**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide treatment in accordance with professional standards of care for a fall resulting in injury for 1 of 16 residents (R65) reviewed for quality of care in the sample of 42. This failure resulted in R65 falling and sustaining a fractured arm which was not treated for two days. Findings include: R65's Physician Order Sheet for September 2022 documents R65 is a [AGE] year-old female with diagnoses of unspecified dementia with behavioral disturbances, elevated white blood cell count, unspecified abnormalities of gait and mobility, other lack of coordination, muscle weakness, cognitive communication deficit and auditory hallucinations. On 9/23/2022 at 10:58 AM, R65's was residing on the dementia unit. R65 had a soft cast to her right arm. R65's Care Plan dated 8/15/2022 documents (R65) has dementia with behaviors. On 9/23/2022 at 10:59 AM, V38, Registered Nurse stated, (R65) is on the dementia unit and has poor safety awareness. She is easily confused. R65's Progress Notes dated 8/29/2022 at 4:16 PM, documents Resident had witnessed fall, playing game in dayroom with other residents, resident began walking backwards and tripped over her own feet and tried to catch herself and landed on her Right wrist, resident did not hit her head. Right wrist swelling noted. PRN (as needed) Acetaminophen administered, wrapped in ace wrap, Ice pack placed alternating on/off for 20 minutes. MD (Medical Doctor) notified, received orders to wrap/immobilize, and get STAT (right away) x-ray. R65's Progress Note dated 8/29/2022 at 8:00 PM, documents x-ray technician here at this time, x-ray done. R65's X-ray Report dated 8/29/2022 document R65 had an acute fracture of the distal radius and ulna styloid of the wrist. (2 long bone fractures close to the wrist). R65's Progress Note dated 8/30/2022 at 5:41 AM, documents Resident's bruise to Right side of eye is healing well, no swelling or redness to resident Left Knee, resident had a fall on 8/29 resulting in a Right wrist injury, resident denies any pain or discomfort at this time, this writer notices that Right wrist swollen with some redness and dark blue bruising, continuing to wait on results of x-ray related to wrist injuries. R65's Progress Notes dated 8/30/2022 at 11:25 AM, documents Edema continues to be noted to right wrist. Pain noted to area with movement. Resident currently has an ace wrap in place to area. Current x-ray results pending at this time. Resident also continues to have swelling to Left knee at this time. Resident denies pain to area. MD (Medical Doctor) previously made aware of knee. Resident able to ambulate normally and expresses no pain. Family in at this time to sit with resident. R65's Progress Notes dated 8/30/2022 at 2:29 PM, documents Power of Attorney (POA), Medical Doctor has been made aware of fracture. R65's Progress Notes dated 8/31/2022 at 11:13 AM, documents Assistant Director of Nursing (ADON) in unit at this time and advises Nurse to send resident out to ER (Emergency Room) to be further evaluated. Resident wrist continues to have swelling and is painful with movement. Movement to area currently limited and radial pulse very faint. This Nurse contacted ems (Emergency Medical System) at 11:17 AM to send to ER (Emergency Room) for evaluation of fracture to area. POA (Power of Attorney) contacted and made aware of concerns. On 9/22/2022 at 8:58 AM, V2, Director of Nursing (DON), stated, If a STAT (Immediately) x-ray was ordered I would expect the turnaround time to be minimum of 3 hours. I would expect staff after three hours to be following up with the lab and finding out where the results are. Typically, the form is faxed back to us at the nurse's station. I would expect the x-ray company to call us to alert us of any critical care including a fracture. I reviewed the notes and saw that there was a delay in reporting the fracture for (R65). I am not sure what exactly happened and why it was not caught earlier. On 9/23/2022 at 10:06 AM, V36, Former Assistant Director of Nursing (ADON), stated, I use to be the ADON but no longer work in the facility. I remember (R65) she was in the dementia unit and had poor safety awareness and was really confused. I remember I came in on a Wednesday morning and (V2, Director of Nursing) told me (R65) had a previous fall a few days later and then she just walked away. (V2) told me they took and x-ray, but she was not sure if there was any injury. I talked with the nurse, and