/2/19; -Jevity 1.5 calorie liquid nutritional supplement, 334 milliliter via G-tube in the morning for nutrition ordered on 9/15/19 and discontinued on 10/2/19. The October 2019 MAR revealed the resident accepted 100% of his ordered calories through tube feeding. He refused the magic cup supplementation 19 times, he consumed 50% or less 33 times, and consumed 75-100% eight times. The October 2019 meal intakes revealed: -Intake was 0-25% for 31 out of 89 meals. (34.8%) -Intake was 26-50% for 21 out of 89 meals. (23.6%) -Intake was 51-75% for 27 out of 89 meals. (30.3%) -Intake was 76-100% for seven out of 89 meals. (7.9%) -The resident refused two out of 89 meals. (2.2%) The 10/2/19 skilled nursing progress notes revealed the resident pulled out his G-tube overnight. His daughter was notified of the incident and said she did not want the G-tube placed again. The physician was notified on 10/2/19 and per the family's request all G-tube orders were discontinued. The facility failed to complete skin assessments to monitor the healing of the G-tube site after it was not replaced. The 10/9/19 RD progress note revealed Resident #76 experienced 4.1% weight loss over 30 days and 2.4% weight loss since the tube feeding was discontinued. She documented the Resident's food and beverage intake was inadequate and recommended the facility provide additional supplementation of choice three times per day. The facility failed to implement the RD's recommended interventions for additional supplementation. The comprehensive care plan, revised 10/9/19, revealed the resident was at risk for a potential nutritional problem due to a history of cerebral infarction with residual effects, missing teeth, nutritional anemia, dysphagia, and history of artificial nutrition support. Interventions included invite resident to activities that promote additional intake, monitor for signs or symptoms of dysphagia and malnutrition, and night time nourishment Magic Cup two times per day. His diet was regular diet, ground meat texture, and nectar thickened liquids. Additional interventions were RD to evaluate and make diet change recommendations, weekly weights, and regular diet, ground meat texture, and thickened liquids. The care plan was revised seven days after the resident removed his G-tube and experienced a weight loss of 4 pounds (2.41%). The 10/10/19 and 10/11/19 speech therapy progress notes revealed the resident was upgraded to regular textured diet, but he required verbal cues for adequate intake. He needed limited distractions during meals for safe and adequate meal intake. -Observations during survey revealed the resident did not receive verbal cues and limited distractions during meals. The 10/11/19 speech therapy note revealed the resident would continue speech therapy two times per week for dysphagia with a new speech therapist. On 10/15/19 the new speech therapy initial assessment was completed, however additional therapy had not been provided at the time of survey. The 10/16/19 physician progress note revealed the physician discontinued Modafinil, a stimulant medication, which promoted brain activity that was affected by the resident's stroke. Additional behavior monitoring and interventions were not implemented at this time. D. Interviews Licensed practical nurse (LPN) #3 was interviewed on 10/30/19. She said Resident #76 pulled out his own G-tube on 10/2/19 during the overnight shift. She said the daughter was contacted the next morning and she did not want the G-tube replaced. She said the physician was contacted after and discontinued the resident's tube feeding. She said the resident was then put on a puree and thickened liquids diet at the time and was upgraded to mechanical soft. She said the facility did weekly weights to monitor the resident's nutrition after he pulled out his G-tube but she did not know who reviewed his recorded weights. Unit manager (UM) #1 was interviewed on 10/30/19 at 1:13 p.m. She said an incident report was not completed when the resident pulled out his own G-tube, however, a skilled nursing note was made by the nurse on 10/2/19. The 10/1/19 skilled nursing note, revealed the nurse on the 3 p.m. to 11 p.m. shift, documented the resident continued to improve and was able to make his needs known. The 10/2/19 skilled nursing note, revealed the nurse on the 3 p.m. to 11 p.m. shift on 10/1/19 reported to the oncoming nurse the resident was putting the G-tube down the front of his brief on their shift. The nurse on the 11 p.m. to 7 a.m. shift documented the resident's roommate turned on his call light to notify staff the resident pulled out his G-tube and was trying to sit up in bed. The facility failed to implement interventions to prevent the resident from pulling out his G-tube after he exhibited behaviors of putting his G-tube down the front of his brief. The director of nursing (DON) was interviewed on 10/30/19 at 5:17 p.m. She said the facility did not have a new nutritional assessment completed after the resident pulled out his own G-tube. She said the care plan was updated with his diet texture. She said the resident was able to eat independently but needed some set-up assistance and cueing to eat. She said the staff in the assisted dining room should offer alternative foods if the resident refused to eat what he was served to encourage increased intakes. She said the