**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility policy, and interviews for 1 of 3 sampled residents (Resident #38) reviewed for falls, the facility failed to ensure the bed was left in a low position following the provision of care and failed to provide the level of assistance according to the plan of care, for a resident who was a high fall risk, which resulted in a fall with a major injury. The findings include: Resident #38 was admitted to the facility in August of 2024 with diagnoses that included history of falling, left hip fracture post hemiarthroplasty (hip replacement surgery), dementia and generalized muscle weakness. The Nursing admission assessment dated [DATE] identified Resident #38 as verbal, confused, and with severe impairment affecting all areas of judgement. Additionally, the Nursing admission Assessment identified that Resident #38 was able to move all extremities. The Resident Care Plan (RCP) dated 8/6/24 identified Resident #38 as a fall risk due to impaired mobility post left hip hemiarthroplasty related to a left hip fracture due to a fall and dementia. Interventions included keeping the call bell within reach, ensuring appropriate footwear is worn, providing verbal reminders of individual limitations, encouraging the use of a call bell, physical therapy as ordered, education based on ability to learn, observing for alterations in gait, maintaining a clutter free environment and an assist of 2 staff for bed mobility, transfers and mechanical lift transfers. The fall risk assessment dated [DATE] identified Resident #38 as a high fall risk with a total score of 16 (according to the fall risk assessment tool, a total score of 10 or greater is considered a high risk for potential falls and prevention protocol should be initiated immediately and documented on the care plan). Resident #38's high fall risk predisposing factors included history of falls, altered level of consciousness (always disoriented), predisposing diagnoses, medications, incontinence, being chairbound, having experienced a change in condition in the last 14 days and having had a recent hospitalization in the last 30 days. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #38 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), was dependent on staff for toileting hygiene, bed mobility and transfers and was incontinent of bowel and urine. In addition, the MDS identified Resident #38 sustained a fall and a fracture related to a fall within a month prior to admission to the facility. The Resident Care Card (RCC) dated 10/11/24 identified Resident #38 required an assist of 2 staff for bathing, toileting, incontinent care at bed level, bed mobility and transfers using a mechanical lift. The Reportable Event form dated 10/12/24 at 11:30 AM identified Resident #38 rolled out of bed onto the floor striking his/her head and was found lying on the floor on the right hip. Resident #38 sustained a laceration to his/her head and was transferred to the Emergency Department for evaluation. The Post Fall evaluation by RN #1 dated 10/12/24 at 11:30 AM identified that Resident #38 had a fall risk score of 16 when he/she fell out of bed, sustained a 2.5cm by 2cm by 0.2 cm laceration to his/her head and was incontinent at the time of the fall. Additionally, the Post Fall evaluation identified that Resident #38's bed was at an improper height at the time of the fall and identified that an air mattress was applied on 10/11/24 and was subsequently discontinued post fall incident. Review of the hospital Emergency Department Provider Notes dated 10/12/24 identified that Resident #38 struck the top of his/her head in addition to the right side, right shoulder and right hip when he/she fell. Head, Ears, Eyes, Nose and Throat (HEENT) assessment identified that Resident #38 sustained a 4 cm scalp laceration to the crown (top of head) which was repaired surgically (wound was prepped and draped in sterile fashion, cleaned with povidone -iodine, irrigated with sterile water and pressure wash and repaired with tissue adhesive). In addition, a computed tomography scan (CT scan) identified nondisplaced cervical fractures at C1 and C2. A CT scan of the chest, abdomen and pelvis identified non-displaced fractures of the sacrum at S3 and S4. Resident #38 was placed in an Aspen Collar with cervical precautions. Observation on 11/8/24 at 12:10 PM, identified that Resident #38 shared a room with Resident #209. Resident #38 was observed sitting in a customized wheelchair with an Aspen Collar around his/her neck and a healing wound on top of his/her head. A dresser was located to the right side of Resident #38's bed (if Resident #38 is in bed, right side). Interview with RN #1 on 11/6/24 at 10:18 AM identified that she responded when Resident #209 was yelling for help. RN #1 indicated