she told me nobody got an x-ray. I went and checked on (R65) her wrist was swollen, and she had a low pulse, so I wanted them to send her (R65) next door to the hospital to get an x-ray. I sent her out and then she had two fractures. When I told (V2) she just told me 'I guess we will just take the tag for that one.' On 9/23/2022 at 11:07 AM, V37, Medical Director stated, I am not sure when I got the x-ray results or when I was notified of (R65) having pain and swelling in her wrist. The facility is usually good about notifying me. I have another patient I cannot talk. The Change of Condition Policy with a revision date of 12/02 documents, The resident is involved in any accident or incident that results in an injury including injuries of unknown source notification will be made within twenty-four hours of a change occurring in residents' condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to monitor food intake, assess insidious weight loss and effectiveness of interventions, and implement progressive interventions based upon this assessment to prevent continued weight loss for 1 of 5 residents (R75) reviewed for nutrition and weight loss in the sample of 42. This failure resulted in R75's severe weight loss of 28.41% in 3 months. Findings include: R75's Undated Face Sheet, documented diagnoses of encephalopathy, dementia, anorexia, hypoglycemia, dysphagia (swallowing problems), congestive heart failure (CHF) and pain. R75's Care Plan, dated 8/31/2021, documents R75's current body weight was 109 pounds. R75's Care Plan documents R75's acceptable body weight is 114-146 pounds. The Goal documents Resident will achieve desired weight of 114-146 pounds. R75's Approaches documented the following approaches with the following start dates: Pureed diet start 9/22/21; Encourage oral intake of food and fluids start 8/13/21; Monitor/record weight weekly, notify physician and family of significant weight change start 8/13/21; and provide supplement of high protein supplement with fortified pudding at all times start 8/13/21. R75's Nurse's Note, dated 5/15/2022 at 6:42 PM documents resident arrived via ambulance at 5:37 PM. Resident was transferred 3 assist from stretcher to bed by EMS (emergency medical services) and staff. NG (nasogastric) feeding tube, 8 FT in place with Jevity 1.5 Cal 45 ml (milliliters)/hr (hour) continuous. No s/s (signs and symptoms) of pain or discomfort noted during assessment. R75's Nurse's Note, dated 5/16/2022 at 2:15 PM documents Hospice nurse removed NG tube per family and order from MD (physician). Resident tolerated removal well. R75's Practitioner Order for Life-Sustaining (POLST) form dated 5/16/2022, had no documentation in the section regarding medically administered nutrition section. This section was not completed. R75's Significant Change Minimum Data Set (MDS), dated [DATE] documents R75 is severely cognitively impaired, no swallow disorder, height 66 inches weight 97 pounds. R75's MDS documents R75 requires extensive assistance with one-person physical assist for eating. R75's MDS documents R75 had no weight loss and was on a mechanically altered diet. R75's Physician's Order Sheet (POS), dated 5/16/2022 documents pureed diet as tolerated, comfort feedings if pt (patient) alert enough. R75's POS dated 5/25/2022, documents Megestrol (Megace appetite stimulate) 125 mg (milligrams)/5 ml every day. R75's Progress Note, dated 6/8/2022 at 11:02 AM documents, resident alert and very talkative during breakfast. With help of staff resident consumed around 30% of breakfast and drank approximately 1 cup of water and half apple juice. Within 5 minutes of resident telling aide 'no more,' resident had small emesis (vomit) that resulted in what she had eaten and drank. R75's POS, dated 6/8/2022 documents high protein supplement with meals. R75's Progress Note, dated 6/12/2022 at 6:30 PM, documents, Resident refused meds and a drink of water this shift. CNA (Certified Nurse Aide) tried to feed resident at dinner, and she also refused to eat and drink. R75's Progress Note, dated 6/14/2022 at 3:18 PM documents, Resident ate about 5% of breakfast and drank 1 cup apple juice and refused all drinks and food for lunch. R75's Monthly Weight dated, 6/15/2022, documents R75 weighed 111.6 pounds. R75's Progress Note, dated 6/17/2022 at 1:02 PM, documents, Resident ate 1 pudding for breakfast with 2 cups ice water and refused all food for lunch but drank 1 cup water. R75's Progress Note, dated 6/20/2022 at 