**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement interventions per resident's care plans and care assessment in preventing falls; and failed to follow policy related to fall investigation for two (R1 and R5) of five residents reviewed for accidents and falls. These deficiencies resulted in R1 sustaining a fall that resulted in bruising to the left side of the head and R1 being transferred to the local hospital for treatment after being found sitting on the floor with left arm hanging on the left bedrail with head slouched over to the left side. R5 who is confused with unsteady gait; had a fall requiring emergent transfer to the hospital and was diagnosed with acute nondisplaced fracture to the left parietal calvarium.Findings include:R5 is a [AGE] year old, female, admitted in the facility on [DATE] with diagnoses of Traumatic Subdural Hemorrhage without Loss of Consciousness, Subsequent Encounter; Syncope and Collapse; Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites; Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance; Contusion of Unspecified Part of Head, Subsequent Encounter; Other Fracture of Base of Skull, Subsequent Encounter of Fracture with Routine Healing; Traumatic Subarachnoid Hemorrhage without loss of Consciousness, Subsequent Encounter; History of Falling and Unsteadiness on Feet. R5's MDS (Minimum Data Set) dated [DATE] documented:Section C: BIMS (Brief Interview for Mental Status) score of 7, which means severe cognitive impairment.Sec GG - Needs partial/moderate assistance when sitting to standing, in walking 10 feet; and dependent on staff when walking 50 feet. R5 uses a manual wheelchair. R5's Fall Risk Evaluations recorded the following scores:[DATE] - 13, high risk[DATE] - 15, high risk[DATE] - 12, high risk[DATE] - 12, high riskFacility's final incident report dated [DATE] documented that on [DATE] at approximately 7:30 PM, R5 was observed laying on the floor in the hallway near her room stating that she was walking to make her normal rounds when she slipped and fell. She complained of pain to her head. V10 (Physician) was notified and ordered R5 to be sent out to the hospital. She (R5) was admitted to the hospital and was diagnosed with an acute nondisplaced fracture to the left parietal calvarium. On [DATE] at 2:41 PM, V7 (Registered Nurse, Agency) was asked regarding R5's fall incident on [DATE]. V7 stated, That day, [DATE] was my first day of meeting her. I was endorsed that she is a wanderer and needs redirection. I was at the nurses' station that time, the CNA (Certified Nurse Aide) said, I tried to catch her, but I couldn't catch her. The aide who reported was not my aide. I and the other nurse went there, and she (R5) was sitting on the floor, she (R5) said she hit her head but not enough to knock her out. I assessed her (R5) and she's able to move. We put her on the wheelchair and brought her to the nurses' station. I called physician and was ordered to send her out because she is on blood thinner. I called paramedics. Upon assessment, she didn't complain of any pain, her ROM (range of motion) was still intact. Paramedics came; she was not in pain. She was transported to the hospital. I was told she is a high risk for falls and told me she does walk but needs redirection. I didn't hear any alarm. Her room was not closed to nurses' station but close enough that I would be able to hear any alarm at the time. I was not aware about the alarm. The nurse who helped me said she has a bed alarm. The aide told me she was not sure if the alarm was on since V11 (Family Member) was still with her when she last saw her. V7 was also asked if R5 uses any type of assistive device to help with locomotion. V7 mentioned, She is alert, oriented to self and place. She is able to verbalize needs and wants but mostly confused during afternoon and night. She is ambulatory, she does not use any walker or wheelchair, I have not seen her using one.According to change of condition progress notes dated [DATE], R5 complained of moderate head pain.On [DATE] at 3:10 PM, V8 (Registered Nurse, RN) was interviewed regarding R5. V8 replied, She is confused, I helped V7 last [DATE] when she (R5) had the fall. I saw her (R5) walking in the hallway without any assistive devices. I told V7 that she (R5) was walking by herself. I wasn't sure if she is supposed to be walking or not, so I called her (V7) attention. I don't know if she (V7) heard me or not. She (V7) was at the nurses' station. After a while, they called me to help because she (R5) was on the floor. I came, she was laying on the floor, by the door of another resident's room. She (V7) did the assessment. At the time, I didn't hear any alarm gone off. I sometimes see R5 walking in the hallway by herself, with unsteady gait. I think she is supposed to have a bed/chair alarm.On [DATE] at 3:20 PM, V9 (CNA) was also asked regarding R5's fall incident on [DATE]. V9 verbalized, On [DATE], last time I checked on her, I put her to bed. I put two blankets on her per her request. She was sleeping in bed and bed alarm was on. When I came back from break, I was informed that she had a fall. She has bed and chair alarm. She uses wheelchair. She likes to walk but she needs to use a wheelchair.R5's medical professional progress notes dated [DATE], documented: Current functional status: wheelchairOn [DATE] at 11:21 AM, V2 (Director of Nursing) was asked regarding R5. V2 stated, She is able to ambulate but for safety we don't want her to ambulate alone. She has a wheelchair that she uses for locomotion. She did have a bed/chair alarm, nurses and CNAs are responsible to check for the functionality of the alarm. Staff must ensure fall interventions are in placed properly. If they see something that resident is doing that is not safe, they have to redirect residents and report any safety hazard, safety concerns. R5 can ambulate but unsteady with her feet so she needs assistance when ambulating, she needs to use her wheelchair. She is very confused all the time. She has unsteadied feet. That time she had a fall on [DATE], she (R5) was seen by V8 walking and tried to catch her not to fall. V9 was the CNA and was on break at the time.Progress notes dated [DATE] indicated R5 was admitted to the hospital due to skull fracture.R5's care plan regarding at risk for falls, dated [DATE] documented:Interventions:Encourage R5 to use her wheelchair when trying to ambulate around the unit to promote safety.Provide bed/chair alarm, and redirect R5 when seen restless or anxious. R1 is a [AGE] year-old, male, originally admitted in the facility on [DATE] with diagnoses of Malignant Neoplasm of Oropharynx, Unspecified; Malignant Neoplasm of Prostate; Secondary and Unspecified Malignant Neoplasm of Lymph Nodes of Head, Face and Neck; Polyneuropathy, Unspecified; Spinal Stenosis, Cervical Region and History of Falling. MDS dated [DATE] documented R1's BIMS score is 11, which means moderate impairment in cognition. R1 requires supervision or touching assistance during sit to stand; chair/bed to chair transfer; walking 10, 50 and 150 feet. He has no impairment on both upper and lower extremity but uses walker for locomotion. Fall incident report dated [DATE] recorded R1 was observed on the floor with left arm hanging on the left bedrail with head slouched over to the left side. An attempt was made to arouse R1 but did not verbally respond, only with eyes closed and opened. His level of consciousness was stuporous and only responsive to vigorous stimulation. On [DATE] at 12:25PM, V4 (CNA) was interviewed regarding R1 and R's fall on [DATE]. V4 replied, On [DATE], I went back to his room after giving morning shower to the other resident. He (R1) was sleeping. I went back in there after lunch, and he was on the floor on the left side of bed. He was sitting up on the floor. I asked him and he did not respond. He was still alert but not verbally responsive. I called the nurse. He was on a low air loss mattress; his left hand was in the rail.V5 (RN, Agency) was also interviewed regarding R1 on [DATE] at 12:52PM. V5 stated, On [DATE] morning shift, the CNA (V4) reported to me he was sitting on the floor. When I saw him, his arm was still holding the side rail. His head was slumped to the side of left side rail. I did head to toe assessment, he was not verbally talking, he can open his eyes a bit but not saying anything. He was sitting on the floor. I don't know if he slid down. He wouldn't keep his eyes open when I call his name. I called paramedics. He kept on grunting and kept closing his eyes. I noticed mild swelling on the left side of his face, by the eyes. There was no laceration, no issues with his eyes. He was not verbally responsive, his mental status is my focus, that is why I called emergency. I saw him on the floor and my first thing is to call paramedics because he was not responding.According to ambulance report dated [DATE], paramedics found patient (R1) lying in bed, alert to painful stimuli only. Nursing staff stated that they were in the room, left for about 5-10 minutes and when they came back, they found patient (R1) half on the floor with his arm wrapped around the side rail of bed. Staff stated the patient (R1) normally alert, oriented to self, time, place and situation and able to hold conversations. Patient (R1) was spitting up mucous and bruising was noted to the left side of his face and his left eye pupil was in a slit and rotated. No other injuries were noted.Emergency department attending physician notes dated [DATE] recorded R1 has bruising to the left side of head; and left eye is irregularly shaped, not circular, linear, not reactive.On [DATE] at 12:19 PM, V2 was asked on what was the cause of R1's fall. V2 verbalized, Based on what I received there was no injury related to the fall. He had a fall; he was observed on the floor by the CNA who reported to the nurse. And upon the nurse entering the room, she noted him not be responding. I did his fall investigation I have witness statements only, but there was no injury noted upon assessment prior to sending out to the hospital. The nurse said she did not know any swelling, nothing pretty much. Facility presented two witness statements related to R1's fall on [DATE], as follows:V5 was asked about representative notification; any bruising; hospital endorsement; last time R1 was seen and how long R1 was transferred to the hospital. V4 was asked when was the last time R1 was seen and his condition; and if she (V4) was the staff who observed R1 on the floor.There was no specific investigation related to the cause of his (R1) fall and how he fell. On [DATE] at 10:38 AM, V10 (Physician) was interviewed regarding R1 and R5. V10 stated, R5 has dementia, had traumatic subdural hematoma and has history of syncope and collapse. On [DATE], I was informed that she had a fall. She was sent to the hospital. R1 