resident received a frozen nutritional supplement twice a day, but there was not an additional supplement added after the resident's G-tube was pulled out. The DON said after the resident's stimulant medication was discontinued on 10/16/19 she noticed the resident was sleeping more often and his appetite decreased. She said the physician was contacted on 10/24/19, however, additional interventions were not implemented and the resident continued to lose weight. The RD was interviewed on 10/31/19 at 9:16 a.m. She said she was in the facility monthly to see residents in person and reviewed charting every other week, however, she was unable to visit the facility in person during the month of October 2019. She said she reviewed any notes in the electronic medical records that referenced the resident's diet changes, weights, and nutritional concerns. She said she evaluated trends in weights if nursing staff notified her, however, she only evaluated weights if they experienced significant weight loss (5% or more in one month or 10% or more in six months). She said she expected nursing staff to notify her of any changes that may affect the resident's nutrition. -Interviews with nursing staff revealed they did not know who monitored weight trends (see interview above). The RD said she was notified when the resident removed his G-tube and she identified initial weight loss on 10/9/19. She said she recommended an additional supplement three times per day at that time, however, she did not follow up to see if the facility started the resident on a supplement. She said she was scheduled to visit the facility on 10/23/19 (the same day the resident had significant weight loss), however, she was unable to go to the facility that day and she did not review the resident's weight loss. She said the facility did not notify her of any significant weight loss and he was not reviewed until 10/30/19 (the day the resident had severe weight loss) when his weight loss was questioned during survey. She said the resident should have received a nutritional supplement in addition to his frozen nutritional supplement. III. Resident #68 A. Resident status Resident #68, age above 80, was admitted on [DATE]. According to the October 2019 CPO, diagnoses included Alzheimer's disease, dementia, and chronic heart failure. The 9/25/19 MDS assessment revealed the resident had a BIMS of four out of 15. Documented was the resident's height: 66 inches and weight: 161 pounds. He had no identified weight loss and no swallowing disorder. The assessment revealed he required supervision and set up help only with eating. -Observations revealed this was incorrect, the resident required assistance in the dining room to eat. B. Observations Breakfast observations on 10/29/19 from 10:23 a.m. to 10:32 a.m. revealed the resident was served breakfast in his room. He was observed pushing and pulling his table back and forth and did not eat his food. He did not receive assistance and was not offered alternative food in his room before the tray was picked up by nursing student (NS) #2 and taken away. Dinner observations on 10/29/19 at 5:44 p.m. revealed the resident did not eat independently when his food was served. His food was served and he waited 20 minutes before he received assistance with his meal. The CNA provided hands on assistance to encourage the resident to eat a few bites. The resident appeared sleepy and disengaged while she attempted to assist for 4 minutes. She did not offer alternative options and he was not provided further prompting to eat his food. He consumed approximately three ounces of juice. Breakfast observations on 10/30/19 from 8:38 a.m. to 5:58 a.m. revealed the resident was sleeping in his wheelchair in the assisted dining room. He consumed approximately 10% of his meal and was not offered an alternative option. The resident was still sitting at the table alone and dietary aide (DA) #2 cleaned his plate and juice off the table. Breakfast observations on 10/31/19 at 8:49 a.m. revealed the resident was sitting in his wheelchair in the assisted dining room. He was served his meal, but did not receive assistance to eat until 20 minutes after his meal was served. The resident was unbuttoning his shirt at the table while he waited for assistance with his breakfast. He ate a few bites and when another resident was offered a chocolate shake the resident requested one also. He consumed chocolate milk but did not eat his breakfast. C. Record review The CPO revealed the resident was ordered weekly weights on 9/16/19 and nourishment of choice in the evening daily on 9/16/19. Review of the weights and vitals summary revealed the following: -9/16/19: 161 pounds; -10/7/19: 151 pounds (6.2% weight loss); and -10/14/19: 149 pounds (7.45% weight loss). The facility failed to obtain weekly weights as ordered upon admission. The admission nutritional assessment was completed on 9/17/19 by the RD. It revealed the resident's usual body weight was 160 pounds and no weight change was identified 180 days prior to admission. His comprehension was identified as disoriented/confused, he was independent to feed himself, and his meal intake was greater than 50%. Additional notes revealed the resident's intake was variable due to dementia and he would benefit from additional nutrition supplementation twice a day to maintain weight. The facility