**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, resident interview and staff interviews, the facility failed to carry out assessments and interventions for 2 of 5 residents reviewed for a change in condition (Resident #10, and #209). The facility failed to carry out assessments/interventions for a resident with a low blood sugar (#10), and failed to carry out interventions after a resident did not have a bowel movement for multiple days (#209). The facility reported a census of 58 residents. Findings include: 1. The MDS assessment dated [DATE] revealed Resident #10 scored a 14 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed diagnoses for acute and chronic respiratory failure with hypoxia, heart failure, renal insufficiency, neurogenic bladder, and diabetes mellitus. The Care Plan revealed a focus area revised on 4/23/24 for risk for alterations in blood glucose levels related to diabetes diagnosis. The interventions dated 4/19/24 revealed glucagon kit as ordered; observation for signs/symptoms of hypoglycemia and report to nurse/provider as needed such as shakiness, sweating, headache, nausea, fatigue, irritability, dizziness, tingling/numbness of lips, tongue, and cheeks. The Progress Note dated 10/24/23 at 4:40 PM, revealed the nurse called into the resident's room due to Certified Nurse Aide (CNA) stated that he acted funny. When the nurse arrived in the room the resident found lethargic and barely kept his eyes open. Blood glucose checked and read 60 mg/dl (milligrams per deciliter). Two glucagon packets and 3 cups of orange juice with sugar administered due to resident still able to swallow and continued to check blood glucose and only able to get resident up to 75 mg/dl. The provider notified and ordered glucagon 1 mg intramuscular injection. The nurse administered glucagon and continued to monitor the resident. Twenty minutes later residents blood glucose was in the 200s. The provider called and ordered for continued monitoring the resident though out the night. The e-Interact Transfer Form V5 dated 10/25/23 at 3:48 PM revealed resident sent to the local hospital on [DATE] at 3:55 PM for hypoglycemia. The blood glucose registered 62 on 10/25/23 at 3:19 PM. The vitals signs revealed 130/60 blood pressure; 70 heart rate per minute; 14 breaths per minute; temperature 96.9 F; and pulse oximetry 90% on oxygen via nasal at 3.5 liters. The resident started antibiotics on 10/20/23 for cellulitis. The Progress Note dated 10/25/23 at 3:45 PM, notified of POA (Power of Attorney) on the condition of resident and notified her of order to transfer resident to local hospital for evaluation and treatment. The Progress Notes lacked documentation of assessments between 10/24/23 at 4:40 PM and 10/25/23 at 3:48 PM. The Transfer to Hospital Summary dated 10/25/23 at 3:55 PM revealed provider notified of resident's condition and received verbal order to transfer to local hospital for evaluation and treatment. At 5:43 PM, 911 notified; at 3:45 PM the POA notified of resident's condition and transferred to local hospital; and EMS (Emergency Medical Services) arrived at the facility and got the resident stable. At 3:55 PM, EMS transported resident to local hospital ER (emergency room) for evaluation and treatment. This form revealed incorrect documentation and struck out on 2/7/24 at 8:03 PM. The Blood Sugar Summary revealed the following blood glucose readings: a. 10/25/23 at 12:32 PM 110.0 mg/dL b. 10/25/23 at 3:19 PM 62.0 mg/dL During an interview on 5/2/24 at 10:54 AM, Staff G, LPN (Licensed Practical Nurse) queried about the incident on 10/25/23 and she stated they fill out a transfer form and document in nursing notes. She stated he had a low blood glucose and they got it back up and then ended up shipping him out to the hospital for awhile. During an interview on 5/2/24 at 3:07 PM, the ADON (Assistant Director of Nursing) queried on the incident with Resident #10 on 10/25/24 and the documentation and she stated she expected a lot more documentation such as what happened, if he was hypoglycemic from the night before. She stated the assessment needed documented. 2. Due to Resident #209 recent admission to the facility, completed MDS assessment not available for review. The Care Plan dated 4/15/24 revealed a focus area for self-care deficit as evidenced by requiring assistance with ADLs, impaired balance during transitions required assistance and/or walking, and incontinence. The interventions revised on 4/23/24 revealed resident needed a person assist with toileting. The EMR revealed the following Medical Diagnoses: a. slow transit constipation b. fracture of superior rim of left pubis, subsequent encounter for fracture with routine healing. On 4/29/24 at 11:48 AM the resident stated he hadn't pooped in 5 days. they gave him MOM and that didn't help. He stated if they give him a can of rotel tomatoes, that would open him up. The Physician Orders revealed the following medications: a. ordered 4/30/24- Milk of Magnesia Suspension (MOM) 7.75 %- give 30 ml (milliliter) by mouth every 24 hours as needed for constipation b. ordered 4/30/24- Enema Disposable Rectal Enema- insert 1 application rectally every 24 hours as needed for constipation c. ordered 4/30/24- Bisacodyl Suppository 10 mg (milligrams)- insert 1 suppository rectally every 24 hours as needed for constipation Give 10 mg suppository per rectum daily PRN constipation d. ordered 4/14/24- Oxycodone/acetaminophen 5/325 mg- give 1 tablet orally every 6 hours as needed for pain e. ordered 4/14/24- Senna-time tablet 8.6 mg- give 1 tablet orally every 12 hours as needed for slow constipation The April MAR (Medication Administration Record) revealed the resident received MOM on 4/27/24 at 9:21 AM. The April MAR revealed the resident didn't receive Senna-time tab one time during the month. The May MAR revealed the resident received enema disposable rectal enema on 5/1/24 at 7:17 AM The POC Response History for Bowel Elimination revealed Resident #209 did not have a bowel movement from 4/25/24 at 1:59 AM through 5/2/24 at 2:42 AM. During an interview on 5/2/24 at 1:32 PM, Staff C, RN (Registered Nurse) stated the facility had a bowel list and the night shift nurse left a bowel list for the nurses every morning. Staff C stated no one said anything to her about the resident's constipation. She stated the resident had this issue before and his home caregiver came in and brought things that worked for him and they received good results. During an interview on 5/2/24 at 3:25 PM, the ADON queried on Resident #209 constipation and she stated they gave him an enema the day before and MOM the day before that. She stated they used a 3-day bowel protocol and if in 3 days no bowel movement, the resident received MOM and if no results, they received a suppository, and then after that an enema. She stated everyone usually gets an order set when admitted and Resident #209 didn't and they came to her about his constipation and they got the order set ordered. She stated they should have noticed on Day 3 and the staff needed to look at the bowel list every day. The facility policy Conducting an Accurate Resident Assessment, implemented 12/1/23, stated residents would receive accurate assessments, reflective of the resident's status at the time of the assessment. The policy directed staff to document resident medical, functional, and psychosocial problems and address areas of decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment dated [DATE] revealed Resident #208 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed impairment on both sides in the upper and lower extremities. The MDS revealed resident needed substantial/maximal assistance with toileting hygiene; shower or bathing self; upper and lower body dressing; rolled from left to right. The MDS revealed resident dependent with toilet transfer and chair/bed to chair transfer. The MDS revealed medical diagnoses of multiple sclerosis and risk for malnutrition. The MDS revealed risk for developing pressure ulcers/injuries. The MDS revealed one Stage 2 pressure ulcer; one Stage 3 pressure ulcer; and one Stage 4 pressure ulcer present on admission. The Care Plan revealed a focus area dated 4/23/24 for Stage 4 pressure ulcer on right hip; Stage 3 pressure ulcer on left heel; and Stage 2 pressure ulcer on the right ankle. The interventions dated 4/23/24 revealed treatments as ordered. The Wound Care Routine dated 3/7/24 at 11:32 AM from a hospital clinic revealed the following special instructions: a. Apply betadine to left heel daily cover with foam border b. Apply a thin layer of Mupirocin along to buttock wounds and red areas daily c. Apply a thin layer of mometasone with Mupirocin to red area along left hip and groin daily The Admission/readmission Narrative dated 4/12/24 on 1:33 PM revealed the following for the skin: a. alterations in skin integrity: multiple b. site 1. right iliac