that when she entered the room, she found Resident #38 lying on the floor on his/her right hip and was bleeding from a laceration to his/her head. RN #1 identified that Resident #38 was non-ambulatory and therefore was not considered a fall risk. RN #1 indicated that even though the call bell was within reach, Resident #38 was not physically or mentally able to use it if he needed help. RN #1 identified that the air mattress placed on 10/11/24 (1 day prior to the fall) was immediately discontinued after the fall because Resident #38 did not have any falls within the facility prior to the placement of the air mattress. RN #1 was unable to provide a specific bed level at the time of the fall but confirmed the bed was not in a low position. Interview with Resident #209 on 10/6/24 at 10:35 AM, who is cognitively intact (BIMS score of 15 according to the quarterly MDS assessment dated [DATE]), indicated that Resident #38 was restless before he fell from his/her bed which was in a high position (approximately 3 feet). Resident #209 identified that he/she was laying in his/her bed watching television and heard a thud, he/she then saw Resident #38 lying on the floor on the right side of Resident #38's bed. Resident #209 identified that Resident #38's bed was so high that he/she could see Resident #38 on the floor on the right side of the bed from underneath the bed. Resident #209 indicated he/she yelled for help and pressed the call bell to alert staff. Resident #209 identified that Resident #38's bed was lowered, and floor mats placed on both sides of the bed after the fall. Interview with NA #1 on 11/6/24 at 12:04 PM identified she was assigned to provide care for Resident #38 on 10/12/24 during the 7 AM to 3 PM shift. NA #1 identified that she was the last person who performed care for Resident #38 at 9:30 AM, 2 hours prior to the fall incident. NA #1 identified that she independently assisted Resident #38 with bathing, dressing and repositioning in bed. NA #1 further identified that she had a difficult time repositioning Resident #38 because he/she was stiff, and she could not turn him/her easily. In addition, NA #1 could not identify at what level she left the bed after providing care. NA #1 indicated that Resident #38 may have attempted to climb out of bed to go to the bathroom since he/she was found to be incontinent of urine and stool when observed on the floor. Interview with Physical Therapist (PT) #1 on 11/7/24 at 1:07 PM identified that Resident #38 received physical therapy services from 8/7/24 to 9/18/24. PT #1 identified that Resident #38 always required a maximum assist of 2 staff during therapy due to the risk of falling. PT #1 indicated that Resident #38's dementia, inability to communicate and little to no command following contributed to a lack of progress towards ambulation. PT #1 further identified that the facility does not evaluate the use of air mattresses from an interdisciplinary approach, but instead, it is the responsibility of the nursing department to evaluate the safety of use, and the risk verses benefit of air mattress use. Interview on 10/7/24 at 10:21 AM with DNS #2 indicated Resident #38 was not a fall risk prior to the fall on 10/12/24 hence no indication for fall risk interventions (e.g. placing floor mats and lowering the bed to a low position). DNS #2 was not aware that Resident #38 was identified as a high fall risk since admission to the facility. DNS #2 indicated that the facility initially identified the cause of the fall incident as the air mattress which was placed on the previous day. DNS #2 further indicated that the air mattress was ruled out as the cause of the fall following the interview with resident #209 who gave a witness statement to the facility that Resident #38 fell out of bed because his/her feet became tangled in bed linens. DNS #2 could not explain why NA #1 performed Resident #38's care independently and left the bed at an inappropriate height after care was provided. The DNS was not able to explain how a resident who was dependent on staff for care was able to roll out of bed and sustain a fall with a head injury and fractures. Interview with NA #1 on 11/8/24 at 2:30 PM indicated that she was not aware that Resident #38 required an assist of 2 for care at bed level and indicated that she did not check the Resident Care Card (RCC) to confirm the level of assistance required before performing care. NA #1 further identified that RCC's are kept in resident rooms, yet did not check the RCC. Review of facility policy, Positioning and Repositioning, identified in part, that, staff should check the care plan, assignment sheet or communication system to determine resident's specific positioning needs including special equipment, resident level of participation and the number of staff required to complete