failed to implement the RD's recommendation intervention for additional supplementation twice a day. The September 2019 MAR revealed Resident #68's nightly nourishment intakes as follows: -120 milliliter (ml) of protein supplement seven out of 15 nights (46.7%). -120 ml of juice five out of 15 nights (33.3%). -He refused two out of 15 nights (13.3%) -There was no documentation one out of 15 nights (6.7%). The September 2019 documented meal intakes were unavailable. The October 2019 MAR revealed Resident #68's nightly nourishment intakes as follows: -240ml of protein supplement one out of 29 nights (3.4%). -120 ml of protein supplement 14 out of 29 nights (48.3%). -120ml of juice one out of 29 nights (3.4%). -90 ml of protein supplement two out of 29 nights (6.9%). -60 ml of protein supplement four out of 29 nights (13.8%). -120 ml of juice one out of 29 nights (3.4%). -He received no supplements three out of 29 nights (10.3%). -He received water as a supplement three out of 29 nights (10.3%). The facility failed to document the type and amount of supplementation in the physician orders (as read in the Medication Orders policy documented above). The resident received inconsistent caloric intakes and water was documented as a supplement. The facility was unable to identify the effectiveness of his nightly nourishment. The October 2019 meal intakes revealed: -Intake was 0-25% for 19 out of 89 meals (21.3%). -Intake was 26-50% for 21 out of 89 meals (23.6%). -Intake was 51-75% for 30 out of 89 meals (33.7%). -Intake was 76-100% for 8 out of 89 meals (9%). -He was hospitalized for one out of 89 meals (1.1%). The facility failed to provide or encourage additional supplementation twice a day to prevent weight loss, as identified in the admission nutrition assessment. On 10/20/19, a physician order was placed to send Resident #68 to the emergency room for evaluation and treatment for change of condition. The 10/21/19 hospital discharge documentation revealed the resident was diagnosed with deep vein thrombosis. The 10/21/19 nursing progress note revealed upon the resident's return from the hospital the family requested the resident be taken to the assisted dining room for meals because he needed more assistance with eating. The 10/22/19 social services progress note revealed the facility met with Resident #68's family upon return from the hospital. The family expressed concerns for a rapid decline in the resident's decline in cognitive function. The resident's nutritional status and ability to feed himself was not reassessed upon return from the hospital or after the families concerns regarding the residents' cognitive decline (see above). Observations revealed the resident was unable to feed himself and required hands on assistance from staff. Breakfast observations on 10/29/19 (see above) revealed the facility did not provide assistance with dining; the resident required and as requested by the family. D. Interviews The assistant director of nursing (ADON) was interviewed on 10/30/19 at 5:30 p.m. She said the resident went to the hospital on [DATE] and she noticed a decline in the resident's cognition and ability to feed himself. She said the resident's family requested comfort care at that time, however, that would still allow nutritional supplements and assistance with meals to meet required caloric intake. She said he received occasional supplements at night but he did not receive the recommended additional supplements twice a day. CNA #2 was interviewed on 10/31/19, she said the facility obtained weekly weights for every resident unless otherwise ordered by the physician. She said Resident #68 would not be weighed today because he was already weighed that week. -The facility failed to provide documentation of consistent weekly weights. The RD was interviewed on 10/31/19 at 9:16 a.m. She said she assessed Resident #68 in the facility on 9/25/19 and recommended a nutritional supplement of the physician's choice in addition to the nightly one he was ordered. She said the facility should review the RD recommendations and notify the physician to order the supplements. She said she did not follow up with the facility or monitor the resident to ensure the supplement was provided and ensure the resident met his intake needs. She said she did not speak with nursing staff directly regarding the recommended nutrition supplement. She said she did not review the resident's significant weight loss on 10/14/19. She said the facility implemented the recommended supplement on 10/31/19, after the significant weight change was identified during the survey. She said the facility policy was to obtain weekly weights on all residents to monitor any significant changes in body weight. She said upon review of the resident on 10/31/19, at the time of the survey, she requested a new weight to be obtained. IV. Resident #34 A. Resident #34 Resident #34, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included Alzheimer's disease with late onset, atherosclerotic heart disease, kidney disease, stage three, and cerebral infarction without residual deficits. The 8/24/19 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired and a brief interview for mental status (BIMS) score could not be completed. The MDS indicated the resident had short and long term memory loss, inattention and disoriented thinking. The resident