crest- no measurement documented 2. coccyx- no measurement documented 3. right knee- no measurement documented 4. left heel- no measurement documented 5. right buttock- no measurement documented 6. left buttock- no measurement documented 7. left ankle- no measurement documented 8. groin- no measurement documented The Progress Note dated 4/12/24 at 2:00 PM, revealed resident arrived by ambulance and ambulance crew. The resident transferred to bed with max assist of 5 people. Resident fully oriented and alert, unable to walk, stand, had multiple skin integrity issues which have been identified on admission skin assessment. Resident incontinent. The Physician Orders revealed the following medications: a. start date of 4/13/24- Mepilex border- apply to sacrum topically in the morning b. start date of 4/13/24- Mepilex border- apply to left ankle topically in the morning for wound c. start date 4/15/24- Weekly skin assessment (Day of Week)- one time a day every Monday d. start date of 4/16/24- clean wound to right hip with normal saline apply maxorb to wound bed cover with foam dressing daily one time a day for wound healing e. start date of 4/16/24- apply betadine to left heel and ankle apply Mupirocin ointment 2% to ankle then cover ankle and heel with foam dressing in the morning for wound healing f. start date of 4/17/24- liquacel liquid orange- give 30 ml orally two times a day for wound healing g. start date of 4/18/24- apply border gauze to bony prominence on bilateral feet for prevention. change every 3 days in the morning every 3 day(s) for wound healing h. start date of 4/28/24- Mupirocin ointment 2% to wound on left ankle The Weekly Nursing Skin Assessment/Shower Skin assessment dated [DATE] at 3:59 PM revealed the following: a. Does this resident have any alterations in skin integrity?- yes b. Are any of the above areas new for this resident- yes The Progress Note from the Provider on 4/15/24 revealed the resident had multiple pressure wounds, patient referred to wound care. Patient had wounds to left ankle, sacrum covered with Mepilex, patient had a wound to right hip covered with Maxorb and foam dressing. Wound to left heel covered with foam dressing with Mupirocin being applied daily. The Physical Exam revealed the Integumentary: Dry, warm, normal color multiple pressure wound and wounds covered at this time, and unable to visualize. The Progress Note dated 4/17/24 at 1:49 PM, revealed the nurse received a phone call from [name redacted] infectious disease physician office located in another city and inquired about resident and how his wounds were progressing. An update given as doing treatments as ordered. phone number if questions arose or resident needed to have a follow-up appointment given. They felt the resident did not need to come back to their office if he under our care, but if needed to call them. The Weekly Nursing Skin Assessment/Shower Skin assessment dated [DATE] at 4:12 PM revealed the following: a. this resident have any alterations in skin integrity?- no b. Are any of the above areas new for this resident- no The Weekly Nursing Skin Assessment/Shower Skin assessment dated [DATE] at 7:48 AM revealed the following: a. Does this resident have any alterations in skin integrity?- no b. Are any of the above areas new for this resident- no The Progress Note from the Provider on 4/24/24 revealed the resident reported that on Thursday he was lifted by a Hoyer and hit his left ankle on the Hoyer, he reported his wound came back open. I assessed left ankle, bruising around wound. Resident reported severe pain to left ankle. discussed ordering an x-ray, resident agreeable. reported to ADON. No other new issues reported. Medications reviewed. Wound #1 on the left ankle was a pressure, with no odor; red wound bed, and periwound- bruising. The Weekly Wound Log dated 4/27/24 for Resident #208 revealed the following: a. right hip - date acquired on admit and measured 2 x 2.3 x 0.5 cm b. left foot - date acquired on admit and measured 4.3 x 1.3 x 0 cm c. heel - date acquired on admit and measured on 1.3 x 1.6 cm The Weekly Nursing Skin Assessment/Shower Skin assessment dated [DATE] at 4:12 PM revealed the following: a. Does this resident have any alterations in skin integrity? no b. Are any of the above areas new for this resident- no The Weekly Nursing Skin Assessment/Shower Skin assessment dated [DATE] at 11:27 AM revealed the following: a. Does this resident have any alterations in skin integrity?- no b. Are any of the above areas new for this resident- no During an interview on 4/29/24 at 11:04 AM, Resident #208 stated he had a pressure ulcer on one of his ankles and one on his hip. He stated the pressure ulcers present prior to admission. He stated the facility did daily dressing changes. During an interview on 5/1/24 at 1:40 PM, Resident #208 stated he thought they only measured his wounds twice and he thought his insurance wanted them measured every week, but he didn't know if they did that here. During an interview on 5/1/24 at 8:18 AM, the ADON queried on where the skin assessment documented and she stated she just audited them this week and they were not completed correctly. The ADON asked if they documented on paper and she stated no. The ADON asked if she documented any skin measurements and she stated she documented one measurement on Resident #208. During an interview on 5/2/24 at 1:25 PM, Staff C, RN (Registered Nurse) queried on where the skin assessments documented and she stated her and the ADON spoke about it this morning and she was doing it wrong. She stated when she clicked off the dressing change, it should go over to the progress note to document. Staff C stated she misinterpreted because the last place she was at, they hired a skin nurse and she thought the skin nurse measured and the floor staff didn't so the measurements were not off. Staff C stated she knew now she needed to measure and document the measurements weekly. During an interview on 5/2/24 at 1:42 PM, the ARNP (Advanced Registered Nurse Practitioner) stated she expected the facility to do measurements on the wounds and she thought they did the measurements. She stated the facility staged the wounds. The ARNP stated she didn't measure the resident's wounds but she looked at them. During an interview on 5/2/24 at 3:14 PM, the ADON queried on Resident #208 pressure wounds and she stated she knew they needed better measurements for sure and wanted the stages of healing with them. She stated measurements needed done weekly. Based on observations, staff interviews, resident interview, provider interview and clinical record review, the facility failed to implement timely interventions for residents identified at high risk for pressure ulcer development and to prevent worsening of wounds, perform thorough and consistent assessment which included wound measurements and wound description, and coordinate which staff from the clinical team staged and measured wounds for two of three residents reviewed for pressure ulcers (Resident #20, Resident #208). Resident #20 developed a deep tissue injury to the right heel and stage two pressure ulcer to the coccyx, and Resident #208 admitted with wounds not thoroughly assessed by the facility on admission, nor consistently monitored, staged, or measured following the resident's admission. The facility reported a census of 58 residents. Findings include: The MDS identified the following descriptions of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 revealed the resident was rarely to never understood. Per this assessment, Resident #20 was at risk for pressure ulcers/injuries, and did not have unhealed pressure ulcers. The assessment revealed Resident #20 had a pressure reducing device for chair and bed, and was not on a turning/repositioning program. The Care Plan initiated on 3/20/23, resolved on 4/30/24, documented, Resident #20 has impaired skin integrity. R (right) heel, unstageable (obscured full-thickness skin and tissue loss) wound. The current Care Plan for Resident #20 dated 4/2/24, revised 4/30/24, documented, Resident #20 has issues with skin integrity. Resident #20 has a deep tissue wound to her R (right) heel. Daily treatments are being applied at this time and Q 3 D (every three days). The Intervention dated 4/2/24 revealed, Monitor and document changes in wound. Measure wound weekly and PRN (as needed). Review of the resident's Braden assessment dated [DATE] identified Resident #20 at high risk for pressure ulcers. The Skin assessment dated [DATE] revealed the resident did not have any alterations in skin integrity. The Late Entry Skin/Wound Note dated 3/11/24 at 10:44 AM documented, family notified of suspected DTI (deep tissue injury-persistent, non-blanchable deep red, maroon or purple discoloration) to right heel as well as Nurse Practitioner. The Weekly Nursing Skin assessment dated [DATE] revealed the resident had an area to