has multiple significant medical issues. Alert, he has cancer of the head and neck and was getting treatment from the hospital. He has cancer of the prostate, chronic kidney disease and multiple several medical issues: chronic or acute. He is getting blood thinners. On [DATE], I was notified that he had a change of condition, so he was sent out to the hospital, and he had a fall. The assumption was he had a fall, and he needs to go to emergency room. Staff should make all efforts to prevent falls. The goal is to prevent falls. Fall interventions should be patient centered. Facility's policy titled Fall Occurrence dated [DATE] stated in part but not limited to the following:Policy Statement: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Procedure:5. The Falls Coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure preventive measures are in place to prevent developing of new skin impairment and deteriorating of current pressure ulcer to resident who is at high risk. This deficiency affects one (R139) of three resident in the sample of 32 reviewed for Pressure Ulcer Prevention management. This failure resulted in R139 developing a new moisture associated skin disorder (MASD) to bilateral buttocks and deteriorating pressure ulcer on sacrum area to unstageable. Findings include: On 1/7/25 at 11:30AM, R139 lying in bed with her V13 Family member/daughter and V14 Caregiver at bedside. V13 stated that she has concern regarding poor nursing services provided to her mother. V13 stated that they arrived today around 8:30AM and found R139 soaked with urine and feces. R139's bed was wet from her upper back/shoulder down to her both ankles. V13 stated that she called and showed observation to V11 ADON (Assistant Director of Nursing). V13 stated she presented concerns of not providing incontinence care to R139 from night shift until morning shift. V13 stated that R139 developed pressure ulcer in her sacral area in the facility and deteriorating. V13stated that R139 has a stage 3 pressure ulcer on sacral area. R139 is on low air loss mattress with flat sheet and cloth pad over the mattress. She (R139) wears disposable adult brief. On 1/9/25 at 12:30PM, R139 lying in bed with low air loss mattress. R139 is alert, oriented and can verbalize needs to staff. R139 stated that she developed bedsore in the facility and causing her pain on her buttocks area. R139 stated that the nurses are changing her dressing on her buttocks, but they are not changing her brief when she was soiled. R139 stated they do not answer her call light. R139 stated that her mattress had a problem, and they switched her bed with her roommate. R139's roommate was not in her room, but the roommates low air loss mattress is unplugged. Verified information given by R139 to V26 WCC (Wound care coordinator). V26 stated confirmed that they switched R139's bed with her roommate just 45 minutes ago. On 1/9/25 at 12:40PM, V27 Wound care tech repositioned R139 on left side lying position. V26 WCC removed foam dressing on sacrum area. Observed R139 has moderate serous sanguineous with greenish wound drainage. V26 said that R139 has unstageable pressure ulcer on sacrum and MASD on bilateral buttocks. Observed multiple open wounds covered with white colored ointment. V26 said that R139 has 70% greenish slough formation attached to wound base, 10% eschar and 20% granulating tissues. V26 said that R139 is being seen by V30 Wound care Nurse Practitioner. V26 provided wound care to bilateral buttocks and sacrum. V26 said that checking resident every 2 hours for incontinence care, skin care after each incontinence episode, low air loss mattress and provided treatment as ordered are some of the wound care preventive measures the provided. R139 is initially admitted on [DATE] and was re-admitted on [DATE] with diagnoses listed in part but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Pressure ulcer of sacral region stage 3 during stay, Type 2 Diabetes Mellitus (DM) with diabetic neuropathy, Obesity. admission and current Braden/skin assessment indicated that she is at high risk for developing pressure ulcers/skin impairments. Active physician order sheet indicated: Bilateral buttocks cleanse with Hibiclens, apply triad wound paste, leave open to air everyday shift, and as needed for MASD. Air Mattress. Santyl ointment 250 unit/gm (Collagenase) apply to sacrum topically everyday shift for wound cleanse with normal saline cover with foam dressing. Right heel cleanse with normal saline apply betadine /gauze /abdominal pad wrap kerlix every day shift M-W-F for DTI (Deep tissue injury). Barrier cream to be applied after each incontinence episode may be applied by CNA and kept at bedside. Comprehensive care plan indicates that she has pressure ulcer on sacrum, right heel, venous ulcer to the right lower leg and is high risk for further pressure ulcers related to impaired mobility, decreased ROM, incontinence, history of right humerus fracture, right side hemiplegia related to CVA (Cerebrovascular accident), DM, Obesity and CHF (Congestive heart failure). Intervention: Follow facility policies/protocols for the prevention/treatment of skin breakdown. She has an ADL (Activity of daily living) self-care performance deficit and impaired immobility. Intervention: totally dependent on staff for toilet use. She is on low air loss mattress due to presence of skin breakdown and to prevent further skin breakdown. Intervention: Check for proper functioning and setting of low air loss mattress every shift. On 1/9/25 at 1:16PM, Reviewed R139 medical records with V28 MDS/Resident assessment Coordinator. V28 stated that R139's MDS (minimum date set) admission assessment on 3/8/24 indicated that she was admitted with stage 2 pressure ulcer on sacral area. MDS assessment dated [DATE] indicated that her skin is intact. MDS assessment dated [DATE] indicated that she was re-admitted with stage 2 pressure ulcer on sacral area from the hospital. MDS assessment dated [DATE] indicated that she has stage 2 pressure ulcer on sacral area. MDS assessment dated [DATE] indicated a significant change of condition due to deterioration of sacral pressure ulcer from stage 2 to stage 3. On 1/10/25 at 12:01PM, V11 ADON stated that she was called to R139's room on 1/7/25 by V13 Family member and showed her observation made that R139 was soiled with urine. V11 stated the bed was wet and soaked from upper back/shoulder down to lower extremities/ankles. V13 presented above concerns to her (V11). Informed V11 that the concern form that she completed dated 1/7/25 did not indicate concerns presented by V13 that incontinence was not done due to R139's bed was soiled from upper back/shoulder to lower extremities/ankles when they visited R139 on 1/7/25. V13 also concern that R139 has pressure ulcers that getting worse. V11 documented on R139's concern form dated 1/7/25 indicated: Daughter expressed concern of her mother being soiled, states her mother is a heavy wetter and needs changing often. Daughter ensured rounds would be made on her mother every two hours and that a indwelling urinary catheter would be placed to ensure less moisture to her bottom. V11 said R139 should be check for incontinence every 2 hours. She said that resident who was left soiled for long period of time could developed pressure ulcer and deteriorate current pressure ulcer. Informed V11 that she did not investigate the night shift (11pm -7am) who worked on 1/6/25 and day shift 1/7/25 staff (nurse and CNA) who worked with R139 why she was soiled from upper back/shoulder down to lower extremities/ankles at 8:30am when V13 Family member and V14 Caregiver. On 1/10/25 at 12:13PM, V26 WCC said that R139 developed new MASD on bilateral buttocks and was seen by V30 Wound care Nurse Practitioner. She said R139 should be check for incontinence care every 2 hours. She said that resident who had prolong exposed to soiled brief and bed could develop pressure ulcer and could deteriorate current pressure ulcer. On 1/10/25 at 12:21PM, V30 Wound Care Nurse Practitioner stated that she has taking care of R139 since July 2024, presented with stage 2 pressure ulcer on sacrum area which now progressed to unstageable pressure ulcer. She recently examined R139 on 1/8/25 with new MASD (Moisture associated skin disorder) to bilateral buttocks. V30 said that she was not aware that R139 was left soiled in bed on 1/7/25 as witnessed by V13 Family member and V11 ADON. V11 stated that prolong exposure to soiled brief and bed from urine and feces are factors in developing new skin impairment and deteriorating current pressure ulcer. The facility should follow its wound/pressure ulcer prevention and management policies. R139's Skin/Wound notes documented by V30 Wound care Nurse Practitioner on 1/8/25 indicated: 1. Sacrum- Unstageable pressure ulcer, measures 10.5cm x 7cm x 0.1cm, 90% slough, 10% granulation. 2. New Moisture Associated Skin Disorder (MASD) on bilateral buttocks, partial thickness, 100% epithelial, Dermatitis, exposed epithelium tissues. 3. Right heel pressure, DTI (Deep tissue Injury), measures 2.5cm x 3cm x 0cm, 100% epithelial. V30 documented: 12/23/24 Upon assessment, patient was noted to be on a deflated air mattress. Sacral worsening. 12/30/24 Patient on regular mattress today, RN to notify facility coordinator to get her another air mattress. Sacral wound worsening. Preventive measures: The resident is incontinent of bowel and bladder, thorough skin care with each incontinent episode. Continues alternating air/low mattress for pressure reduction. On 1/10/25 at 12:53PM, Informed V1 Administrator and V2 Director of Nursing (DON) of above concerns and requested for Wound /Pressure Ulcer Management policy. Facility's policy on Skin Care Regimen and Treatment Formulary Reviewed 1/24/24 indicated: Policy statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Procedures: 6. Residents who are not able to turn and reposition themselves will be turned and repositioned at least every 2 hours unless otherwise specified by the physician. 