the procedure. It also identified that head of bed should be raised to waist level, prior to providing care and bed lowered into lowest position and side rails placed in the appropriate position as indicated in the resident's plan of care after care provision. Documentation of the position in which the resident was placed should be done. Review of facility policy, Falls: Minimizing Risk of Injury, identified in part, that, residents shall be assessed for risk of falling upon admission, quarterly, annually and after a significant change in condition. Residents who are at risk shall have a care plan that addresses interdisciplinary measures to prevent falls and environmental/equipment recommendations to prevent injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, clinical record review and facility policy, for 1 of 3 residents (Resident #3) reviewed for nutrition, the facility failed to monitor and accurately document fluid intake and bowel movements resulting in a prolonged hospitalization related to a severe fecal impaction and failed to make speech therapy and dietician referrals with a documented weight loss and poor meal intake. The findings include: Resident #3 was admitted to the facility in August of 2022 and had diagnoses that included spinal stenosis, dementia and protein-calorie malnutrition. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 0), dependent for bathing, dressing, and bed mobility and required substantial/maximal assistance for eating. The MDS identified Resident #3 was always incontinent of both bowel and bladder, was at risk for developing pressure injuries and was on a mechanically altered diet. The Resident Care Plan (RCP) dated 7/16/24 identified Resident #3 was at risk for weight loss and dehydration related to poor intake of meals and included interventions to monitor dietary intake and monitor intake and output (I&O). The RCP identified Resident #3 had pain with interventions to include administering Tylenol and Tramadol (opioid). The RCP did not identify Resident #3 as at risk for constipation despite pain regimen and lack of mobility. a. Review of the facility Laboratory Report dated 8/26/24 identified lab values outside of normal ranges to include an elevated blood urea nitrogen (BUN): 51.3 (normal range: 9-23 mg/dL), creatinine: 1.20 (normal range: 0.55-1.02 mg/dL), and sodium: 146 (normal range: 135-145mmol/L). Elevated BUN, creatinine and sodium levels are all indications of impaired kidney function and/or dehydration. An APRN order dated 8/27/24 directs to encourage an extra 240 milliliters (ml) of fluid every shift. Review of the facility Laboratory Report dated 8/29/24 identified lab values outside of normal ranges to include an elevated BUN (46.2), Creatinine (1.16), and Sodium (146). The physician order dated 8/30/24 directs to decrease Lasix (diuretic) to 20mg for 5 days and then to restart Lasix 40mg daily. Review of the facility Laboratory Report dated 9/4/24 identified lab values outside of normal ranges to include an elevated BUN (50.1), Creatinine (1.11), and Sodium (150). A late entry APRN Progress note dated 9/6/24 at 2:52 PM by APRN #1 identified she spoke at length with Person #3 and that Person #3 was very concerned regarding dehydration. The progress note further identified a plan to continue an extra 240 ml of fluids by mouth every shift, to continue Lasix 40 mg daily, to repeat bloodwork (basic metabolic panel (BMP) the next week and included a new order for a low sodium diet. Review of the Facility Order Summary Report dated 9/10/24 identified an order for Senokot-S 8.6-50 mg (2 tablets) to be administered at bedtime with a start date of 8/23/22, Tramadol 25 mg to be administered 2 times a day with a start date of 1/3/24, and Senna 8.6 mg (2 tabs) to be administered in the morning with a start date of 2/5/24. Review of the facility Laboratory Report dated 9/12/24 identified lab values outside of normal ranges to include an elevated BUN (77.3), Creatinine (1.57), and Sodium (156). A late entry APRN Progress note dated 9/12/24 at 4:14 PM identified Resident #3 continued to have abnormal labs, and that Person #3 and the nursing staff reported Resident #3 as having less alertness and agitation at times. The progress note identified a new order for IV fluids (dextrose 5% water to run at 50ml per hour for 500ml), bloodwork the following morning, a urine analysis and a chest X-ray to rule out pneumonia. The progress note identified the plan for the current situation was discussed with Person #3. Review of the Medication Administration Record (MAR) for August and September of 2024 identified Lasix 20 milligrams (mg) was administered daily from 8/31/24 through 9/4/24 and Lasix 40 mg was administered daily from 9/5/24 through 9/13/24. Review of the facility I&O report from 8/31/24 to 9/13/24 