the right heel, and documented, duoderm in place, heel protectors on and float heels on blue pillow. This assessment documented the wound as not new. The Weekly Pressure Wound assessment dated [DATE], locked 3/15/24, revealed the resident had a deep tissue injury (DTI) to the right heel, which measured 3 cm (centimeters) length (L) by 3 cm width (W) by 0.0 cm depth (D). The stage documented, suspected deep tissue injury. The assessment documented date of onset as 3/11/24. The Physician Order, start date 3/11/24, revealed, heel booties on at all times every shift for skin. Review of the resident's Treatment Administration Record (TAR) dated March 2024 revealed documentation of floating heels/heel booties began 3/11/24. The Progress Note dated 3/12/24 at 3:10 AM revealed, resident received N.O. (new order) to wear heel protectors at all times and float heels while lying in bed. Resident complied with booties all this shift. The Progress Note dated 3/15/24 at 7:20 AM revealed, Daily dressing change done on coccyx area. Review of the resident's Medication Administration Record (MAR) and TAR dated March 2024 lacked documentation of a treatment to the resident's coccyx. The Weekly Nursing Skin assessment dated [DATE] revealed the resident had an area to the right heel. The assessment lacked description of the wound, and lacked measurements of the wound. The skin assessment did not address a wound present to the resident's coccyx. The Provider Progress Note for Resident #20 dated 3/27/24 authored by the facility's Nurse Practitioner (NP) revealed the following Chief Complaint/Nature of Presenting Problem: Wound. Per the Progress Note, Resident #20 had a stage two pressure ulcer to the coccyx which measured 3 cm x 3 cm x 0.25 cm, had mild serous drainage, and a fragile periwound. The resident also had a deep tissue injury to the right heel which measured 3 x 2 cm. The Plan section documented, in part, the following: a. Pressure injury of sacral region, stage 2: Medihoney, and Mepilex to be changed daily and PRN (as needed). b. Pressure-induced deep tissue damage of right heel: Now open, Change to Medihoney and Mepilex to be changed daily. Review of a Physician Order Form for Resident #20 dated in March (date and year unable to be read) revealed, change wound care to R (right) foot (and sign) bottom to Medihoney (and sign) cover with Mepilex to be changed daily (and sign) PRN (as needed). This Physician Order not signed on the nurse signature line and no date present next to nurse signature line. Although date and year unable to be read, it was noted per the resident's MDS assessment the resident admitted to the facility in November 2023. The Physician Order dated 3/27/24 at 7:00 AM started on the resident's MAR on 3/27/24: MEDIHONEY GEL WOUND Apply to right heel topically in the morning for wound healing. A prior treatment order to the right heel which started 3/14/24 remained active as well as the more current treatment order for the resident's heel dated 3/27/24. Both orders remained active on the resident's April 2024 TAR as well. Review of Resident #20's MAR and TAR for the month of March 2024 lacked a Physician Order to address the resident's pressure injury of the sacral region, or charting to indicate completion of treatment. The Nurses Note dated 3/29/24 at 1:25 PM revealed, prostat 30 ml (milliliter) TID (three times per day) and stress tab ordered for wound healing per Nurse Practitioner. The Weekly Nursing Skin assessment dated [DATE] and 4/6/24 revealed the resident had an area to the right heel, and duoderm in place. heel protectors on at all times along with floating heels on pillow. The assessment also revealed, open area to coccyx. Mepilex in place. The assessment lacked wound measurements or additional descriptions of the wounds. Per this assessment, the areas were not new for the resident. The assessment dated [DATE] revealed, treatments done daily. Review of the resident's TAR dated April 2024 revealed treatment to the coccyx began to be documented 4/5/24, although first noted in Progress Notes on 3/15/24. The Orders-Administration Note dated 4/8/24 at 1:09 PM revealed, ACETAMINOPHEN 650MG (milligram) TAB Give 650 mg orally every 8 hours as needed for Pain residents complaining of pain on her coccyx. The Weekly Nursing Skin assessment dated [DATE], locked on 4/30/24, and the assessments done 4/20/24 and 4/27/24 revealed the resident had an area to the right heel, and duoderm in place. heel protectors on at all times along with floating heels on pillow. The Weekly Nursing Skin assessment dated [DATE] also revealed, open area to coccyx. treatment in place. The assessment dated [DATE] and 4/27/24 provided the same description, although the word treatment had been changed to Mepilex on these assessments. The Assessments 4/13/24 4/20/24, and 4/27/24 lacked wound measurements or additional descriptions of the wounds. The Weekly Wound Log dated 4/27/24 provided by the Assistant Director of Nursing (ADON) revealed the resident had a deep tissue injury to the right heel. Per the log, the wound measured 3 by 2 by 0.1 (no unit of measure documented). Per the log, the resident had a moisture associated wound to the buttock which measured 3 x 2 x 0.2 (no unit of measure documented). Observation on 5/1/24 at 1:19 PM revealed Resident #20 present in the common area between the 300/400 unit. The resident had blue soft boots to their lower legs/feet. Observation conducted 5/2/24 at 10:04 AM revealed Staff C, Registered Nurse (RN) performed wound care to the resident's right heel wound. Resident #20 observed in bed with a cushion under the lower legs to elevate the resident's lower legs from the bed. Per Staff C, the wound was facility acquired. Staff C further explained the wound had necrotic eschar (dead or devitalized tissue), and the Medihoney got it off of there. The resident observed to have the wound to the inner right heel, and Staff C explained the wound looked so much better. Per Staff C the area did not have redness present, was not boggy, and dried. On 5/02/24 at 10:12 AM, Staff C explained the resident had an open area near the right inner cheek which was facility acquired. The resident assisted to turn in the bed, and the old dressing removed. The sticky surrounding edges of the dressing pulled when the dressing was removed from the resident's backside, and some bloody drainage present with the old dressing removal. A wound observed to the top of the resident's gluteal cleft. During the observation the resident noted to have yellow substance which appeared to be urine in their brief when the resident's brief was partially removed in order to access the area of the resident's wound. Staff C described the wound bed as white fibrous tissue, maceration, and healing wound bed with red beefy granulation. Per Staff C, the wound had slight clear serosanguineous drainage, and the area surrounding the wound was a little red. Staff C explained it was better than a week ago. Staff C completed the dressing change, and per observation the same brief as previously described was reapplied for Resident #20. On 5/2/24 at 11:10 AM Staff G, Licensed Practical Nurse (LPN) queried about assessment of skin. Staff G explained if she saw anything it would be reported to the ADON (Assistant Director of Nursing) to let them know if there is a pressure sore, or even thought a pressure sore, anything like that. Per Staff G, they would open up a skin sheet so could continue to monitor it at least on a weekly basis. Staff G acknowledged this would occur in the assessment tab. When queried who measured the wounds, Staff G responded she did not as she worked nights (night shift), and responded she was not sure. Staff G further explained she knew the NP was measuring them when she came in, but did not know if she did so any more. On 5/2/24 at 1:09 PM the ADON explained there was a time where the Nurse Practitioner (NP) monitored wounds every week, the facility did not have an actual full-time person to do the wounds, and the nurses were asked to help keep the measurements up. When queried what nurses were to do weekly, the ADON responded weekly pressure and weekly non-pressure assessments should be opened with all skin issues/skin wounds, and after opened populate weekly unless healed. The ADON explained they needed to be opened first. The ADON explained there was a time she measured weekly, however could not always keep up with it when the facility didn't have a Director of Nursing (DON). Per the ADON, she charted in weekly pressure and non-pressure. When queried about staging of wounds, the ADON responded the NP staged, said we don't stage at all, and further explained the facility did not call a pressure until they said so. The ADON explained the DON (Director of Nursing) was going to take over wounds for the facility. It was noted the facility had a new DON starting during the week of the survey. On 