9. Residents with stage 3 or 4 pressure injuries will be placed in specialized air mattress like low are loss mattress Facility's policy on Incontinent and Perineal Care Revised 7/31/24 indicated: Policy statement: It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation and to observe the resident's skin condition. Procedures: 1. Do rounds at least every 2 hours to check for incontinence during shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for fall prevention by not providing toileting assistance as needed in a timely manner and by not ensuring fall risk assessments were completed quarterly and annually. This failure applied to one of three residents (R2) reviewed for falls and resulted in R2 sustaining a left foot fracture. Findings include: R2 is a [AGE] year-old female with a diagnoses history of Partial Paralysis following a Brain Injury, history of falling, Chronic Heart Failure, Peripheral Vascular Disease, Presence of Cardiac Pacemaker, Major Depressive Disorder, and Anxiety Disorder who was admitted to the facility 01/12/2023. On 05/24/2024 at 2:48 PM R2 observed with a stability shoe on her left foot. R2 stated her foot is in a lot of pain and is worse at night because she can't sleep with her stability shoe on. R2 stated she takes pain medication for her foot before going to sleep but wakes up at night and has to take more. R2 stated when she fell on [DATE] she had toileted herself. R2's current ADL (Activities of Daily Living) care plan initiated 01/25/2023 documents she requires assistance with ADL's including bed mobility, transfers, walking, personal hygiene, eating, dressing, and toileting related to signs and symptoms of Depression, Cognitive Deficit, history of falls, pain, decreased range of motion, diagnoses of left side weakness due to history of Stroke, Diabetes Mellitus, Congestive Heart Failure, Coronary Artery Disease, Anxiety, Peripheral Artery Disease, Atrial Fibrillation, Depression, medication side effects from Antidepressant, Opioids, impaired balance and pain with interventions including: assist with toileting at regular intervals and as needed (initiated 04/17/2024), Keep call lights within reach when in bedroom or bathroom. And encourage to ask for staff assistance as needed (initiated 01/25/2023). R2's current Falls care plan initiated 01/13/2023 documents she is high risk for further falls related to (signs and symptoms of depression, cognitive deficit, diagnoses of left side weakness due to history of Stroke, Diabetes Mellitus, Hypertension, Congestive Heart Failure, Coronary Artery Disease, Anxiety, Atrial Fibrillation, Depression, incontinence, medication side effects, decreased range of motion, pain, and history of falls with interventions including: Keep call light within reach when in bedroom or bathroom, encourage to ask for staff assistance as needed (Initiated 01/13/2023), toilet at regular intervals and as needed (Initiated 04/17/2023). R2's quarterly Minimum Data Set, dated [DATE] documents she required substantial maximum assistance with toileting, toilet transfer, chair to bed or bed to chair transfer, and requires supervision or touching assistance with walking from 10-150 feet. R2's Fall Risk Evaluation dated 04/24/2024 documents she is continent of bowel and bladder, has an unsteady gait, just had a fall, and had a score of 17 indicating she is at high risk for falls. R2's hospital report dated 04/24/2024 documents R2 reported she was walking to the bathroom and slipped, falling, and striking her head on the left side of the floor; she presented to the emergency department after a fall. Radiology Results Report dated 04/29/2024 documents an x-ray was performed for R2 with results showing an acute fracture of the left foot, no Osteoporosis or Osteopenia. Fall Incident Report dated 04/24/2024 documents on 04/24/2024 V20 (Agency Nurse) heard R2 call out for help from her room bathroom, V20 ran down there to see her sliding off her wheelchair in the bathroom. R2 reported she was trying to use the bathroom by herself. Final Facility Incident Investigation Report dated 05/08/2024 documents R2 was observed on the floor in the bathroom, complained of pain to the left foot, the physician ordered an x-ray of the left foot which resulted in an acute fracture to the left 5th toe. R2 was sent to hospital for evaluation. R2 reported she hit her left foot on a pipe under the sink in the bathroom during a fall on 04/24/2024 while attempting to self-transfer from the toilet to the wheelchair. R2 was seen by ortho with recommendation for a postop shoe and follow up on x-ray in three weeks. On 05/24/2024 at 2:41 PM V14 (Registered Nurse) stated R2 requires assistance with transfers on and off the toilet and usually uses her call light if she needs assistance. On 05/24/2024 at 2:52 PM V15 (Certified Nursing Assistant) stated someone always assists R2 with going to the bathroom and she always asks for assistance for toileting. On 05/24/2024 at 3:03 PM when asked by V3 (Assistant Director of Nursing) how staff were alerted that she fell and needed help on 04/24/2024, R2 stated she yelled out for help and a nurse came to get her. On 05/24/2024 at 3:08 PM V16 (Certified Nursing Assistant) stated on 04/24/2024 R2 had put her call light on because she needed to be toileted, but she was busy providing care to other male residents. V16 stated she observed R2's call light was on when she went into the hall to get towels. V16 stated she responded to R2's call light, cut it off and let her know that she would return after she finished providing care to other residents and R2 agreed to wait. On 05/24/2024 at 3:20 PM V17 (Certified Nursing Assistant) stated on 04/24/2024 while watching residents in the dining area a nurse came and asked her for help because R2 had fallen. V17 stated when she asked R2 what happened R2 stated she had gotten herself out of bed and went to the bathroom on her own. V17 stated she believed this was not true because R2 cannot physically transfer herself out of bed, into her chair, or onto the toilet. V17 stated R2 has become increasingly confused lately. V17 stated there were a total of four certified nursing assistants working during the evening shift when R2 fell. V17 stated R2 usually won't get up without assistance. V17 stated she heard R2's call light right before the nurse came and asked her for help with a resident who fell. On 05/24/2024 at 3:25 PM R2 stated sometimes it takes staff a long time to respond to the call light. R2 stated if staff take too long to respond to the call light when she has to urinate, she won't be able to hold it. Fall Incident Witness statement completed by V16 (Certified Nursing Assistant) dated 04/24/2024 documents V16 reported she was R2's assigned CNA during that shift, she last saw R2 a few minutes before her fall, she was giving care to another resident during R2's fall incident, she had answered R2's call light and she stated she needed to use the bathroom, she told R2 she was in the middle of giving care to another resident and asked if she could give her a few minutes to finish with them and she will be right back to assist her to the bathroom. Fall Incident Witness statement completed by V22 (Certified Nursing Assistant) dated 04/24/2024 documents the last time she saw R2 was at dinner, she was providing patient care during the incident, and she was not present at the time of the incident. Fall Incident Witness statement completed by V15 (Certified Nursing Assistant) dated 04/24/2024 documents she was giving care to a resident in her assigned area and was not aware of R2 falling until after she was back in bed. On 05/24/2024 at 3:40 PM V2 (Director of Nursing) stated fall risk assessments are completed on admission, when a fall occurs, after a change in condition, quarterly, and annually for minimum data set assessments. V2 stated R2 requires one person assistance with transfers and usually calls for assistance. V2 stated R2 uses her call light, verbalizes the need for assistance when in the dining area, and will ambulate in her wheelchair to the nurse's station to ask for assistance with toileting. V2 stated R2 walks with restorative as part of a program. V2 stated toileting assistance for R2 includes ambulating her in her wheelchair to the handrail so she can stand, then she'll turn and pivot to sit down on the toilet, then the staff will need to assist her with pulling down and up her pants and brief during the process. V2 stated after R2 is done with toileting staff will clean her, pull her brief, and pants up or change her brief if necessary. V2 stated R2 will then turn and pivot back to the wheelchair. V2 stated staff can then place R2 in front of the sink where she can wash and dry her hands independently. V2 stated typically staff will close the door to provide R2 privacy while toileting and she will pull the call light to inform staff she has finished toileting. V2 stated staff can either stand outside the bathroom or room door while R2 is toileting. V2 stated staff should definitely be in either area while R2 is toileting. On 05/24/2024 at 4:58 PM V2 (Director of Nursing) stated she recalls now that R2 transferred herself from the bed to the wheelchair and then to the bathroom on the day she fell 04/24/2024. V2 stated R2 shouldn't transfer herself but is capable of doing so. On 05/24/2024 at 5:31 PM V2 (Director of Nursing) stated if a resident who can be toileted needs to go to the bathroom and their certified nursing assistant can't immediately assist them the expectation is the aide would ask another aide or nurse to assist the resident, or for the aide to finish up their task and then assist the resident. V2 stated older residents may only be able to wait for assistance with toileting for 2-3 minutes because they can't hold their bladder very long. V2 stated the aide should ask for assistance with getting the resident toileted in a timely manner. V2 stated it would not have been safe for R2 to transfer herself from her bed to her wheelchair, from her wheelchair to her bathroom toilet, and then back to her wheelchair after toileting on 04/24/2024 when she fell. V2 stated V16 (Certified Nursing Assistant) could have gotten someone else to assist R2 with using the bathroom during that time if she was not available to assist her. V2 stated the appropriate thing for V16 to do if she couldn't immediately assist R2 with going to the bathroom would have been to get someone to assist R2 to the bathroom right away. V2 stated it is possible that having to wait to go to the bathroom could have placed R2 in a position to attempt to transfer herself to the bathroom. R2's medical records only included an admission fall risk assessment dated [DATE] and post fall risk assessment dated [DATE]. The facility's Fall Occurrence Policy received/reviewed 05/24/2024 states: It is the policy of the facility to ensure that residents are assessed for risk for falls. A Fall Risk Assessment form will be completed by the nurse or the Falls Coordinator upon admission, quarterly, and annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure dialysis services were provided in a manner consistent with professional standards for 1 of 3 residents (R1) reviewed for dialysis in the sample of 3. This failure resulted in R1 being transferred to the acute care hospital on 3/17/24, treated for peritonitis, sepsis, and R1's abdominal dialysis catheter had to be removed requiring R1's mode of dialysis to change. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include spontaneous bacterial peritonitis, anemia, elevated white blood cell count, hyperlipidemia, hypertension, pressure ulcer of sacral region, pressure-induced deep tissue damage of right ankle, right heel, and left heel, end stage renal disease, and dependence on renal dialysis. R1's facility assessment dated [DATE] showed R1 had no memory problems and requires assistance from staff for most cares. R1's care plan initiated 2/13/24 showed, Resident requires peritoneal dialysis . Resident will not exhibit complications related to dialysis services. Interventions: Assess for fluid excess (weight gain, increased blood pressure, full/bounding pulse, jugular vein distention, shortness of breath, moist cough, rales, rhonchi, wheezing, edema, worsening edema .) and notify MD (physician). Check and change dressing daily at access site. Monitor labs and report to MD . R1's care plan initiated 2/14/24 showed, [R1] is on Enhanced Barrier Precaution r/t (related to) Peritoneal dialysis. Potential spread of infection will not occur until the new review date. Change gown and gloves before caring for the next resident. Ensure that gown and gloves are used during high-contact resident care activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care for peritoneal dialysis catheter that provide opportunities for transfer of MDROs to staff hands and clothing . Gown and gloves will be discarded in the regular trash can . R1's care plan initiated 2/20/24 indicated, [R1] is on peritoneal dialysis related to end stage renal disease . [R1] will have immediate intervention should any signs/symptoms of complications from dialysis occur . Peritoneal dialysis catheter exit dressing change as ordered . R1's nursing note dated 3/16/24 at 9:56 PM showed, Prior to setting up patient dialysis, writer notices the cap is missing from the patient dialysis catheter. Dialysis nurse on call has been notified and recommended for the patient to be sent out for catheter exchange. MD made aware of dialysis nurse recommendation and agreed. Order to send out to emergency room for the catheter line to be changed. R1's nursing note dated 3/16/24 at 10:27 PM showed, Writer called for (non-emergency transportation company) for transport to [acute care hospital]. ETA (estimated time of arrival) 2 hours. R1's nursing note dated 3/17/24 at 1:55 AM showed, Resident out to [acute care hospital] for dialysis catheter exchange on stretcher accompanied by family and 2 paramedics. Resident alert, oriented to self, verbally responding and in NAD (no acute distress) at time of departure. R1 Nursing Note dated 3/18/24 showed, Followed up [Acute Care Hospital] per admitting nurse on the floor - admitted with sepsis. R1's Acute Care Hospital documentation printed 3/20/24 showed, Date/Time of admission: [DATE] at 2:02 AM . history of hypertension, end-stage renal disease on peritoneal dialysis history of bacterial peritonitis received IV antibiotics sent in from subacute rehab to emergency room . patient was found sepsis Leukocytosis and lactic acidosis and was started on IV antibiotics and is being admitted to the medical floor, also has electrolyte imbalance with hypokalemia, hypomagnesemia, and hypercalcemia and CT scan of the abdomen showed possible esophagitis, gastritis, enteritis, and stercoral proctitis . Assessment: Sepsis with leukocytosis and lactic acidosis, possible recurrent peritonitis . Plan: Admit to medical floor with Infectious Disease and nephrology on consult started on IV antibiotics . [AGE] year-old female with hypertension, dyslipidemia, End Stage Renal Disease . She was recently getting her PD (peritoneal dialysis) at subacute rehabilitation. PD stopped. Plan to remove PD catheter due to infection. Permacath placed 3/19 and got HD (hemodialysis) that day . On 4/29/24 at 11:55 AM, V9 (R1's Home Dialysis Company) stated, [R1] was our patient before she went into the facility and we continue to provide supplies while the patient is in the facility . Our company provides training to the facility, but it is the facility's responsibility to make sure that their staff attend the training and that they have someone in the building providing the dialysis that has been trained Some facility's hire a PD specialist to handle the patient and help reduce infections . When dialysis is completed, each day there is a sterile cap that goes onto the end of the peritoneal dialysis catheter. There is absolutely an increased risk of infection if the cap is mishandled, misplaced, or the tubing is mishandled. The end of the peritoneal catheter must stay sterile. We teach all our patients about this. If the cap is not there, we automatically treat for infection prophylactically . [R1's] infection would likely be from the missing cap . On 4/28/24 at 9:45 AM, V13 (R1's granddaughter) stated R1 was admitted to the acute care hospital from the facility on 3/17/24 with diagnoses of sepsis. V13 stated R1's dialysis port that was in her abdomen had to be removed due to the infection and R1 had a new port put into her chest. V13 stated due to the abdominal infection R1 can no longer do peritoneal dialysis overnight while she is sleeping but now has to go to an outpatient facility and receive hemodialysis which requires R1 to have transportation coordinated and requires her to be in the dialysis chair for 4 hours several times a week. On 4/28/24 at 9:55 AM, V22 (R1's daughter) stated her mother had been doing peritoneal dialysis for many years herself prior to coming into the facility. V22 stated R1 told her the nurses were not handling her dialysis in a sanitary way and she was well aware of how to perform it due to her handling her dialysis herself for many years. V22 stated she went into the facility on the morning of 3/16/24 at approximately 11:00 AM and her mother was in her bed and her dialysis tubing was still attached to the dialysis machine. V22 stated the machine was beeping. V22 stated she notified the nurse, and they were going to take care of it. V22 stated her sister contacted her when she went into the facility on 3/16/24 at approximately 5:30 PM and she found her mother still connected to the dialysis tubing. V22 stated R1 should have been disconnected from the dialysis machine at around 8:00 AM. V22 stated she contacted the facility and asked to speak with the charge nurse. V22 stated she was told that they were not going to do R1's dialysis because they noticed the cap was missing from R1's catheter tubing. V22 stated the charge nurse asked the nurse on the floor (V7 Registered Nurse) about the cap and she said she didn't know when it went missing. V22 stated R1 was nauseous and there was vomitus on her bed linens. On 4/28/24 at 11:13 AM, V2 ADON (Assistant Director of Nursing) stated, . On 3/16/24, from my understanding, when they disconnected [R1] from the dialysis machine there was no sterile cap. Can't say for sure how long the cap was gone . If they are disconnected and the clamp isn't properly closed and there is no cap you run an increased risk of peritonitis . [R1] wasn't having symptoms of infection, the family was present and was going to do patient care and notified that the cap was not in place. From 4/28/24 through 5/1/24, the surveyor made several attempts to get into contact with V7 RN (Registered Nurse) who provided R1's cares on 3/6/24, with no return calls received. The facility's policy and procedure reviewed 7/28/23 showed, Peritoneal Dialysis, Purpose: The facility will comply with the standard of practice for care of resident with Peritoneal Dialysis before, during, and after the procedure. Procedure: 1) Inspect peritoneal catheter sit daily for any signs of redness, drainage, tenderness or swelling that could indicate infection. If there is any change in the catheter site, the physician will be notified immediately. 2) When not in use, ensure that the peritoneal catheter is capped. 3) Prior to peritoneal dialysis, wash hands and put mask on .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately assess and obtain medical treatment following a fall with injury for one of three residents (R2) reviewed for falls with injuries in the sample of four. These failures resulted in (R2) lying in bed with a fractured right leg (tibia) without medical treatment for over 24 hours. Findings include: R2's admission Record documents R2 was admitted to the facility on [DATE] and discharged from the facility on 4-29-23. This same Record documents R2 had the diagnoses of Chronic Kidney Disease Stage Four, Hypotension, Chronic Pain Syndrome, Hallucinations, Peripheral Vascular Disease, Psychosis, Renal Dialysis, Bipolar Disorder, Anxiety Disorder, history of Falling, Ileostomy, Dementia, and Anemia. R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 was moderately cognitively impaired and required extensive assistance of one staff for transfers and toileting. R2's Progress Notes dated 4-29-23 at 2:59 PM and signed by V6 (RN/Registered Nurse) documents, R2 has right knee and leg swelling with bruising. Call to nurse practitioner on call who states to ice, elevate, Tramadol, Tylenol, and x-ray of right knee. R2's Progress Notes dated 4-29-23 at 9:05 PM document, R2's right leg is swollen and bruised. R2 complained of pain 20 out of 10 (1-10 scale). Started on 4-29-23 and has gotten worse. Ambulance notified for transfer. R2 transferred out of facility via stretcher accompanied by two EMTs (Emergency Medical Technicians). R2's Progress Notes dated 4-30-23 at 2:04 AM document, (Hospital) called for status of (R2) to be admitted . Diagnosis: Right leg pain/closed fracture of proximal right tibia. R2's Hospital History and Physical dated 4-30-23 documents, Date/Time of admission: [DATE] at 10:15 PM. Admitting Diagnoses: Closed fracture of the proximal end of right tibia. Subjective: R2 was sent in for evaluation of her right leg and knee pain. R2 had a fall on Thursday (4-28-23). R2 states has swelling and pain with pain increasing on movement and patient has not been able to stand and weight bear on the right leg since the injury. CT (Computerized Tomography) scan of the right knee and leg showing marked diffuse Osteopenia and Comminuted (broken in two or more places) Fracture Proximal Tibial (leg bone) and Prominent Oblique Fracture component from the Mid-Tibial spine extending obliquely to include the Lateral Cortex of the Proximal Metaphysis (area of bone above the growth plate) with marked soft tissue swelling and edema surrounding the knee. Ecchymosis (discoloration under the skin due to bleeding) right leg. R2's Electronic Health Record dated 4-28-23 does not include documentation of R2's fall or an assessment following R2's fall. On 5-26-23 at 3:45 PM V21 (Agency RN/Registered Nurse) stated, I was not aware that R2 had fell on 4-28-23 during my shift so I did not do an assessment of R2 or document anything at all about R2. I had no idea R2 had hurt her leg. No staff had reported to me that R2 had fell. On 5-26-23 at 4:35 PM V6 (RN) stated, I was working on 4-29-23. I seen R2 in the morning 4-29-23 when I gave her medications