identified large volumes of fluid intake documented by NA #8 during the 7 AM to 3 PM shift as follows: 9/2/24: 1400 ml, 9/4/24: 1800 ml, 9/5/24: 1800ml, 9/6/24: 1400 ml, 9/9/24: 1800 ml, 9/10/24: 1800 ml, and 9/11/24: 1800 ml. Review of the facility Bowel Movement (BM) report from 8/31/24 to 9/13/24 identified NA #8 documented the following BM's: 9/4/24: large loose/diarrhea, 9/5/24: Medium loose/diarrhea, 9/6/24: large loose/diarrhea, 9/9/24: medium formed stool, 9/11/24: medium loose stool/diarrhea. Review of the facility SBAR Communication Form document dated 9/13/24 at 3:22 PM by RN #6 identified Resident #3 was found to have an altered mental status, weakness and was transferred to the hospital for further evaluation and treatment. Review of a hospital Discharge Summary document dated 10/4/24 identified Resident #3 was admitted to the hospital on [DATE] and was found to have an acute kidney injury with water deficit (kidneys are suddenly damaged primarily from a lack of fluids in the body), bilateral hydronephrosis (urine unable to drain from the kidneys) related to significant stool impaction, stercoral colitis (rare inflammatory form of colitis that occurs when fecal material leads to distension of the colon) and a urinary tract infection. The Discharge Summary identified Resident #3 had a prolonged hospitalization and initially was ordered to have nothing by mouth, received IV fluids (half normal saline at 100 ml per hour), was treated with IV antibiotics for the urinary tract infection, underwent multiple stool disimpactions, required aggressive bowel regimen, enemas and manual disimpaction. During an interview with the Medical Director (MD #2) on 11/7/24 at 9:32 AM, the I&O report and BM report for the dates of 8/31/24 to 9/13/24 were reviewed. MD #2 identified Resident #3's fluid intake obviously wasn't great and the ordered Lasix should have been held due to worsening lab values. MD #2 identified that if Resident #3 was having BM's at all, the BM's were not sufficient and the facility should have identified that and ordered an X-ray. MD #2 identified that if the bowel regimen was last reviewed in February 2024, it should have been reevaluated since then, due to Resident #3's progressive decline, decrease in mobility and active order of Tramadol (opioid drug). MD #2 further identified he was not notified of any change in condition leading up to the 9/13/24 hospitalization. Interview on 11/7/24 at 10:58am with NA #8 identified Resident #3 did not drink the large volumes of fluid she documented from 8/31/24 to 9/13/24. NA #8 stated she just did not take the time to add up the numbers like she should have and she just wasn't thinking. NA #8 further identified Resident #8 had frequent loose stools and that she reported BM's to the nurses but did not report that the stools were loose because she thought loose stools were normal for Resident #3. She further identified that when documenting in the electronic medical record, she thought the number options were for the number of times residents had BM's verses stool consistency (1: formed stool, 2: loose/diarrhea). During an interview on 11/7/24 at 11:15 AM, the I&O report and BM report for the dates of 8/31/24 to 9/13/24 were reviewed with APRN #1. APRN #1 identified she ordered IV fluids the day before Resident #3 was transferred to the hospital because that is when the nursing staff reported Resident #3 was refusing fluids and further identified she would have ordered IV fluids sooner if she knew fluid intake was poor. When the Lasix orders were reviewed, APRN #1 identified there was a resident representative (Person #3) who insisted Resident #3 have Lasix for edema. APRN #1 indicated she did not review the risk verses benefit of continuing the Lasix with Person #3. During an interview on 11/12/24 at 11:47 AM, DNS #2 was informed that NA #8 identified she documented I&O's and BM's incorrectly. DNS #2 identified incorrect documentation could affect an accurate assessment of care needs and that the RN supervisor should have identified the incorrect documentation and reported it to the APRN. DNS #2 identified NA #8 should have reported Resident #3's loose stools so the RN supervisor could have performed an assessment. Subsequent to surveyor inquiry of inaccurate documentation, the facility initiated staff education for accurate documentation of I&O, BM's and the reporting of any issues/concerns to the charge nurse or nursing supervisor. b. Review of the facility Nutrition assessment dated [DATE] identified Resident #3 was readmitted to the facility on [DATE] with a significant weight loss. Goals identified in the Nutrition Assessment included Resident #3 tolerating the current diet without signs or symptoms of aspiration and meal intake of 50% or greater for 2 out of 3 meals per day. Review of the