5/2/24 at 1:40 PM during an interview with the NP, the NP explained she was doing measurements, and it then went back to the facility. When queried about the facility measuring wounds, the NP responded she thought it was being done. Per the NP, the facility would stage wounds. The NP explained she measured Resident #20's wound on 3/27/24, and this was the last time took care of wound. The Facility Policy titled Skin and Wound Management System dated 4/17, revised 9/22 revealed, it is the policy of this center's Skin Management System to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Such residents are then provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment dated [DATE] revealed Resident #19 scored a 11 out of 15 on the BIMS exam, which indicated moderately impaired cognition. The MDS revealed impairment on one side of the upper extremity. The MDS revealed resident needed partial/moderate assistance with toileting hygiene; chair/bed to chair transfer; and toilet transfer. The Care Plan revealed a focus area revised on 1/10/24 for risk for fall due to heart failure, cervicobrachial syndrome, and history of fall with fracture prior to admission with a fall on 1/8/24 with a right hip fracture. The resolved intervention dated 1/8/24 revealed floor alarm in room, and floor alarm removed on 1/18/24 and pull away alarm placed on resident. The EMR (Electronic Medical Record) revealed the following Medical Diagnosis: a. Fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing. The Fall-Initial Note dated 1/8/24 at 8:10 AM, revealed the following: a. Type of Incident: unwitnessed fall b. Date and Time: 1/08/24 at 8:10 AM c. Location of fall: in resident's room d. Description & Potential Root Cause: non-compliant self-transferred e. Injuries: complaining of inner et outer right hip pain f. Pain: 5/10 on pain scale g. Vitals (include ortho's if able to stand): h. Footwear at time of fall: yes, his regular shoes i. Assistive devices and their location at time of fall: he has 4 wheeled walker that was by his bed at the time of fall j. If resident wore glasses, were they on? no k. Was the call light on at time of fall? yes l. Last time toileted: right before fall m. Any Incontinence: no n. ROM (Range of Motion) Impairments: able to move bilateral lower extremities, but is complained of right leg pain o. Care Provided (how assisted up, first aid): assisted to standing position with assist x 2; neuros initiated p. Intervention/prevention to prevent recurrence (Must complete): floor mat put in room q. received order for resident to be taken to local hospital emergency room for x-rays. r. Provider/ Family notifications: provider and POA (Power of Attorney) The Progress Notes for the resident documented the following: On 1/8/24 at 8:28 AM, Resident #19 fell in his room self-transferring to the bathroom. He stated that he was able to transfer himself. The resident unable to use his right hip at this time order obtained from the provider to transfer resident to local hospital emergency room for evaluation. POA notified verbalized understanding. On 1/8/24 at 10:26 AM, resident noted to be laying on back with legs out in front of him in front of his window. Resident noted to have his regular shoes on, walker over by his bed. Call light on for assistance. Resident started complaining of right outer and inner hip pain. Received order per provider to transfer to local hospital emergency room to be evaluated and treated. POA notified. Neuros initiated. On 1/8/24 at 10:33 AM, CNA responded to call light and asked resident to give her a second so she could gown up, at that time another CNA called and stated that other resident climbing out of her wheelchair. They repositioned that resident and the CNA then finished gowning up and then at that point she heard a crash and heard Resident #19 say ouch. She then opened the door and saw resident laying on the floor and called for the nurse. On 1/8/24 at 11:22 AM, Fall Committee Meeting: Resident fell on 1/8/2024 at 8:10 AM. Resident found on the floor. Resident stated that he was getting a pair of socks out of his dresser. Root cause analysis performed showed that resident attempted to self transfer, lost balance/got weak and fell. Based on the root cause analysis the intervention will be to place a floor alarm in residents room and place it in front of him while he is in his room. Care Plan updated with changes. On 1/8/24 at 1:30 PM, the resident returned per facility vehicle with facility staff. Resident weight bearing as tolerated with walker, continue with NSAIDS (non-steroidal anti-inflammatory drugs) for pain, follow-up with hospital. Resident noted to have multiple fractures to right hip. Resident assisted to his room to his recliner, call light within reach. On 1/13/24 at 3:32 PM, resident alert resting in bed at this time with call light within reach continue to encourage to use call light for all assist verbalized a good understanding. Denies any pain at this time, still verbalized pain when he moved, encouraged to let the nurse know if he needed anything for pain. He verbalized an understanding. Stand aid with assist x 2 utilized today for all transfers. The Provider Progress Note dated 1/8/24 revealed resident seen in ER (Emergency Room) after fall that resulted in fracture to right pelvis and hip. Resident to be referred to Ortho. Patient reports pain about a 5 out of 10. Tramadol 50 mg every 6 hours PRN (as needed) ordered. The Plan indicated closed fracture of right pubis, unspecified portion of pubis, sequela. Repeated falls: Encouraged use of assistive device. Change positions slowly to avoid dizziness that could result in fall. Ask for assistance from staff when ambulating/transferring. The IDT Resident Care Conference dated 1/17/24 at 12:21 PM, documented looked into more local hospitals for an appointment to see if Resident #19 needed to have surgery on his hip. Coming out of isolation on 1/17/24 at midnight due to diagnosis of COVID. The Progress Note dated 1/19/24 by provider revealed the following information: a. [AGE] year-old male resident seen today for follow-up visit related to recent fractures and COVID. b. Resident appeared to be feeling better. Resident's lungs clear throughout. Patient continues to have 2 liters of oxygen nasal cannula as needed. c. Resident waiting on Ortho referral. d. Resident reported continued constant pain to the hip. Patient currently prescribed tramadol 50 mg every 6 hours as needed, will increase to every 4 hours as needed. e. Plan: Right hip pain: Waiting on ortho referral tramadol for pain, increased to every 4 hours PRN During an observation on 4/30/24 at 12:57 PM, the resident sat in his wheelchair and self-propelled down the hallway. The chair alarm hooked to his shirt and attached to the wheelchair. During an interview on 5/2/24 at 10:45 AM, Staff G, LPN (Licensed Practical Nurse), stated she believed she worked the day Resident #19 fell and fractured his hip. She stated he needed assistance with walking because he wasn't steady on his feet. She stated he self-transferred when he broke his hip, and we always wanted him to ask for assistance. During an interview on 5/2/24 at 1:57 PM, Staff I, CNA stated Resident #19 supposed to be a one assist but not always compliant. During an interview on 5/2/24 at 2:05 PM, Staff J, CNA stated Resident #19 a one assist and he would try to self-transfer and we tried to get him, but hard for him to understand to not transfer. During an interview on 5/2/24 at 3:27 PM, the ADON queried on Resident #19 fall on 1/8/24 and she stated the resident not compliant, and you couldn't convince him to wait and use the call light and he self transferred and fell. He was not compliant, you could not convince him to wait and use his call light, he self transferred and he fell. She stated the situation tricky, you can try and prevent one fall and another one happened. Since the CNA didn't go into the room yet, she went and helped someone else. The ADON stated the situation depended on the other person, if it was Resident #19 neighbor who had dementia, he would need assistance. You weigh your options. Resident #19 oriented. If someone else falling, easier to catch the person who wasn't safe. 3. The MDS assessment dated [DATE] revealed Resident #211 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed resident impaired on side of upper and lower extremity and used a wheelchair. The MDS revealed resident dependent to wheel 50 feet with two turns once seated in wheelchair. The MDS revealed diagnoses of stroke, CVA (cerebral vascular accident), or TIA (transient ischemic attack); hemiplegia or hemiparesis; and seizure disorder. The Care Plan revealed a focus area dated 5/1/24 for a self-care deficit due to diagnosis of chronic kidney disease, hypotension, gatroesophageal reflux disease, Type II diabetes mellitus, depression. The interventions dated 5/1/24 revealed