to her. R2 was lying in bed that morning and did not get up. R2 normally lays in bed throughout the day when she does not have dialysis. Later, that day around 2:00 PM R2 was trying to get out of bed without assistance. I asked R2 what she was doing and R2 told me her leg was hurting and that she had fell the night before. R2's right leg had bruising to almost the entire leg and R2 was in pain. There was no documentation in (R2's) medical record about R2 falling the night before, so I called (V2/Director of Nursing) and reported what R2 had reported to me and R2's injuries to the right leg. I called the physician and got orders to obtain x-rays of the right knee and give pain medication as needed. On 5-26-23 at 7:45 PM V24 (R2's Power of Attorney) stated, I met R2 at the hospital on 4-29-23. R2 was in excruciating pain and was crying. R2 told me she had fell the day before and was put into bed by the staff. R2 stated her leg hurt after the fall but she just stayed in bed and tried not to move her leg. R2 told me V24 a nurse did not help her until the next day when R2 stated the pain had gotten to a 20 out of a 10. R2 should have been assessed immediately after the fall and received medical treatment immediately for the injuries to her leg. On 5-26-23 at 5:15 PM V2 (Director of Nursing) stated, I had no idea that R2 had fallen and sustained an injury on 4-28-23 until (V6/Registered Nurse) called me on 4-29-23 around 2:00 PM and reported to me that R2's right leg was bruised extensively. V6 called to obtain orders for an x-ray. The x-ray company did not come timely and R2's pain worsened so R2 was sent to the emergency room around 9:30 PM for treatment. I started an investigation immediately and found out by (V20/CNA/Certified Nursing Assistant) and (V22/CNA) that R2 had a fall the night before on 4-28-23 around 5:00 PM and V20 and (V22) used a (mechanical lift) to transfer (R2) back to bed from the floor. I tried to notify R2's nurse (V21/Agency RN) but did not get an answer. V21 was R2's nurse on shift the night R2 had the fall on 4-28-23 around 5:00 PM. There was no documentation in R2's medical record or an assessment of R2 after the fall on 4-28-23. An assessment should have been completed immediately after R2 fell and R2 should have received treatment for the fracture immediately after the fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pain management, assess a resident for pain as ordered and when experiencing an increase in pain for one of three residents (R3) reviewed for pain management in the sample of four. This failure resulted in R3 experiencing severe, sharp, and stabbing pain for over a week that radiated from the buttock down to the right knee. Findings include: The facility's Pain Policy dated 7-28-22 documents, It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain. For pain complaints and for situations that might result to pain the nursing staff may document it in any part of the resident's medical record that includes Nurse's Notes, Incident Report, and Medication Administration Record. If available in the convenience box or facility house stock, the pain medication ordered with be administered to the resident as soon as possible. If the resident is still in unrelieved pain despite pharmacological and nursing measures, the resident's physician will be called to refer the lack of relief. The facility Pain Assessment Sheet (undated) documents this pain assessment sheet will be completed during assessment of pain. R3's MDS (Minimum Data Set) assessment dated [DATE] documents R3 has frequent pain. R3's Pain Plan of Care dated 10-25-22 documents, Focus: R3 is at risk for pain related to the diagnoses history of NSTEMI (Non-ST-Elevation Myocardial Infraction), CAD (Coronary Artery Disease), and DM (Diabetes Mellitus), and Pain in the Right Knee. Goal: R3 states that level of pain is tolerable or has relief with interventions. No signs and symptoms of non-verbal pain. Interventions: Evaluate efficacy of pain management. Notify MD (Medical Doctor) if inadequate pain relief. Observe for non-verbal signs of pain. Provide Analgesic as ordered. Utilize non-pharmacological interventions. R3's Physician Orders dated 10-12-22 documents Norco (Hydrocodone-Acetaminophen) Oral Tablet 5-325 mg (milligrams) one tablet by mouth every six hours as needed for severe pain. Pain Assessment every shift for pain: Numeric Scale (0=no pain; 1 to 3=mild pain; 4 to 7= moderate pain; 8 to 10=severe pain). R3's MAR (Medication Administration Record) dated 5-1-23 through 5-26-23 documents, Pain Assessment every shift for pain: Numeric Scale (0=no pain; 1 to 3=mild pain; 4 to 7= moderate pain; 8 to 10=severe pain). This same MAR documents R3's Pain Assessment was not completed on 19 shifts from 5-1-23 through 5-26-23. R3's MAR dated 5-1-23 through 5-26-23 documents R3 last received Norco 5-325 mg on 5-18-23. R3's Controlled Drug Administration Records dated 4-21-23 through 5-26-23 document on 4-23-23 the facility accepted 30 tablets of R3's Norco and all 30 tablets were administered between 4-23-23 and 5-17-23. R3's Controlled Drug Administration Records do not include any documentation of R3's Norco getting refilled since 5-17-23. On 5-26-23 at 9:15 AM R3 was observed lying in bed. R3 had facial grimacing and was rubbing her right knee and right leg. R3 stated, My pain has been at a level eight for over a week. I have not had my Norco for over a week. The nurses keep telling me they have ordered the Norco, but I have never received it. The nurses have been giving me Tylenol. The Tylenol does not help. I still have been having a severe, sharp, stabbing pain that has been going from my butt to my right knee. I should not have to lay in pain like this. I cannot walk, or I would get up and go get the medicine myself. On 5-26-23 at 9:30 AM (V8/LPN/Licensed Practical Nurse) stated, I took care of R3 last night. Around 10:00 PM R3 was stating she had pain in her right leg and knee that she rated as a seven on a one to ten scale. R3 told me she hurts all over and the pain was unbearable. R3 was requesting a Norco because the Tylenol was not controlling the pain. R3 did not have Norco available. I re-ordered the Norco in the computer, but the doctor needs to provide a prescription for it. R3 should not have to lay in pain and should be able to have her Norco whenever she wants it. I did not document in the progress notes or pain assessment that R3 was having pain last night. On 5-26-23 at 10:45 AM V2 (Director of Nursing) stated, R3 should never have to go without her Norco or ever have to be in uncontrolled pain. The nurses should have been doing R3's pain assessments every shift as ordered on the MAR and whenever R3 was experiencing an increase in pain. I see where the nurses have not been doing R3's pain assessments every shift as ordered. The nurses could have pulled the Norco from the back-up (automated medication dispensing system) if they would have just called the pharmacy and received a code to get into the pixus. R3's Norco should have been refilled before R3 ran out of the Norco on 5-17-23. There is no documentation that the nurses have tried to re-order R3's Norco or have notified R3') physician of R3 being out of Norco since 5-17-23. On 5-26-23 at 12:36 PM V14 (Nurse Practitioner) stated, I work under V13/R3's Primary Care Physician. I collaborate with V13 about R3's cares. I have been responsible for R3 for the last week. The staff have not notified me that R3 was in pain and was out of Norco since 5-17-23. I should have been notified prior to R3 running out of Norco. On 5-26-23 at 5:50 PM V13 (R3's Physician) stated, I am very sensitive to the resident's needs. R3's increase of pain should have been documented and I should have been notified to ensure R3 received proper pain relief and a prescription for her Norco.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and records reviewed the facility failed to implement interventions to prevent or reduce the risk for falling and failed to investigate the root cause of resident fall incidents for 4 of 4 residents (R2, R8, R9 and R7) reviewed for falls and fall prevention. This failure resulted in R2 falling face forward sustaining an acute depressed fracture of the distal nasal bone. Findings include: R2 is an [AGE] year-old with diagnoses including, but not limited to Diabetes, Cataract, Dementia, Sciatica, history of Falling, Cerebral Infarction, and Chronic Pain. On 1/3/23 at 2:10PM surveyor knocked on R2's door which was closed. R2's room is the last room in the hallway, farthest from the nurses' station. Upon entering R2 was observed walking independently in his room. R2 was wearing a brief and one grippy sock to his left foot and no sock on his right foot, with a shoe on each foot. R2 was only alert to name. The surveyor spoke to R2 in Spanish, R2 still only smiled and waved On 1/3/23 at 2:15PM V22, Certified Nursing Assistant/CNA, stated R2 can walk alone in his room. V22 stated R2 removes his clothing and throws it away or puts in laundry bins. V22 stated I check R2 every 20 minutes. On 1/4/23 between 9:45AM and 11:09AM surveyor observed R2's room. Observation was continuous from 9:45 - 9:58AM, at which time the surveyor entered another resident room. At 10:12AM the surveyor resumed continuous observation of R2's room. Of note, staff must apply identified PPE including gown and gloves to enter room. The door is closed. No staff observed to open his door. At 11:10AM V7, Nurse observed entering R2's room, after applying gown and gloves. When she came out of the room V7 was heard stating she needed housekeeping to come to R2's room. On 1/4/23 at 11:10AM the surveyor observed R2's name plate outside of R2's door and it does not have his name, or a star placed on it. On 1/4/23 at 1:44PM V12, Nurse, stated on 12/30/22 the CNA reported to her that R2 was on the floor next to the bed. V12 stated R2 was on the floor, wrapped in the comforter with a pillow and the bed was in the lowest position. V12 stated R2 could not say how he got on the floor. V12 stated R2 has Dementia and was a little combative when we were helping him to get off the floor. V12 stated R2 was in an isolation room and the door is supposed to be closed. V12 stated rounding is done hourly between the nurse and CNA.V12 stated she was aware that R2 is a fall risk, and he had a fall prior to 12/30. V12 stated fall interventions for R2 includes frequent rounding. V12 said she had notified the CNA that R2 will get up and ambulate and he may need assistance. V12 said R2's behavior could be related to his room change and having a COVID infection. V12 said following the fall on 12/30/22 the intervention was to continue frequent monitoring and keep the bed in the lowest position. V12 stated she asked about using floor mats but was told they are in limited supply. On 1/4/23 at 3:04PM