required extensive with most activities of daily living, including on person physical assistance for eating. B. Observations Resident #34 was observed in a reclining wheelchair in the dining room with his eyes closed on 10/29/19 at 12:16 p.m. All other residents were served their meals. There was no attempt to arouse the resident. -At 12:19 p.m., Resident #34 opened eyes as his lunch was placed on the table beside him. -At 12:23 p.m., student nurse (SN) #1, proceeded to feed the resident his meal of pureed chicken fried steak. For each bite SN #1 referred to the as Mister. Between 12:23 p.m. and 12:35 p.m. The SN did not interact with the resident other than to refer to him as Minster or take a bite. She did not sit in front of Resident #34, but beside him having to reach across his chair to reach his mouth. Resident #34 consumed 2 small bites of pureed steak and several sips of his glass of thickened juice. -At 12:35 p.m., Resident #34 coughed slightly as he chewed the last bite. SN diverted her attention away from Resident #34 to feed another resident. -At 12:36 p.m., the resident finished chewing. Between 12:36 p.m. and 12:43 p.m. the resident sat next to his meal, with her eyes open. He was not offered additional food or drink. The NS continued to feed another resident and talked to other staff members. -At 12:43 p.m., she offered another him another sip of thickened juice and a bite of his pureed carrots. The resident accepted the offers. -At 12:44 p.m., NS #1 left the resident to speak to another staff member at the next table. -At 12:45 p.m., she sat next to Resident #34 as she continued to speak to another staff member. Between 12:47 p.m. and 12:49 p.m., she offered the resident two more bites of pureed steak referring to the resident as mister. -At 12:49 p.m. she diverted again to focus on a conversation between other staff members next to her. Between 12:51 p.m. and 1:00 p.m., the NS offered more juice and 2 more small bites of his meal as she continued to focus on staff conversations and looking around the dining room. She did not interact with the resident. - At 1:00 p.m., she got up and walked around the dining room. - At 1:01 p.m. offered the resident another drink, placed his chair in a reclined position. Resident #34 then coughed and sneezed. She did not attempt to offer the resident more food. From 1:01 p.m. and 1:05 p.m. the resident sat awake next to the remainder of his meal. - At 1:05 p.m. NS #1 left without offering or asking if he wanted more food. - At 1:11 p.m. CNA #1 took the resident out of the dining room. - At 1:18 p.m. DA #1 recorded his meal intake at 25%. On 10/30/19, Resident #34 was observed during lunch between 12:10 p.m. and 12:44 p.m. - At 12:14 p.m., the lunch meal was placed next to Resident #34. The resident sat in his wheelchair with his eyes closed. The resident was not prompt to open his eyes nor was there attempts to feed him. - At 12:23 p.m., certified nursing aide (CNA) #3 sat beside him to the resident an attempt to feed by placing a spoon on the resident's lips. She did not speak to the resident. The resident did not accept the two offered bites. -At 12:24 LPN #4 provided the resident his med pass. CNA #3 left the resident. -At 12:27 p.m., CNA #1 sat next to Resident #34. She did not speak to the resident or attempt to encourage him to open his eyes and she made two offers to feed the resident by placing the spoon on his lips. -At 12:30 p.m., CNA# placed his chair in a reclined position and left Resident #34 to feed another resident. -At 12:31 p.m. the director of nursing (DON) approached CNA # 1. The CNA told her Resident #34 would not eat. Between 12:31 p.m. and 12:44 p.m., the DON sat in front of the resident. She called him by his name, rubbed his arm, encouraged and cued him to eat starting with his dessert. His chair remained in a reclined position. The resident consumed four spoon fills of his thickened juice, a portion of his whipped creamed Jell-O and two bites of his entree before he stopped accepting offers. The DON assisted him out of the dining room. 2. Record review The October 2019 CPO identified the resident was on a pureed diet with honey thickened liquids. According to the CPO, the resident had an order for a house supplement three times a day since 9/1/17. The 5/23/19 annual history and physical physician assessment read the resident was Declining to nearly non-restorative state with full dependence .comfort care only .tolerated current diet. The 7/17/19 and 9/28/19 physician notes indicated the resident did not have a change in condition. The weight summary record was reviewed for weight loss. According to the record, the resident lost 10 lbs. in a month indicating a 7.30% loss between 10/1/19 and 10/29/19. The resident had a 9.29% total loss between 8/27/19. All recorded weights were taken with the tub scale. The weight change note on 10/23/19 identified the resident was recommended by the registered dietitian for liquid prostat at 30 ml twice a day. The October 2019 medication administration record (MAR), identified the resident primarily received thickened juice as his house supplement. The 10/29/19 physician phone order read the prostat was not advised, Does not accept thickened fluids very well. The 10/29/19 nurse note read the physician did not advise prostat. According to the note, the resident &quo[TRUNCATED]