resident utilized her left foot pedal and didn't use the right foot pedal, if she self-propelled. During an observation on 4/30/24 at 12:00 PM, the resident pushed in the wheelchair by Staff O, CNA with left foot on the foot pedal and the right foot barely lifted off the floor (no foot pedal on the right side of wheelchair). During an observation on 4/30/24 at 12:03 PM, the resident pushed by Staff O, CNA out of the shower room with the right foot lifted off the floor (no foot pedal on the right side) and the left foot on a foot pedal. During an interview on 5/2/24 at 9:18 AM, Staff N, CNA queried where a resident's feet needed located when transferred in a wheelchair and she stated on the foot pedals and or if able then could raise their feet. She stated she had the resident raise their feet and she would push slowly and watch them to make sure their feet stayed off the ground. She stated if the resident self-propelled and they had a bag on the back of their wheelchair with foot pedals in them, she would take them out of the bag and put the foot pedals on the wheelchair. During an interview on 5/2/24 at 1:16 PM, Staff C, RN stated if a resident is being pushed, they needed foot pedals. During an interview on 5/2/24 at 2:00 PM, Staff I, CNA stated they shouldn't move the resident in a wheelchair unless their feet are placed on foot pedals. She stated the facility used a policy called no pedal, no push. During an interview on 5/2/24 at 2:15 PM, Staff O, CNA queried where the foot should be when pushing a resident in a wheelchair and she stated on foot pedals, unless they can propel themselves. Staff O asked about Resident #211 and she stated no, you can't push her without foot pedals, she messed up on that. During an interview on 5/2/24 at 2:49 PM, the ADON queried where a resident's feet needed located when pushed in a wheelchair and she stated on the pedals. She stated if a resident didn't use foot pedals, they shouldn't be pushed, they are supposed to be mobile. 4. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 revealed the resident was rarely to never understood. Per this assessment, Resident #18 had fallen since admit, entry, reentry, or prior assessment, and had two or more falls since admit or prior assessment with no injury. The Care Plan dated 9/27/23, revision date 4/26/24, documented the following: Resident #18 has had an actual fall without injury from a rolling chair in the dining room. She didn't realize this type chair would roll out from underneath her due to her poor communication/comprehension. Falls documented on: 8/30/2023 9/26/2023 12/24/2023-No Injury 12/29/2023- No Injury 2/16/2024-No Injury 2/19/2024-No Injury 2/23/2024-No Injury 3/04/2024-No Injury 3/29/2024- No Injury 3/31/2024- No injury 4/15/2024-No Injury 4/18/2024-No Injury 4/23/2024-No Injury Care Plan interventions in 2024 included the following: a. Date initiated 3/31/24: 3/31/2024 Ensure proper footwear while ambulating. b. Date initiated 4/26/24: 4/18/2024 Broda chair was given to resident d/t (due to) weakness at times of walking. c. Date initiated 9/27/24: Be sure the rolling chairs in the dining room are kept out of residents reach. d. Date initiated 2/16/24: 2/16/24 Offer fresh water multiple times a day. (resident is sick at this time) e. Date Initiated 12/26/23, revised 2/19/24: 2/19/24 PCP (Primary Care Physician) review medication. f. Date Initiated 2/26/24, revised 3/4/24: 2/23/24 Funding verification paper work is being filed to see if resident can get PT/OT (physical therapy/occupational therapy) UPDATE: Funding form approved g. Date Initiated 3/4/24, revised 3/6/24: 3/4/24 Request an eye appointment. (Son stated that resident would not wear glasses even if she had them). h. Date Initiated 12/29/23: 12/29/23 give resident a snack when she is agitated. i. Date Initiated 4/1/24: 3/29/24 PCP (Primary Care Provider) see resident on rounds. j. Date Initiated 4/26/24: 4/23/24 Recliners in 300 alcove replaced with a couch for a large circumference to sit on. Review of Resident #18's clinical record revealed the resident had fallen eleven times between 12/24/23 and 4/23/23. The Fall-Initial Note dated 12/24/23 at 9:00 PM revealed the resident fell in the 300 common area. The Description and Potential Root Cause section revealed, resident in the 300 common area and was trying to sit in a chair but missed it landing on her buttocks. The Fall Initial Note dated 12/29/23 at 1:57 PM revealed the resident fell in another resident's room. The Description and Potential Root Cause section revealed, resident was seen sitting on the floor in [room number redacted], feet out in front of her facing the hallway. The Incident Report revealed there were no witnesses to the event. The Progress Notes for the resident documented the following: On 1/9/24 at 10:18 AM assessed left knee noted blue hematoma from fall earlier this week no s/s (signs/symptoms) of pain noted no moaning yelling or facial grimacing noted will continue to monitor. On 2/16/24 at 6:01 PM called to 300 hall per CMA (Certified Medication Aide) [Name Redacted] noted res sitting in high back chair per staff noted res attempt to sit in chair missed hit posterior head on arm of the chair fell on floor neuro's stated and vitals obtained no injury noted. The Fall Initial Note dated 2/19/24 at 8:43 AM documented: the resident had an unwitnessed fall in their room. The Description & Potential Root Cause documented, resident found lying between wall and bed. resident has recently been ill with flu. Due to cognition resident is unaware of safety issues, is unable to communicate verbally and wanders throughout building 24/7. resident does become restless and agitated at times. Resident can be redirected at times. The Incident Report revealed there were no witnesses to the event. The Fall-Initial Note dated 2/23/24 at 10:10 AM revealed the resident had an unwitnessed fall with no injury noted. The Description & Potential Root Cause documented, weakness after having influenza last week. The Progress Notes for the resident documented the following: On 2/26/24 at 2:32 PM Fall committee meeting: Resident had a fall on 2/23/2024 at 1010. Resident was found sitting on the floor between 2 recliners and had bedside table behind her. Resident appears to have been attempting to sit in a chair but missed with and fell to floor. Root cause analysis was performed and showed that resident thought she was in front of chair, but obviously was not. Based on the root cause analysis the intervention will be to have a funding verification paper filed to see if resident would be able to work with PT/OT (physical therapy/occupational therapy). On 3/4/24 at 8:38 AM resident had an un witnessed fall this morning attempting to sit in recliner missed chair sat herself on the floor. Neuros started vitals obtained no injury noted with assessment .Going to move recliners to see if that helps with the falls. The Incident Report revealed there were no witnesses to the event. The Fall-Initial Note dated 3/29/24 at 2:47 PM documented the resident fell in the 300 hallway, with location of fall documented as 300 alcove. The Description & Potential Root Cause: section documented, resident missed the recliner when she went to sit down. The Fall-Initial Note dated 3/31/24 at 1:45 PM documented the resident had a fall with no injury, and fell at the 200 alcove in front of beauty shop. The Description & Potential Root Cause documented, this nurse was called over walkie to the 200 alcove where resident was sitting on the floor next to the recliner in front of the beauty shop with feet out in front of her wearing gripper socks and no shoes. Cna (Certified Nursing Assistant) witnessed fall. Cna stated that resident was attempting to sit in the recliner and slipped. Review of the Incident Report revealed staff was summoned by a family member. The Fall-Initial Note dated 4/15/24 at 11:44 AM documented the resident slid off of recliner and onto floor. Location of fall documented the 3/400 common area, and documented per the Description & Potential Root Cause section, resident has UTI (urinary tract infection) and is on an antibiotic. The Fall-Initial Note dated 4/18/24 at 7:16 AM for a witnessed fall revealed the resident fell in the 300 common area. The Description & Potential Root Cause revealed, went to sit to soon in the chair. The IDT Note dated 4/20/24 at 9:46 AM documented, Fall Committee Meeting: Resident had a fall on 4/18/2024 at 0550. Resident was found sitting on the floor by recliner. Resident appears to have gotten weak and sat before making it to the recliner. Root cause analysis was performed and showed that resident may have gotten weak while walking and wanted to sit down in recliner. Based on the root cause analysis the intervention will be to assist resident to broda chair when resident appears to be getting weak. Care Plan updated with changes. The Fall-Initial Note dated 