V7, Nurse, stated R2 is taking himself to the bathroom, I was told that is how he goes. V7 stated the CNAs do 30 minutes rounds on R2 because his environment is new to him. V7 stated she expects the CNAs to open the door and go into the room when checking on R2, the only way to see him is to go in the room. V7 stated when I checked on R2 today he had urinated on the bathroom floor, and I had to call for Housekeeping to come clean the room. On 1/5/23 at 12:04PM V11, Director of Nursing stated a fall is when a resident changes planes. V11 stated a resident does not have to be seen on the floor to have fallen. V11 stated if a resident reports they fell then it is a fall. V11 stated R2's daughter reported he said he had fallen on 11/19/22. The surveyor asked V11 what the root cause of R2's 11/19 fall was. V11 stated we do not know what happened. V11 said following R2's fall on 12/30 we make sure he has proper footwear and do frequent rounds when R2 is in his room alone. (R2 is positive for COVID and is in an isolation room with his door closed.) V11 stated when rounding on R2 she expects staff to open the door to see him. V11 stated R2 is safe to walk around the room by himself. V11 stated R2 has an unsteady gait. V11 stated R2 has mild Dementia that caused him to fall. V11 said R2 had a change in routine, because he was moved to another room once he was COVID positive, and he was already a high risk for falls. Additionally, V11 stated staff was new to R2. V11 stated the facility standard time to check residents is every 2 hours. V11 said to check a resident frequently means at least 2 hours. V11 said residents at high risk for falls are near the nurses' station. On 1/5/23 at 2:31PM V20, Restorative Nurse Director, stated R2 has grooming, dressing, and walking restorative programs. V20 said R2 uses a rollator walker to ambulate when the restorative staff is assisting him, but he is not able to use the walker independently. V20 stated no additional programs have been provided to R2 related to his falls. V20 provided documentation supporting R2's restorative program for ambulation with staff initiated on 6/24/21 and a bathing/grooming program initiated on 10/24/22. At 3:28PM V20 stated the purpose of restorative assessments are to assess if the patient needs a new task to be implemented. If a resident is unable to balance without staff assistance, then they need hands on to be steady during a transfer in the event of instability. V20 stated R2 attempts to walk alone. V20 said R2's does not have a goal to walk independently. V20 stated she has not received a concern that R2 is walking independently. R2's cognitive pattern assessment dated [DATE] score is 6 and unable to answer questions of orientation and needing cueing with recall. R2's Health condition assessment dated [DATE] notes he had a fall in the past. R2's fall risk evaluation on 7/14/22 has a score of 10 and on 12/30/22 he has an increased score of 14. On 12/30/22 R2 is noted to have an unsteady gait. Incident report for R2 dated 11/19/22 notes R2's daughter reported that R2 said he fell. No one witnessed him on the floor. An incident report dated 12/30/22 notes the CNA reported that R2 had fallen. Progress notes dated 11/22/22 note attempting to ambulate to restroom independently. Noted siting on buttocks with urine in pants. R2 has inappropriate footwear. There was no incident report provided for this fall. Progress note dated 11/11/22 note Fall Precautions. A progress note written on 12/19/22 for R2 notes he is attempting to get up without assistance and transfer self. Interventions noted offer assistance with transfers and ADL cares. There was not in incident report provided for this fall. The facility provided a list of incident reports for R2 for 12 months. The list notes incident nature other on 11/19/22; 7/14/22 falls; 7/1/22 other, and 1/24/22 skin tear. Progress notes and incident report document falls on 11/19/22; 11/22/22; 12/19/22 and 12/30/22. Restorative Assessment for R2 dated 10/24/22 notes R2 is alert with confusion. He is ambulatory has a decline in self-care and cognition and is unable to use his call light. History of falls is identified on the assessment. Balance is identified as only able to balance with staff assistance. Restorative programs include walking initiated on 6/24/22. Program notes to ambulate with side by assistance. R2's Care Plan identifies him to be a high risk for falls related to Cognitive Deficit, Vision and Hearing Deficits, Medication Side Effects, Dementia, Cerebral Vascular Accident, Incontinence, history of Falls, and Wandering. This Care Plan was initiated on 9/7/21. There is no intervention following the 11/19/22; 11/22/22 and 12/19/22 falls. There are interventions dated 12/30/22 to ensure R2 has proper footwear and frequent wound on R2 while in his room, and to offer assistance with toileting. On 1/6/22 V3, Administrator, provided a Care Plan initiated on 1/5/23 for R2's Impulsive Behaviors which place him at risk for falls. All interventions are dated 1/5/23. R8 is a [AGE] year-old with diagnoses including, but not limited to Diabetes, Metabolic Encephalopathy, Pressure Ulcer of Right Heel, Chronic Kidney Disease, Vitamin D Deficiency, and History of Falling. R8 has a history of sustaining a Communicated Fracture of the Nasal Bone. On 1/4/23 at 11:10AM the surveyor observed R2's name plate on her door does not have a star. On 1/4/23 at 1:05PM V9, Licensed Practical Nurse (LPN), stated on 11/26/22 I was walking past R8's room when I saw she was not on the bed. V9 stated R8 was face down on the floor, there was blood everywhere. V9 stated R8 said she was trying to get up on her own. V9 stated R8 usually requires supervision for transfers. V9 stated R8 was sent to the emergency room for evaluation due to the bleeding. V9 stated R8 was not considered a fall risk, but she had a history of falls. On 1/4/23 at 3:04PM V7, Nurse, stated on 10/28/22 R8 was on the floor and stated her leg was weak and she fell. V7 state R8 was able to safely self-transfer. V7 stated she reminds R8 to use the call light, but R8 won't use it. V7 stated the wheelchair was in the room and R8 had locked it. V7 stated R8 had fallen before, and she was already a fall risk patient. V7 stated fall interventions included re-educating R8, keep the call light close to her, keep her wheelchair locked for transfers, and I would tell her we are close just call us for assistance. Surveyor asked what intervention was implemented after this fall and V7 responded, post fall I can't think of anything new added. On 1/5/23 at 10:24AM V8, Certified Nursing Assistant (CNA), stated on 1/1/23 she had seen R8 sitting on her bed, as usual, around 3:40 or 3:45PM. V8 stated I was answering another call light when I noticed R8 was on the floor in her room. V8 stated R8 told her she was trying to go to the washroom. V8 stated R8 requires one person assistance for transfers, she is not independent with transfers. V8 stated R8 is not steady on her feet. V8 stated R8's wheelchair was in the room, but it was pushed back away from R8. V8 stated I don't if the wheelchair was locked. V8 said R8 rarely uses the call light for help. V8 stated she assisted R8 to the bathroom after she had been assessed by the nurse and R8 did urinate. On 1/5/23 at 12:04PM while discussing R8's falls, V11 stated the intervention to prevent a further fall after 11/26 was to focus more on transfers. V11 stated R8 needs to listen to education and be more compliant. V11 stated following R8's fall on 1/1/23 the new intervention is to keep the call light in reach. V11 said the intervention had nothing to do with her fall because she wasn't feeling good. V11 stated we know she falls when she doesn't use the light. On 1/6/23 at 10:51AM V19, Orthopedic Surgeon, stated I met R8 a couple years ago from her past injuries. V19 said R8 has had other fall related injuries. V19 stated we (the partners) don't treat nasal fractures. V19 said he was asked to look at R8's fracture. V19 said R8's nasal fracture looked to be in the same location as a prior fracture. V19 stated when you have trauma in the same areas, such as the R8, you can have more bleeding. V19 said when he saw R8 in November, following the 11/26 fall, she had bruising, and it was an acute injury. V19 said any women over the age of 65 is at higher risk for fractures and a Vitamin D deficiency can affect her potential for fractures. V19 stated anyone who has fallen numerous times will always be a high risk for falls and V19 would expect staff to be vigilant. The surveyor reviewed R8's balance assessment from 10/6/22 which states R8 is only able to stabilize with staff assistance while moving from seated to standing position, moving on and off toilet, and surface to surface transfers (between bed and chair or wheelchair) with V19. Based on this review V19 stated I would not expect her to be doing it independently. V19 stated since he told the staff face fractures are not his area of expertise, he did not bill for this visit with R8, nor did he write a progress note. On 1/6/23 V3, Administrator, stated the facility would use the appropriate physician to evaluate any situation or change in resident condition. Incident report dated 11/26/22 notes R8's roommate called for help and R8 was observed on the floor, laying faced down, in a pool of blood. R8 stated she stood up and lost her balance. Predisposing factors note gait imbalance, recent change in condition, recent illness, and weakness/fainted. Predisposing physiological factors note R8 has a lack of safety awareness, lower extremity weakness, and recent change in medication. Incident report dated 1/1/23 notes R8 found in her room on the floor next to her bed lying on her right side. R8 stated she was trying to get out of bed to use the bathroom and fell. Mental status notes R8 is oriented to person and time. Predisposing factors indicate a gait imbalance. R8's Functional Status assessment dated [DATE] notes she requires extensive assist with bed mobility, transfers, and toilet use. R8's Health Condition history dated 10/6/22 notes she has a history of one fall one month prior and in the last 2-6 months. R8's Fall risk evaluation dated 10/28/22 notes a score of 16 = high risk. R8's Care Plan initiated on 10/5/21 notes R8 is high risk for falls related to impaired balance, incontinence, medication side effects, visual deficits, pain, and history of falls. Interventions include assist with toileting (date 7/22/21). Encourage resident to lock wheelchair before transfers to prevent falls (date 10/28/22). Keep bed in low position (date 1/1/23). R8's Care Plan includes focus on her impulsive behavior, does not wait for help, will attempt to self-transfer with intervention to monitor for safety. Focus initiated on 7/30/21. Focus on R8's need for assistance due to poor endurance, impaired mobility, and