6:03 PM, documents, Poor appetite for supper, refused to let staff feed her. R75's Progress Note, dated 6/21/2022 at 6:45 PM, documents, Resident has refused all meals from help or staff. R75's Monthly Weight dated, 7/1/2022, documents R75 weighed 108 pounds. R75's Monthly Weight dated, 8/2/2022, documents R75 weighed 92 pounds. R75's Progress Note, dated 8/7/2022 at 8:52 AM, documents, Resident ate about 50% of breakfast and drank 25% of liquids this morning. Staff encouraged resident to drink more of her liquids, resident continued to put blanket on top of her head and refused to drink anymore. Writer of this note will continue to encourage fluids during all mealtimes. R75's Dietitian Assessment, dated 8/9/2022 at 5:09 PM documents, on a Pureed diet as tolerates with High Protein Supplement. Fortified Pudding at meals. Intakes poor. Refuses assistance at meals and refuses food and fluids. On Megace which can stimulate appetite. Weights: (8/2): 92, (7/1): 108, (5/4): 97, and (2/1): 111. Current weight is down 16# (14.8%) x/1 month and down 19# (17.1%) x/6 months. Below IBW Range 114-146. Body Mass Index: 14.85 (Underweight). History of edema, on (2) diuretics (Diagnosis CHF). Potential risk for weight changes and dehydration. Fluids encouraged and dietary offers 15+ servings/day. Skin free of open areas. No new labs to review. On Iron Supplement. Estimated Needs: 1260 calories (30 kilo-calories per kg), 1260 cc (cubic centimeters) fluids (1 cc per kilo-calories), and 42-50 gram protein (1.0-1.2 injury factor). History of weights up and down. Monitor. R75's Progress Note, dated 8/9/2022 at 4:55 PM, documents, this nurse left voicemail to resident's family to return call to facility in regards to unplanned weight loss. R75's POS dated, 8/10/2022 documents weekly weight related to unplanned weight loss. R75's Care Plan, dated 8/10/2022 documents resident has unplanned weight loss. Goal resident will have no weight changes +/- 2 pounds during this quarter. Approaches monitor weight, serve diet as ordered R75's Medication Administration Record (MAR), dated 8/10/2022 documents she weighed 93 pounds. R75's Dietitian/Quarterly Assessment, dated 8/16/2022 at 1:45 PM documents, on a Pureed diet with High Protein Supplement. Comfort feedings if alert. Fortified Pudding at meals. Intakes poor. Refuses assistance at meals and refuses food and fluids at times. On Megace which can stimulate appetite. Weights: (8/2): 92, (7/1): 108, (5/4): 97, and (2/1): 111. Current weight is down 16# (14.8%) x/1 month and down 19# (17.1%) x/6 months. Below IBW Range 114-146. Body Mass Index: 14.85 (Underweight). History of edema, on (2) diuretics (Diagnosis CHF). Potential risk for weight changes and dehydration. Fluids encouraged and dietary offers 15+ servings/day. Skin free of open areas. Labs (4/27/22): Glucose 60(L), Sodium 134(L), Potassium 5.0, Blood Urea Nitrogen 57(H), Creatinine 1.9(H), Total Protein 6.5, Albumin 3.2(L), Hemoglobin 9.5(L), and Hematocrit 28.2(L). On Iron Supplement. Estimated Needs: 1260 calories (30 kilo-calories per kg), 1260 cc fluids (1 cc per kilo-calories), and 42-50 gram protein (1.0-1.2 injury factor). History of weights up and down. Monitor. R75's MDS, dated [DATE] documents R75 is severely cognitively impaired, no swallow disorder, height 66 inches weight 92 pounds. R75's MDS documents R75 is totally dependent with one person physical assist for eating has had no weight loss and is receiving mechanically altered diet and feeding tube (nasogastric or abdominal). R75's MAR, dated 8/17/2022 documents she weighed 94 pounds. R75's Progress Note dated, 8/22/2022, documents, resident continues with poor appetite. Resident did however take around 4 bites of breakfast but then told aide that she was full and done eating. Half cup water drank. R75's MAR, dated 8/24/2022 documents she weighed 94 pounds. R75's Progress Note dated, 9/1/2022 at 6:56 PM, documents, Poor appetite continues. Resident stated she wanted some candy or cookies, but when given some soft candy resident refused saying 'I'm not hungry'. R75's Progress Note dated, 9/6/2022 at 1:04 PM, documents, resident ate approximately 5-6 bites of breakfast and 5-6 bites of lunch, 1 cup of apple juice for breakfast with half cup of water, and for lunch 1 cup apple juice. R75's Dietitian Assessment, dated 9/7/2022 at 5:20 PM documents, on a Pureed diet with High Protein Supplement. Comfort feedings as alert. Fortified Pudding at meals. Intakes poor. Refuses assistance