4/23/24 at 11:15 AM documented the resident had a witnessed fall in the 300/400 alcove sitting common area. The Description & Potential Root Cause section revealed, resident was witnessed sitting self down on floor between two chairs. On 4/30/24 at 12:18 PM observed Resident #18 stand up from a recliner chair in the 300/400 common area, then sit back down. The resident had yellow grip socks to her feet. Observation on 5/1/24 at 9:56 AM revealed Resident #18 in the common area/tv area between the 300 and 400 hallways. Resident #18 had yellow socks to their feet, and staff not observed in the common area or the medication cart area. At 9:57 AM, a staff member walked past the common area, another staff walked near the common area, and one staff went towards 300 hall while the other staff went towards 400 hall (away from the common area). Staff members walked past the common area and went in different directions away from the common area. At 10:04 AM, the resident observed in a recliner chair with yellow grip socks to her feet. Observation on 5/1/24 at 1:28 PM revealed Resident #18 on a couch in the common area. The resident had yellow socks to their feet. On 5/2/24 at 11:03 AM, Staff G, Licensed Practical Nurse (LPN) explained sometimes Resident #19 would sit too soon and would miss the chair. Staff G explained the resident mainly stayed in the 300/400 area. On 5/2/24 at 1:12 PM when queried about Resident #18's falls, the Assistant Director of Nursing (ADON) explained for almost every one of the falls the resident tried to sit in a chair and did not make it to the chair. The ADON acknowledged this occurred in the 300 alcove for the most part, where the resident spent a lot of time. Per the ADON the resident did wander, and stop signs were present as the resident liked to go into other people's room. Based on observations, clinical record review, policy review, and staff interviews, the facility failed to ensure an environment free of accidents and hazards for 4 of 6 residents reviewed for supervision. The facility failed to provide adequate supervision to prevent falls for Residents #42 and #18, and #19, and failed to utilize both foot pedals during wheelchair locomotion for Resident #211. The facility reported a census of 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 10/27/23, listed diagnoses for Resident #42 which included fracture of the right femur (leg bone), non-Alzheimer's dementia, and heart failure. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating impaired cognition. The MDS stated the resident required partial/moderate assistance for transfers and walking. The MDS stated during the review period, the resident had 1 fall with injury and 2 falls with a non-major injury. The MDS listed the Brief Interview for Mental Status (BIMS) score as 6 out of 15, indicating severely impaired cognition. The Care Plan initiated 7/3/23 documented the resident at risk for falls related to impaired balance and impaired safety awareness. The Care Plan lacked any interventions dated prior to 8/3/23. The Fall Report dated 7/21/23 at 9:00 p.m. stated the resident laid on the floor of his room on the right side. Staff toileted the resident at 8:30 p.m. The resident sustained an abrasion to the right side of his nose and had pain in his right thigh. The Nurse Notes documented the following: On 7/22/23 the resident had an acute fracture of the right hip. On 8/2/23 the resident returned from the hospital with a diagnosis of right hip fracture and had a surgical incision. On 8/4/23 the resident had a surgical repair of the right hip. The Medicare Part B Note dated 8/9/23 stated therapy would work with the resident on strengthening. The Fall Report dated 8/30/23 stated the resident was on the floor lying on his right side. He sustained a skin tear to the right wrist and an abrasion to the right knee. The facility educated the Certified Nursing Assistants (CNA's) to place the bed in a low position. The Fall report dated 9/10/23 stated staff found the resident between the bed and the bathroom door on the floor. The facility carried out additional education to CNA's regarding frequent toileting and toileting immediately following meals. The Nurse Notes documented the following: On 9/10/23 the resident was educated on the use of the call light. On 9/14/23 the family requested to have the resident's diuretic (a medication used to rid the body of fluid) reduced in an effort to reduce his falls due to self-transferring. On 10/12/23 the facility would begin 1-hour checks at bedtime due to the resident's falls. The Fall Report dated 10/12/23 stated staff found the resident sitting on the floor with his legs stretched out in front of him and the resident stated he had to urinate. The resident sustained a skin tear to the right elbow. A 10/12/23 Care Plan entry stated the family was aware that he fell due to him falling at home. The entry stated there were no new intervention ideas from the family. A 10/26/23 Therapy to Facility Communication form stated the resident required the assistance of 1 staff and a 4 wheeled walker for walking and transfers. The Fall report dated 10/27/23 stated the resident laid on his floor in the bathroom on his left side. A 10/27/23 Fall-Initial note stated staff would take him to the bathroom every 2 hours and encourage him to sit for at least 10 minutes. A 10/27/23 Care Plan entry directed staff to utilize a pressure activated call light to the exiting side of the bed. A 10/30/23 Interdisciplinary Team (IDT) Note stated the resident was placed on a fluid restriction as an intervention to the 10/27/23 fall. A 10/30/23 Care Plan entry stated the resident had an evaluation with urology (a medical specialty focused on the urinary tract) on 10/24/23. The Fall Report dated 11/1/23 stated the nurse was called into the front offices where the resident laid on his right side. The resident complained of left hip pain. Staff took the resident into a common area for increased supervision and the resident started yelling that his hip hurt. The facility obtained an order to send the resident to the ER for evaluation. The Fall-Initial note dated 11/1/23 at 7:00 p.m. stated the resident fell in the office of the Business Office Manager and the Activity Supervisor and when found the resident stated he wanted to see what was going on in there. The note stated staff last toileted the resident at 5:30 p.m. The Nurse Notes documented the following: On 11/1/23 at 9:32 p.m. the resident transferred to the hospital. On 11/1/23 at 11:15 p.m. the resident had a left hip fracture. An 11/9/23 hospital History and Physical stated the resident had a fall on 11/1/23 and sustained a fracture of the left hip. The resident underwent a left hip hemiarthroplasty (surgical repair of the hip). An 11/10/23 admission Assessment stated the resident returned to the facility. On 5/2/24 at 11:31 a.m., the Activity Supervisor stated the resident fell in her office when it was after office hours and the door was not locked. She stated he got into the room sometime around supper and no staff were in the office at the time. On 5/2/24 at 11:36 a.m., the Business Office Manager stated normally the last person to leave the office would lock the door. On 5/2/24 at 2:08 p.m., the Administrator stated the door to the office the resident fell in was usually kept locked. He stated there were documents and items in the room and the room needed to be locked. The facility policy Falls Management System, revised 2016, stated the facility would provide an environment that remained as free of accident hazards as possible. The policy stated the facility would provide each resident with adequate supervision to prevent accidents and would provide appropriate evaluations and interventions to prevent falls. Resident Care Plans would include interventions which addressed elements determined as probable causal factors which contributed to the fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment dated [DATE] revealed Resident #13 scored a 6 out of 15 on the BIMS exam, which indicated moderately impaired cognition. The MDS revealed the resident required set up or clean up assistance with eating. The MDS revealed diagnoses of depression, schizophrenia, and non-Alzheimer's dementia. The MDS revealed a loss of 5% in one month or 10% in 6 months without a prescribed weight-loss regimen. The MDS revealed the resident took an antidepressant. The Care Plan revealed a focus area revised on 3/18/24 for dysphagia and a risk for aspiration pneumonia, excessive salivation, airway obstruction and dehydration. The interventions dated 10/19/23 revealed encourage resident to eat slowly and take small bites and small single sips and provide appropriate diet consistency as ordered. The Care Plan revealed a focus area revised on 4/25/24 for a nutritional problem related to her history of dementia, diabetes mellitus hyperlipidemia, GERD (gastroesophageal reflux disease), depressive episodes, constipation and the need for a mechanically altered diet texture. Resident at risk for weight loss related to her history of decreased appetite (significant losses noted March and April 2024). The interventions dated 3/10/24 revealed to honor food preferences and special requests as able. The resident enjoyed drinking chocolate milk, hot chocolate, orange juice, or water, which needed thickened to nectar consistency. The interventions revised on 3/10/24 revealed general/pureed, nectar thick liquid diet with provided assistance as needed. The Weight Summary revealed the following weights: a. 10/2/23 12:26 AM 131.8 Lbs b. 11/25/23 11:07 AM 129.4 Lbs c. 12/5/23 11:16 AM 128.0 Lbs d. 1/1/24 1:02 PM 124.6 Lbs e. 2/2/24 10:42 AM 121.4 Lbs f. 2/22/24 12:06 PM 121.0 Lbs g. 3/11/24 10:01 AM 117.4 Lbs h. 4/4/24 1:59 PM 113.0 Lbs On 10/02/2023, the resident weighed 131.8 lbs. On 02/23/2024, the resident weighed 117.4 pounds which is a -10.93 % Loss. On 10/02/2023, the resident weighed 131.8 lbs. On 04/04/2024, the resident weighed 113 pounds which is a -14.26 % Loss. The Physician Orders revealed the following orders: a. ordered on 3/7/24- regular diet, pureed texture, nectar consistency with small bites and sips liquid to assist for dysphagia b. start date of 3/12/24- House Supplement 60 ml - two times a day The Progress Note dated 3/12/24 at 1:34 PM, revealed the Dietician recommends adding House Supplement 60 ml (milliliter) BID (twice a day) due to weight loss. The resident representative called and notified of new order, and the doctor faxed. The Dietary Note dated 4/25/24 at 8:15 PM, revealed based on April monthly weight of 113 pounds (4/4), Resident #13 experienced significant weight losses of 9.3% x 3 mo. and 14.3% x 6 mo. She triggered for loss last month as well. The diet texture downgraded on 3/7/24. House supplement 60 ml BID between meals ordered on 3/18, and will continue this intervention. Meal intakes averaging 50-60% at meals. Noted GDR for Duloxetine ordered 4/11, which had the potential to impact appetite/intake. Care plan updated. Requested nursing notify provider of weight status. The Provider Note dated 4/11/24 lacked documentation of the resident's significant weight loss. The April MAR revealed the following dates the resident did not received the house supplement due to medication not available: a. 4/13/24 at 10:00 AM b. 4/13/24 at 2:00 PM c. 4/14/24 at 10:00 AM d. 4/14/24 at 2:00 PM e. 4/15/24 at 10:00 AM f. 4/15/24 at 2:00 PM g. 4/16/24 at 10:00 AM h. 4/16/24 at 2:00 PM i. 4/17/24 at 10:00 AM j. 4/17/24 at 2:00 PM k. 4/18/24 at 10:00 AM l. 4/18/24 at 2:00 PM m. 4/19/24 at 10:00 AM n. 4/19/24 at 2:00 PM o. 4/28/24 at 2:00 PM p. 4/29/24 at 10:00 AM q. 4/29/24 at 2:00 PM r. 4/30/24 at 10:00 AM s. 4/30/24 at 2:00 PM During an interview on 4/30/24 at 9:17 AM, the resident representative stated Resident #13 had weight loss and she had a hard time swallowing. She stated the resident didn't like the soft food and it being all mixed up, but the resident representative thought her mom was getting to used to it. During an observation on 4/30/24 at 12:24 PM, the resident served lunch of glass of water and a glass of milk. The meal served in a divided plate with pureed beans and franks in one section, and pureed Italian blend vegetables in another section. During an observation on 4/30/24 at 12:36 PM, staff came over to the resident and pushed her plate gently in front of her, and the resident shook her head sideways. The staff member left and the resident continued to drink her milk. During an observation on 4/30/24 at 12:53 PM, Resident #13 ate less than 25% of her meal, and drank her 8 ounces of milk. She didn't get served her pureed bread. During an interview on 5/1/24 at 1:43 PM, the Dietary Manager queried if the resident received any options at meals and she stated puree diets don't get options. She stated they get whatever is on the menu. The Dietary Manager asked if the resident given choices if she didn't eat what she was served and she stated she never really thought about it. The Dietary Manager asked if anyone prompted Resident #13 to eat and she stated she prompted her once or twice but she didn't think the CNA prompted her. During an interview on 5/2/24 at 1:18 PM, Staff C, RN (Registered Nurse) stated at times it was hard to get Resident #13 to eat. Staff C stated they gave her supplements to help build her weight back up. During an interview on 5/2/24 at 1:44 PM, the ARNP (Advanced Registered Nurse Practitioner) stated she didn't see Resident #13 for weight loss but her and the doctor alternate. During an interview on 5/2/24 at 2:03 PM, Staff J, stated Resident #13 felt like a hit and miss situation, sometimes the resident ate everything and other times wouldn't eat at all. Staff J didn't know if it was because of the texture or something else. She stated when the resident did eat, it took a lot of encouraging and she needed to approach her multiple times to eat. Staff J stated she thought the resident's drink were optional and they could give her cottage cheese or yogurt. During an interview on 5/2/24 at 2:51 PM, the ADON queried on Resident #13 weight loss and she stated she knew they had issues with her weight loss and tried to implement different things. She stated at one time they had issues getting her weights completed, but now they hired someone to do the weights. The ADON stated the nurse needed to put in the weights on the computer otherwise the weight loss wouldn't pop up. She stated she hoped with the nurse putting in the weights, the communication would improve with her and the provider. The ADON stated if the alert came up, the resident needed assessed earlier, and a fax needed sent at the very least. The ADON stated if the residents had a 3 pound weight loss, the doctor needed notified. The ADON asked if the resident received choices or prompted to eat her meals and she stated with Resident #13, it was difficult because they tried to assist her before and the resident wouldn't eat. The ADON stated they should probably give her choices, but if the resident not eating, she not going to eat. She stated the staff needed to least offer the residents options. 3. Review of the MDS assessment dated [DATE] for Resident #18 revealed the resident was rarely to never understood. The Physician Order dated 9/7/23 for Resident #18 revealed, an order for House Supplement three times a day for Dietary Supplement 90 ml (milliliter). Review of the resident's Medication Administration Record (MAR) dated April 2024 revealed 21 instances in the month of April when the resident's supplement was marked with a code of 11, which indicated the medication was not available. 4. The MDS assessment for Resident #34 dated 2/1/24 revealed the resident scored 00 out of 15 on a BIMS assessment, which indicated severely impaired cognition. The Physician Order dated 10/28/22 documented, an order for House Supplement three times a day 120 ml. Review of the resident's Medication Administration Record (MAR) dated April 2024 revealed 26 instances in the month of April when the resident's supplement was marked with a code of 11. During an interview conducted on 5/2/24 at 12:56 PM, the facility's Assistant Director of Nursing (ADON) queried about trouble getting the house supplement, and responded there was a time when had issues with back ordered and not being available. Per the ADON, it did take a little while to come in, and with the change of corporations and suppliers there were a few times it took longer to come in. Based on observations, clinical record review, policy review, staff interviews, family interview and resident interviews, the facility failed to develop and implement interventions to prevent/treat weight loss for 2 of 5 residents reviewed for nutrition (Residents #13 and #52) and failed to provide ordered supplements for 2 of 5 residents reviewed for nutrition (Residents #18 and #34). The facility reported a census of 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 3/27/24, listed diagnoses for Resident #52 which included dementia, adult failure to thrive, and muscle weakness. The MDS stated the resident required partial/moderate assistance with eating and listed her Brief Interview for Mental Status (BIMS) score as 7 out of 15, indicating severely impaired cognition. A Dietary Assessment, dated 3/26/24 listed the resident's weight as 97.8 lbs. The residents Weight Summary report documented the resident weighed 99.8 lbs on 3/22/24 and 93.0 lbs on 4/16/24, which calculated as a 6.81% loss. Care Plan entries, dated 3/26/24, stated the resident had the potential for altered nutritional status and directed staff to: a. provide alternate meals if she did not like the meal served; b. offer milkshakes with meals; c. provide supervision and assistance at meals as needed; d. notify the physician of significant weight