history of falls initiated on 10/4/22. X-Ray nasal bones dated 11/26/22 documented mildly Depressed Fracture of the Distal Nasal Bone. Final Incident report provided to IDPH dated 11/30/22 states on 11/28/22 at around 1:11PM received Nasal Bone x-ray result with impression - mildly Depressed Fracture of the Distal Nasal Bone. Report notes R8 attempted to get up unassisted without activating the call light or asking for assistance and fell to the floor causing bleeding from old mildly Communicated Fracture of the Nasal Bone. R9 is an [AGE] years old with diagnoses including, but not limited to, Parkinson's, Unsteady on Feet, Chronic Kidney Disease, Legal Blindness, Dementia, Restless Leg Syndrome, Polyneuropathy, and history of falling. On 1/3/23 at 12:30PM the surveyor observed a star on R9's name plate on the wall, next to her door. On 1/4/23 at 2:17PM V13, Nurse, stated on 12/24/22 she went into R9's room and R9 was observed sitting on the floor. V13 stated R9 said she had been reaching for her sock that was on the floor. V13 stated she saw the sock on the floor. V13 said R9 had no shoes or socks on when she was on the floor. V13 said she saw the bed had moved and R9 said the bed moved when she got up. V13 stated the facility usually has the bed wheels locked, for safety. V13 stated I believe she (R9) had fallen before. Change in condition form for R9 dated 12/24/22 at 6:40AM notes R9 responded to a voice yelling and entered R9's room and observed R9 sitting on the floor in her room. According to notes R9 stated she sat at the side of her bed to pick up her sock off the floor. R9 said when she tried to stand the bed started moving and she slid to the floor. Additional information notes staff nurse educated resident about calling for assistance and engaged brakes on the bed. (No Incident Report was provided for this fall.) R9's Functional Status assessment dated [DATE] notes she requires assistance to balance with moving from seated to standing position and surface to surface to surface transfer. R9's cognitive status assessed on 10/26/22 notes a score of 9, cognitively impaired. R9's Functional Status assessment dated [DATE] noted R9 requires extensive assistance with transfers and toilet use R9's Care Plan noted she is high risk for falls. The last interventions are dated 10/31/22 assess for pain and treat if present and Restorative Program as indicated to prevent further falls, gait strengthening, and transfers. R7 is an [AGE] years old with diagnoses including, but not limited to Diabetes, Obese, Dementia, Pain in Shoulder, Hypothyroid, hyperlipidemia, Restless Leg Syndrome, Macular Degeneration, Glaucoma, Hypertension, Atrial Fibrillation, Heart Failure, Chronic Obstruction Pulmonary Disease, History of Falling, Transient Ischemic Attack, and Vertigo. Progress Notes dated 12/26/22 notes R7 observed by CNA on her buttocks by her bed and R7 states she was trying to transfer herself in bed. There was no incident report provided for R7's fall on 12/26/22. R7's Care Plan does not include an intervention for fall prevention after 10/21/22 which is to offer and assist with toileting at regular intervals and as needed. R7's Care Plan notes Focus statements including R7 requires assistance with Activities of Daily Living, Limited Active Joint Movement in extremities, Impaired Bed Mobility related to poor motivation and decreased strength and coordination due to diagnosis of Transient Ischemic Attack. R7 is cognitively impaired. R7 is high risk for falls. R7's Fall Risk Evaluation dated 10/4/21 notes a score of 14 = high risk. R7's Functional Status assessment dated [DATE] notes she requires extensive staff assistance for bed mobility, transfers, and toilet use. R7's balance assessment notes she can only stabilize her balance with staff assistance when moving from seated to standing position, moving on/off toilet, and during surface-to-surface transfers. On 1/4/23 at 9:07AM V11, Director of Nursing, state following a fall a new intervention should be implemented right away. V11 stated the facility uses a leaf symbol where the resident name is on the door. V11 stated she is currently the fall coordinator. At 12:45PM V11 stated fall root cause investigations are done while developing the intervention but is not documented. On 1/5/23 at 12:04PM V11 stated there is no other Fall Policy for Fall Prevention or Fall Program. V11 said the nurses are responsible for entering the fall intervention into the Care Plan as it is being done. V11 said if it is not documented, then it was not done. V11 said when a fall occurs, she is notified. V11 stated a fracture is a serious injury. V11 stated high fall risk residents are placed near the nurses' station. On 1/6/23 at 11:30AM V11 stated the intervention for R9 was not in the Care Plan and the nurse forgot to write an Incident Report. V11 said she found out about R9's fall on 1/5/23 when the surveyor asked about the root cause of R9's fall. The surveyor asked V11 about R7's 12/26/22 fall and what intervention were in place. V11 said R7 is prone to call when she has a urinary tract infection. V11 said she was not sure if the urine analysis/culture was received and if treatment was started. V11 said the Care Plan was not updated since the fall. The facility Fall Occurrence police revised 5/17/22 notes: It is the policy of the facility to ensure that residents are assessed for risk for fall, that interventions are put in place, and interventions are re-evaluated and revised as necessary. If a resident had fallen the resident is automatically considered as high risk for falls. An incident report will be completed by the nurse each time a resident falls. The nurse may immediately start investigations to address falls in the unit, even prior to the Falls Coordinator's investigation. The falls Coordinator will add the intervention in the resident's Care Plan. The interventions will be re-evaluated and revised as necessary. The facility policy for Physician Visits revised 7/28/22 notes Physician visits should not be superficial visits but must include an evaluation of the resident's condition and total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident's current medical regimen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide oral nutritional supplements, and accurately document monthly weights to identify weight loss triggers. This resulted in a significant weight loss (>5% change over a span of 1 month and >10% change over a span of 6-month period) for 1 (R134) of 6 residents reviewed for nutrition in a sample of 29. Findings include: On 10/25/22 at 1:36pm, surveyor observed R134 eating by himself in his (R134) room. R134 consumed the following items: 1 piece of baked breaded [NAME] fish, small bowl of broth-based soup, 1 piece of chocolate brownie, 2 glasses of juice. There were no oral nutritional supplements observed on R134's lunch tray. The following items were listed on R134's meal ticket but missing from R134's lunch tray: 1 each Magic Cup, 4 oz. Vanilla Ensure Pudding. On 10/26 22 at 12:15pm, surveyor requested for R134's weight to be obtained based on visual appear R134 appeared to weigh less than documented weight of 155.2 pounds. On 10/26/22 at 12:27pm, surveyor observed V35 (Restorative Certified Nursing Assistant) bring R134 to the 1st floor dining room to be weighed on a digital standing/wheelchair scale. V35 stated that the digital standing/wheelchair scale in the 1st floor dining room is the scaled used to weigh R134 every month, including the weight obtained in the beginning of October 2022. V35 stated that weighing process at the facility is as follows: one of the restorative CNAs first weigh R134's wheelchair alone without R134 sitting in the wheelchair and document this wheelchair weight on a census list. V35 stated that then R134 is put into the wheelchair and weighed on the digital standing/wheelchair scale and that this weight is also documented on the census list. V35 stated that the weight of the wheelchair is then subtracted from the total to get an accurate measure of R134's weight. V35 stated that the restorative aides do not keep a list of the resident's wheelchair weights to be re-used for the monthly weights but rather V35 stated that the resident wheelchairs are weighed every month because the restorative staff would not be aware if extra equipment was added to the wheelchair and/or if the wheelchair was changed in some way which could affect the overall accuracy of the weight. Surveyor observed R134 being weighed in his (R134)'s wheelchair and this weight was 173.6 pounds. R134 was then transferred from his (R134)'s wheelchair to a standard chair to sit in while the weight of his (R134)'s empty wheelchair was checked. R134's empty wheelchair was wheeled back onto the scale and the weight of R134's wheelchair was 39.4 pounds. The difference between these two numbers makes the weight of R134 to be 134.2 pounds. On 10/26/22 at 12:50pm, V36 (Certified Nursing Assistant) stated that R134 usually eats for lunch 1 bowl of soup, 2 cups of juice, and the dessert being served. V36 stated that intake of the main meal is highly variable depending on what is being served. V36 stated that R134 does verbalize what he (R134) likes and does not like and will let the staff know if he (R134) doesn't like the food he (R134) received. R134 stated to surveyor, I like ice cream and I like pudding! Surveyor observed R134's lunch ticket which listed 8 oz. beef stroganoff, 1 Tsp chopped parsley, 4 oz. buttered egg noodles, 4 oz. buttered green peas, 1 each dinner roll, 1 each margarine, 1 each frosted yellow cake, 8 oz. whole milk, 6 oz. hot coffee or hot tea, 8 oz. ice water, 1 each Magic Cup and 4 oz. Vanilla Ensure Pudding. The following items were missing from R134's lunch tray: 1 each Magic Cup, 4 oz. Vanilla Ensure Pudding. Surveyor asked V36 if there was a Magic Cup on R134's lunch tray and V36 stated, no. Surveyor asked V36 if there was a Vanilla Ensure Pudding on R134's lunch tray and V36 stated no and that the nurses pass the Ensure Pudding with medication pass. On 10/26/22 at 2:46 pm, V6 (Food Service Manager) stated that the Magic Cup supplements are distributed during meal service with meals if ordered and that the Ensure Puddings are distributed by the Registered Nurse or Licensed Practical Nurse during medication pass. V6 stated that the Magic Cup supplements are in stock. V6 took surveyor to the kitchen freezer and surveyor observed cases of Magic Cup supplements in the kitchen freezer. Surveyor requested copies of R134's meal tickets for breakfast/lunch/dinner on 10/25/22 and 10/26/22. V6 stated that it is the CNAs responsibility to read out loud to the dietary aides serving the food from the satellite kitchen on the 2nd and 3rd floor units all of the items listed on the resident's meal ticket. V6 stated that if the CNAs does not read out loud