at meals and refuses food and fluids at times. On Megace which can stimulate appetite. Weights: (9/6): 86, (8/2): 92, (6/15): 111.6, and (3/1): 108. Current weight is down 6# (6.5%) x/1 month, down 25# (22.9%) x/3 months, and down 22# (20.4%) x/6 months. Below IBW Range 114-146. Body Mass Index: 13.88 (Underweight). History of edema, on (2) diuretics (Diagnosis CHF). Potential risk for weight changes and dehydration. Fluids encouraged and dietary offers 15+ servings/day. Skin free of open areas. No new labs to review. On Iron Supplement. Estimated Needs: 1170 calories (30 kilo-calories per kg), 1170 cc fluids (1 cc per kilo-calories), and 39-47 gram protein (1.0-1.2 injury factor). Continue with diet Rx and encourage intakes. Monitor. R75's MAR, dated 9/7/2022, documents R75 weighed 87 pounds. R75's Progress Note dated, 9/8/2022 at 8:55 PM, documents, resident refused all meals this day stating 'I'm not hungry.' Resident would hold head down and staff could only get resident to take few sips of a drink. R75's MAR, dated 9/14/2022, documents R75 weighed 86 pounds. R75's Progress Note dated, 9/20/2022 at 8:12 PM, documents, resident continues with poor appetite for all meals this day. Approximately 5% total eaten this day with resident also denying most fluids. Family (who is aware of resident's decline and not eating) has called up to check on resident and was told no change in eating habits. On 9/20/2022 at 12:15 PM, staff were feeding R75 pureed food with fortified pudding and fortified milk. R75 sat in a geri chair with her head was half way under the blanket. Staff encouraged her to eat and drink. R75 ate less than 5% of the meal. On 9/21/2022 at 8:50 AM staff pureed food with fortified pudding and fortified milk. R75 sat in a geri chair, her head was under the blanket. Staff encouraged her to eat and drink. R75 ate less than 5% of the meal. On 9/21/2022 at 12:30 PM, staff were feeding R75 pureed food with fortified pudding and fortified milk. R75 sat in a geri chair, her head was laying against the chair and half under the blanket. Staff encouraged her to eat and drink. R75 ate less than 5% of the meal. R75's Progress Note dated, 9/21/2022 at 1:01 PM, documents, Appetite continues to be poor with aide of staff. Resident took around 5-6 bites for breakfast and same for lunch. Fluids encouraged with taking very little sips. Resident continued to hang down and again encouraged to lift head to eat and drink Resident would lift head a little but kept wanting head covered stating she was cold. On 9/21/2022 at 1:35 PM V24, Certified Nurse's Aide (CNA) and V11, CNA transferred R75 to bed using a full body lift to weigh R75. R75's weigh was 79.9 pounds. V24 and V11 stated they are familiar with R75, she doesn't ever eat well but lately R75 is eating less and less they feed her at all meals as much as she will eat. V24 and V11 both stated they don't offer R75 snacks in between meals because no one told them to do that. R75's Electronic Medical Record dated 6/15/2022 documents she weighed 111.6 pounds and 9/22/2022 documents she weighed 79.9 pounds which resulted in R75 had a 28.41% weight loss in 3 months. R75's EMR during this time period has no documentation R75's physician was notified of the significant weight loss and no additional interventions/recommendations were added from the licensed dietitian and R75's care plan was not updated during this time. On 9/21/2022 at 2:00 PM, V6, Licensed Practical Nurse (LPN), stated R75 was on weekly weights in the past and then her weight was stable so they discontinued her weekly weights and reordered weekly weights in August 2022. V6 stated she documents the weekly weights in the computer. V6 stated R75 was on hospice for one day in May 2022 but the family didn't want her on hospice so it was discontinued. R75's Progress Note dated, 9/21/2022 at 6:04 PM, documents, Notified family of weight loss and continued poor appetite. Discussed options and conditions. Family would like to see if resident is a candidate for G (gastrostomy) -Tube placement. MD (physician) notified of weight loss and continued poor appetite, gave OK for GI (gastrointestinal) consult. R75's Progress Note dated, 9/21/2022 at 8:51 PM, documents, resident ate 50% of meal during dinner. Resident consumed all her mashed potatoes and chocolate pudding. On 9/21/2022 at 3:20 PM, V2, Director of Nursing (DON), stated R75 is on dietary supplements ordered by the physician of fortified foods and staff feed her as much as she