changes. The Care Plan did not address the resident's weight loss and did not include additional interventions to assist the resident in gaining weight. A 4/24/24 Clinic Note did not address the resident's weight loss and stated nursing reported no concerns. The facility lacked documentation of provider notification of the resident's weight loss and lacked documentation of further interventions attempted from 4/16/24 until the start of the survey week on 4/29/24. On 4/29/24 at 4:00 p.m., observed the resident sitting in her room and a plate of food untouched in front of her. The utensils clean and had not been used. On 5/1/24 at 3:30 p.m., the Assistant Direct of Nursing (ADON) stated if a resident had a weight loss, they would start supplements and consult with the dietician and the provider. She stated she would look to see if there was any physician communication to the provider. On 5/2/24 at 10:04 a.m., the ADON stated the facility obtained an order for supplements and they implemented that nurses would document the weights. She stated she spoke with staff about providing feeding assistance to the resident. The facility policy Nutrition and Hydration to Maintain Skin Integrity, revised October 2010, stated the procedure would provide guidelines for the assessment of resident nutritional needs to aide in the development of an individualized care plan. The policy directed staff to conduct nutritional assessments for each resident as indicated by a change in condition and to define meaningful interventions for the resident at risk for or with impaired nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interviews, the facility failed to safely provide cares when turning a resident in bed which led to a fall with facial fractures for 1 of 4 residents reviewed for supervision. (Resident #1) The facility reported census was 53. Findings include: According to the Quarterly Minimum Data Set (MDS) with an assessment reference date of 5/17/23, Resident #1 had long- and short-term memory deficits and a severely impaired cognitive status. Resident #1 required extensive to total dependence of two staff with mobility, transfers, dressing, toilet use and personal hygiene needs and a diagnosis, which included Non-Alzheimer's Dementia. In an interview on on 7/25/23 at 8:17 a.m. Staff J, Certified Nurse Aide (CNA), stated on 6/8/23 she was preparing to get Resident #1 ready for supper. As was a common practice, Staff J was changing and positioning a Hoyer sling beneath her. As she rolled Resident #1 by her shoulders and waist towards her, Resident #1 was stiff and pushed up against her and then without notice let go and began sliding off of her bed. Staff J stated she tried to stop her, but she fell onto the floor injuring herself. Staff J stated she had been an aide for ten years and had never known differently that one person couldn't position a sling under a resident unless specifically indicated on the care plan. Staff J stated she was instructed by the facility that what she did was an acceptable practice at the facility but was unable to identify who told her. In an interview on 7/31/23 at 10:24 a.m. Staff Q, Licensed Practical Nurse (LPN), stated on 6/8/23 at around 5:00 p.m. she was in the 300/400 hall nurse's station when Staff J, CNA approached her stating she had screwed up. Staff J stated Resident #1 had rolled out of her bed onto the floor. Staff Q immediately responded and when she entered the room saw Resident #1 on the floor and knew she would need help. Staff Q ran and got Staff P MDS Coordinator and Staff F, ADON, then called 911 before returning to Resident #1's room and assisting with care. Staff J stated she had rolled Resident #1 from her stomach to her back, before getting help and stated she was attempting to position a Hoyer sling beneath her when she rolled and fell to the floor. According to Resident #1's Plan Of Care she is unable to complete activities of daily living due to her cognitive status and weakness with interventions which include completing bed mobility, toileting hygiene, dressing and mechanical lift transfers with two person assist. According to Resident #1's Bedtime [NAME] Report under resident care, Bed Mobility, Resident #1 is able to complete bed mobility with two staff assistance. In an interview on 7/25/23 at 3:32 p.m. Staff I, CNA, stated she was assigned 300 hall and Staff J was assigned 400 hall on 6/8/23 and together they would help one another with the two person residents. That evening supper had started and Staff J had not started getting her residents to supper yet. Staff I stated she had been getting residents to the dining room and stayed in the dining room to help with feeding and told Staff J to call her when she needed help. The next thing she knew an ambulance was arriving. Staff I stated it did not need to happen if Staff J had just called for help. In an interview on 7/26/23 at 10:40 a.m. Staff P, MDS coordinator, stated Resident #1 was coded as an extensive assistance of two people with mobility due to her decline and contracture status making her unsafe to move by yourself. This level of assistance needed is also reflected in the care plan. Staff P stated some residents are coded as a two person assist for mobility on the MDS, but on the care plan they may only be an assist of one noting those residents are felt to be safe to move by one person. However, regardless of their mobility status, all residents who are a two-person mechanical lift transfer requires two staff to be moved, including positioning the sling underneath the resident prior to the lift. Staff P indicated there was no facility policy clarifying the need for a second staff person when positioning the sling, but that has always been their expectation. Staff P stated in the case of Resident #1's fall on 6/8/23, she was care planned as a two person assist with mobility and the staff failed to have the second person present while positioning the sling at the time of the fall. In an interview on 7/25/23 at 3:10 p.m. Staff F, Assistant Director of Nursing, stated Resident #1 was a large-women, was stiff and sometimes resisted with cares and that is why she was determined as needing two-person assist with bed mobility. Staff F stated she would normally consider bed mobility in the context of repositioning, but admits positioning a sling beneath her, requires her being rolled. Staff F stated they train their aides to use two people when positioning a sling beneath a resident in bed, but notes there is no policy. The facilities Orientation for Agency CNAs form indicates: #2 You will partner with another aide for your two-person transfers after cares are completed. #4 Mechanical Lifts-there must be two people whenever using a mechanical lift (either a standing lift or a full body lift). No exceptions. Make sure the leg strap is secured when utilizing a standing lift. During observations on 7/26/23 at 4:46 p.m. P and Staff F accompanied surveyor to Resident #1's old room and demonstrated the height and positioning of the bed when they arrived into the room following her fall on 6/8/23. The bed was positioned with the left side against the wall and the bed height was 29 inches to the top of the mattress. Ambulance Report dated 6/8/23 with dispatch time of 5:09 p.m. indicated resident observed on floor following a fall with a large laceration/avulsion to her forehead across most of her forehead, blood and an abrasion on her left eye just below the eye on her lower eye lid and a tear on her upper lip under her nose and going up along the left side of her nose. Resident reportedly slipped off the side of bed onto her face as a staff member was attempting to position a Hoyer lift sling under her. According to the Emergency Department report, a CT scan noted nondisplaced right occipital condyle (base of the skull, above C1 vertebrae) fracture and nondisplaced angulated nasal bone fractures. According to Major Injury Determination form Resident #1 sustained a major injury, noting a fractured nasal bone and right condyle occipital fracture. According to the facilities investigative conclusion for incident that occurred on 6/8/23 at approximately 5:00 p.m., after review of the incident and review of statements of the certified nurse aides involved and other staff present, it is apparent that Staff J, who had previously worked with Resident #1 and knew that two staff were needed for bed mobility and transfers, chose not to wait for additional staff prior to doing bed mobility and care. Staff were present and available to assist. Staff J also had previous knowledge Resident #1 and how she transferred, yet chose to proceed without any assistance resulting in a fall from the bed onto the floor. Resident #1 sustained injuries related to this incident. Staff J had everything needed to perform the task safely; experience and knowledge of the resident and available staff assistance.