facility Weight Summary identified a weight of 145.2 pounds on 10/8/24 and a weight of 136.9 pounds on 10/31/24, identifying a further 5.7% weight loss. During an observation in the dining room on 11/4/24 at 12:32 PM, LPN #4 was observed assisting Resident #3 with drinking a chocolate supplement. Resident #3 coughed intermittently with sips of the supplement. By 12:46 PM Resident #3 drank 75% of the supplement and LPN #4 presented a spoonful of mashed potatoes which Resident #3 did not respond to and did not open his/her mouth. At 12:58 PM NA #5 assisted Resident #3 with the remainder of the supplement and removed the meal tray. There was only 1 presentation of food to Resident #3's mouth throughout lunch. Interview with NA #5 on 11/4/24 at 12:58 PM identified Resident #3 ate well prior to a recent hospitalization but since readmission to the facility, Resident #3 does not eat much food. NA #5 identified Resident #3 would eat oatmeal during breakfast on some days but otherwise takes in only fluids. During an observation in the dining room on 11/5/24 at 12:47 PM NA #6 was observed presenting a spoonful of lasagna (mechanical soft) to Resident #3 multiple times. Resident #3 did not respond to the presentation of food, and did not open his/her mouth. NA #7 told NA #6 to stop attempting to feed Resident #3 because Resident #3 only takes in fluids. NA #6 assisted Resident #3 with drinking a chocolate supplement. Resident #3 coughed intermittently with sips of the supplement. Interview with NA #6 on 11/5/24 at 12:55 PM identified she had never previously fed Resident #3 because she usually works on a different nursing unit. Interview on 11/5/24 at 12:56 PM with NA #7 indicated Resident #3 had not been eating food for the past 2 to 3 weeks and Resident #3 often coughed while drinking fluids. NA #7 identified Resident #3 received a meal tray despite not eating food because the nursing supervisor (RN #2) stated it is state mandated for residents to receive meal trays even if they do not eat. Review of the Document Survey Report identified Resident #3 ate less than 50% for more than half of the meals served from 11/1/24 to 11/7/24 and of those meals 5 were documented as refusals. Interview on 11/7/24 at 9:32 AM with MD #2 indicated that due to Resident #3's progressive decline and poor meal intake, the diet should be downgraded to identify if Resident #3 better tolerates a different texture. Interview on 11/7/24 at 4:33 PM with Speech and Language Pathologist (SLP) #1 identified Resident #3 last received speech therapy services from 10/4/24 to 10/10/24 with a recommendation for a mechanical soft texture and thin liquids and stated Resident #3 had a delayed response to presentation of food. SLP #1 indicated food consistency effects palatability of food and when the goal is for residents to take in more food, efforts are made to maintain food consistency. The SLP identified she had not received any reports of poor meal intake or further weight loss for Resident #3 and would have expected to receive a referral if there was a change in condition. SLP #1 further identified that if Resident #3 had poor meal intake, safety would be the priority over palatability and Resident #3 should be evaluated for a diet downgrade. Subsequent to surveyor inquiry, SLP #1 downgraded Resident #3's diet on 11/7/24 to a puree texture and nectar thick liquids. Review of the Speech Therapy SLP Evaluation and Plan of Treatment document dated 11/11/24 identified Resident #4 presented with further decline in swallow function, with decreased intake and observed coughing with thin liquids. Interview on 11/12/24 at 11:51 AM with RN #2 identified she was not aware of Resident #3's poor meal intake and if she were aware, she would have referred Resident #3 back to the SLP and the RD for an evaluation. The facility policy titled Intake/Output states, in part, the purpose is to ensure adequate hydration and prevent dehydration to the extent possible based on each residents individualized care needs and choices and that I&O are instituted for a resident with a change in condition which may alter hydration status. The facility policy titled Charting and Documentation states, in part, documentation in the medical record will be complete and accurate. The facility policy titled Notification Change in Condition, Change in Treatment/Services states, in part, that the facility will inform the resident, resident's physician and the resident's family/legal representative when there is a change of condition. The policy states an RN will perform an assessment once a change of condition is identified and the policy provides examples of changes in condition to include diarrhea, vomiting (assess for dehydration and /or constipation) and changes in intake and output (assess for dehydration and/or fecal impaction).