will eat. V2 stated every day is different with R75, some days she eats more than others. V2 stated she expects staff to document in the nurse's notes when R75 doesn't eat well. V2 stated she didn't know if staff document meal intake for R75. V2 stated the Dietary Manager does a weight report that documents 5% or more weight loss in a month and she reviews it. V2 stated the Registered Dietitian (RD) comes in weekly to review residents that have weight loss. V2 stated R75's physician recommended hospice but (R75's) family doesn't want her to be on hospice. V2 stated R75's physician would be responsible to discuss a G-Tube with R75's family and she wasn't sure if it was discussed or not. V2 stated R75 had an NG tube when she was readmitted from the hospital in May 2022, but they had to discontinue it because the facility doesn't allow NG tubes at the facility. On 9/22/2022 at 9:00 AM, V2, DON stated staff are not documenting how much R75 eats per meal. V2 stated if she doesn't eat well for a meal V2 expected staff to document that in the nurse's notes. V2 stated she doesn't know if staff are offering R75 comfort food/snack between meals, but they should and if R75 eats the snack staff should document how much of the snack she ate in the nurse's notes. R75 was on weekly weights in the past but she gained weight and the weekly weights were discontinued and were reordered in 8/2022. V2 stated R75 was on hospice for a few days but her family didn't want her on hospice, so it was discontinued. V2 stated she expected staff to follow the facility weight monitoring policy. On 9/22/2022 at 1:00 PM, V2 stated she called R75's POA to update her on R75's weight loss and asked if she wanted R75 to have a G-Tube if her physician would clear her for surgery and the POA stated she would agree to a G-Tube. On 9/22/2022 at 1:55 PM, V40, R75's Power of Attorney (POA) stated she wanted R75 to have a G-Tube for a long time. V40 stated R75 was hospitalized in May 2022, and she was readmitted to the facility a few days later with a naso-gastric tube. V40 stated R75's NG tube was removed at the facility the next day she was readmitted staff took her NG tube out because she couldn't stay at the facility with it. V40 stated she asked multiple staff about R75 getting a G-Tube, but it fell on deaf ears, no one wants to do their job. V40 stated the DON called her in the evening on 9/21/2022 and told her R75 was losing more weight and asked her if she would be ok with R75 getting a G-Tube and she said yes. On 9/23/2022 at 9:00 AM, V34, Licensed Dietitian, stated R75 she comes to the facility every two weeks. V34 stated R75 is on Megace to increase her appetite and on high protein supplement of fortified milk and pudding. V34 stated the facility doesn't document how much the residents eat so it's hard to tell how many calories she's getting. V34 stated she talks to staff when she is at the facility to see how much residents are eating. V34 stated R75 has a history of not eating well. V34 stated her weight was stable a few months ago and now she's losing weight again. V34 stated she hasn't recommended a G-Tube for R75 and she didn't have a reason why she hasn't recommended it. V34 stated she expected staff to feed R75 between meals and a bedtime snack to ensure she is getting as many calories as possible. V34 was not aware R75's current weight is down to 79.9 pounds. The facility's Weight Monitoring Policy, revised 6/2021 documents, Objective to consistently assess residents for significant weight loss or gain. Procedure record weight in the proper place in the resident's clinical record, weekly and monthly weights are recorded by dietary in Electronic Medical Record (EMR.) Licensed staff will notify the physician of the following: 5% loss in a 30-day period, 7.5% loss in a 90-day period, 10% loss in a 180-day period. Notification to the physician must be documented, and also whether or not new orders were received. Families/POA must be notified of significant weight loss. The weight committee will review all residents with significant weight losses and other residents of concern and refer to the RD (registered dietitian) as needed. The RD will review significant weight losses and any other residents referred by the weight committee on a monthly basis and make recommendations to physician as necessary. Residents that are confined to bed may be weighed with a lift scale. Responsible staff include licensed staff, CNAs, food service supervisor and the RD.