all of the items on the meal ticket to the dietary aides, then the dietary aides would not know what food to put on a resident's tray and therefore a resident would not receive all of the food items listed on their meal ticket at that meal. On 10/26/22 at 3:05pm, V30 (Registered Dietitian) stated that R134 triggers for a significant weight loss over 6-month span based on 10/01/22 weight of 155.2 pounds compared to 04/06/22 weight of 175.4 pounds. V30 stated that she (V30) completed an assessment on 10/05/22 however R134's 6-month weight loss trigger was not addressed because R134's monthly October weight was still pending at the time the assessment was completed and that the 10/01/22 weight entered into the electronic medical record (EMR) must have been back dated because it was not available when V30 completed the assessment on 10/05/22. V30 stated that the Registered Dietitians have until the end of the month to address weight change triggers. V30 stated that R134 does not have a big appetite and that his (R134) meal intake is inconsistent. V30 stated that supplements were added to help stabilize R134's weight to prevent continued weight loss. V30 stated that the Magic Cup supplements are distributed by the CNAs during meal service. V30 stated that when a resident has a significant weight loss change the resident's weight is rechecked for accuracy and then the resident's doctor is notified of the weight trigger. V30 stated that she (V30) did not know if R134's doctor was notified about the 6-month weight loss trigger. On 10/27/22 at 10:09am, V36 stated that she (V36) reads the meal ticket to the dietary aides and the dietary aides put the food on the resident's tray. V36 does not remember seeing Magic Cup written on R134's meal ticket and stated R134 has not been receiving Magic Cup. R134 stated that she (V36) thinks R134 tried the supplement once before but didn't like it. V36 does not remember if she (V36) told anyone that R134 did not like the Magic Cup. On 10/27/22 at 10:12am, R134 stated, I like ice cream and pudding. I'd eat it if they gave it to me. On 10/27/22 at 10:21am, V37 (Restorative Certified Nursing Assistant) stated that all residents are weighed in their wheelchair on the digital standing/wheelchair scale in the 1st floor dining room monthly by the restorative aides. V37 stated this is the only scale used to weigh the residents other than those that require a mechanical lift scale. V37 stated that the wheelchairs are weighed every month for accuracy, and then the residents are weighed in the wheelchair using the same scale. V37 stated that once the two weights are obtained the wheelchair weight is then subtracted to obtain the resident's actual weight. V37 stated the restorative aides document all of the resident's monthly weights on a census report document which is then given to the restorative director who then enters the weights into the EMR. V37 provided surveyor with a copy of the census report used for October weights titled, Midnight Census Report dated 09/30/22 which lists R134's weight as 140.8 pounds (wheelchair weight 38.8 pounds, combined weight 179.6 pounds). V37 also provided surveyor with a copy of the census report used for September weights titled, Midnight Census Report dated 09/01/22 which lists R134's weight as 140.6 pounds. On 10/27/22 at 10:35am, V34 (Restorative Director) stated that she (V34) is responsible for entering the monthly weights provided by the restorative aides into the EMR. V34 stated that she (V34) looks at the previous months weights to see if a resident needs to be reweighed due to a discrepancy or change and would discuss with the Registered Dietitians and Director of Nursing. On 10/27/22 at 10:44am, upon surveyor's request V34 asked R134 if he (R134) would allow staff to recheck his (R134) weight again. R134 agreed to have his (R134) weight rechecked. Surveyor accompanied R134, V37, and V34 to the 1st floor dining room wherein surveyor observed R134 get weighed in his (R134)'s wheelchair on the digital standing/wheelchair scale. This weight was read to surveyor as 175 pounds. V37 stated the digital scale always gives the readings in pounds. R134 was then assisted out of his (R134) wheelchair and into a standard chair. R134's empty wheelchair was then weighed and read off to weigh 39.4 pounds. The difference between these two numbers makes the weight of R134 to be 135.6 pounds. On 10/27/22 at 10:47am, surveyor reviewed weight data entered into the EMR on 10/01/22 by V37. V37 confirmed that she (V37) was the one who entered the 155.2 pounds into the EMR on 10/01/22 and that she (V37) received this weight from the restorative aides on the weight census report form. V37 stated that R134 would be referred to the Registered Dietitian due to weight loss that occurred based on R134's weight today of 135.6 pounds. On 10/27/22 at 10:55am, surveyor asked for V37 to show surveyor where V37 obtained the 155.2-pound weight data for R134 which was then entered into the EMR. V37 brought surveyor to the restorative office and showed surveyor a document titled, Midnight Census Report dated 09/30/22 which listed R134's weight as 140.8 pounds (wheelchair weight 38.8 pounds, combined weight 179.6 pounds). Surveyor pointed out that the weight entry for September and October 2022 were exactly the same 155.2 pounds. V37 stated that she (V37) may have put 155.2 pounds in EMR on 10/01/22 as an error. On 10/27/22 at 11:01am, V2 (Director of Nursing) stated that the kitchen staff is responsible for reading the meal tickets and putting the food and supplements on resident's trays at meals. V2 stated that the potential problem with a resident not receiving an oral supplement as ordered is that the resident could have a weight loss or impaired wound healing. On 10/27/22 at 1:31pm, V41 (Nurse Practitioner) stated that she (V41) was not aware of R134's weight loss trigger (times) x6 months or of any recent weight loss which may have occurred this month for R134. V41 stated she (V41) has not heard anything about R134's eating habits, refusing supplements or weight loss. V41 stated that in the past the Registered Dietitian called her (V41) directly but that she (V41) has not talked to either of the Registered Dietitians in the past few months. V41 stated that her (V41) expectation is that if R134 has an order for oral supplements the staff should be providing these as ordered and V41 would have expected R134 to have gained some weight with the use of supplements. V41 stated if R134 is not receiving supplements and meal intake is variable then R134's oral intake may not be adequate. V41 has not heard of R134 refusing supplements but if R134 was refusing V41 would expect staff to try a different alternative and to notify the Registered Dietitian to adjust interventions. V41 state R134 does have a diagnosis of congestive heart failure (CHF) but does not have any swelling and has been very stable. V41 stated there has been no change in diuretic dosage and does not think weight change is related to CHF. V41 stated that the weight may be related to a weight error. R134 was admitted to the facility on [DATE] with diagnoses which included but not limited to chronic diastolic (congestive) heart failure, anemia in chronic disease, hypertensive heart disease, chronic kidney disease stage 3, unspecified dementia, major depressive disorder, age-related cataract left eye, bilateral age-related nuclear cataract. R134's MDS (Minimum Data Set) from 10/11/22 BIMS (Brief Interview for Mental Status) score is 11 indicating moderate cognitive impairment. R134's care plan dated 01/27/22 documents in part, R134 is at risk for alteration in nutritional status relate to variable/declined PO intakes and dx of CHF, will be free from sign and symptoms of malnutrition, monitor for signs and symptoms of weight loss, obtain weight as ordered, and provide diet and supplements as ordered. R134's care plan dated 10/07/21 documents in part, R134 has the following conditions and risk factors that put him at risk for fluctuating weights - CHF, diuretic use with goal for dry weight to be stable within +/-5% of 159.2# x1 month by next review and interventions to include in part, notify physician of weight changes. R134's Dietary Evaluation dated 10/05/22 completed by V30 (Registered Dietitian) documents in part, that goal is for weight maintenance though wt (weight) fluctuation may be expected r/t (related to) age, diuretic therapy, CHF and based on Mini Nutritional Assessment (MNA) score 8.0 - at risk for malnutrition in view of impaired cognition and mobility with recommendation to continue with current regimen which includes unrestricted diet, Magic Cup BID and Ensure Pudding BID. Weight used to complete this assessment was 155.2 pounds. R134's Nutrition progress note completed by consultant RD dated 10/26/22 at 12:49 documents in part, 20.2-pound weight loss x6 months (-11.5% - significant) and that weight change may be expected r/t (related to) CHF, age, diuretic therapy, and res (resident) reports tolerating ensure pudding and magic up. At 21:56 consultant RD documented, MD notified of weight change. Based on percentage weight loss over 6-month period, the weight used to complete this assessment was 155.2 pounds. R134's Nutrition progress note addendum completed by V30 dated 10/27/22 at 10:50 stated sig (significant) wt (weight) loss x6 mo (month) likely r/t (related to) hx (history) intentional weight loss couple with fluid fluctuation 2/2 (secondary to) CHF, diuretic use. Encouraged to maintain wt (weight) at this time, Magic Cup BID added to order 6/11 and Ensure Pudding added to order 7/10 to aid with adequate PO intake in view of varied intake at meals as well as resident preference for these ONS (oral nutrition supplement). Per R134's Medication Administration Record for October 2022 printed 10/27/22 documents in part, Ensure Pudding two times a day at 0900 and 1700 hours started on 07/10/22 and Magic Cup two times a day at 0900 and 1700 hours stated on 06/11/22 both given on 10/25/22 and 10/26/22. Per R134's Physician Order Sheets documents in part, R134 receives Torsemide 1-20 mg tablet one time a day with a start date of 05/19/21 without any changes in dosage since initiation. Facility document titled, Midnight Census Report dated 09/30/22 documents in part, R134's weight as 140.8 pounds. Facility document titled; Midnight Census Report dated 09/01/22 which listed R134's weight as 140.6 pounds. Facility policy titled, Weights dated 5/19/22 documents in part, that the significant weight changes (monthly 5%), quarterly (7.5%) and every 6 months (10%) will be assessed and addressed by the IDT which includes but not limited to the Dietitian, Physician. Facility policy titled, Physician Order dated 07/28/22 documents in part, the facility shall ensure to follow physician orders as it is written in the POS.