**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to implement the intervention of the use of a mechanical lift for one (1) of three (3) sampled residents, Resident #39. The facility assessed Resident #39 and care planned the resident to require the use of a mechanical lift (an assistance device used to transfer residents from one (1) surface to another who required support more than the manual support provided by caregivers alone) with two (2) staff assisting. However, on 02/06/2024, State Registered Nurse Aide (SRNA) #8 and Licensed Practical Nurse (LPN) #1 transferred Resident #39 from the bed to the Geri chair (geriatric, a large padded chair with a wheeled base designed to assist patients with limited mobility) then later from the Geri chair to the bed without the use of the mechanical lift. The following day, LPN #2 assessed Resident #39 to have external rotation to his/her right lower extremity, and the resident was subsequently found to have a femur and vertebra fracture. The findings include: Review of the facility's policy, Comprehensive Care Plans, last reviewed 11/30/2021, revealed the facility must develop and implement a comprehensive person-centered care plan (CCP) for each resident, consistent with residents' rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. Further review revealed the care planning process would include an assessment of the resident's strengths and needs and incorporate the resident's personal and cultural preferences in developing goals of care. Additional review revealed that qualified staff responsible for carrying out interventions specified in the care plan would be notified of their roles and responsibilities for carrying out the interventions, initially and when changes were made. Review of the facility's policy titled, Care Plan Policy & Procedure, reviewed 01/31/2024, revealed care plans were put in place to ensure safety, quality, and individual care for residents. Per policy review, staff members were expected to follow the resident's care plan when providing care. Review of Resident #39's admission Record revealed the facility admitted the resident on 10/05/2022 with diagnoses including unspecified sequelae of cerebral infarction, muscle weakness, and unspecified dementia. Review of Resident #39's most recent Minimum Data Set (MDS) assessment was a Significant Change Assessment, dated 02/01/2024, and indicated that the resident was dependent for chair/bed-to-chair transfers. Review of Resident #39's Quarterly Minimum Data Set (MDS) Assessment, dated 01/04/2024, revealed chair/bed-to-chair transfer was rated as not attempted due to medical condition or safety concerns. Review of Resident #39's Comprehensive Care Plan history revealed the Minimum Data Set (MDS) Coordinator updated the care plan interventions for transfers on 01/22/2024 to total care with a two (2) staff assist with mechanical lift and Geri chair. Review of Resident #39's [NAME], or nurse aide care plan, revealed it was undated and included the requirement for total care with two (2) staff assistance with a mechanical lift and Geri chair. Review of Resident #39's Progress Note, dated 02/07/2024 at 10:45 AM, revealed the Hospice State Registered Nurse Aide (SRNA) asked LPN #2 to look at Resident #39's right leg because it looked abnormal. Further review revealed LPN #2 stated she went immediately to the room, performed an assessment, and noted Resident #39 had facial grimacing and moaning when his/her right leg was moved. Continued review revealed the resident's right leg appeared to be rotated outwardly. Additional review revealed LPN #2 notified the Advanced Practice Registered Nurse (APRN), who gave an order to obtain x-rays. The facility transferred Resident #39 to the local hospital via Emergency Medical Services. Review of Resident #39's Discharge Summary from the local hospital, dated 02/07/2024, revealed Resident #39 had sustained an intertrochanteric comminuted fracture (bone was broken in at least two (2) places) to the right proximal femur and a thoracic eleven (T11) vertebral fracture. Further review revealed the age of the T11 fracture was indeterminate, although it was new since the last imaging he/she had undergone. However, there was no reference given for that date. Further review revealed Resident #39 was discharged back to the facility. During interview with SRNA #8 on 02/20/2024 at 2:34 PM, she stated for a resident transfer, she asked the aide from the previous shift, she would receive that instruction from the nurse, or she would check the care plan. In further interview, she stated most residents required either a one (1) or two (2) person assist. SRNA #8 stated there had never been an issue with the care plan not being clear. During additional interview with SRNA #8 on 02/20/2024 at 5:10 PM, she stated she got Resident #39 up with Licensed Practical Nurse (LPN) #1. The SRNA stated they did not use a mechanical lift on 02/06/2024 because the resident's room was being deep cleaned. She also stated she and another aide transferred Resident #39 back to bed the same way. SRNA #8 stated she later learned Resident #39 was supposed to be transferred by using the mechanical lift. During interview with LPN #1 on 02/20/2024 at 3:13 PM, she stated when determining a resident's transfer status, she looked at the [NAME], the aide care plan, because it was a quick view. During additional interview with LPN #1 on 02/20/2024 at 5:47 PM, she stated SRNA #8 came to her for help with transferring Resident #39 on 02/06/2024, and they just picked the resident up from the bed by his/her pants and moved the resident over to the chair. She stated she and the aide bore the weight. LPN #1 stated Resident #39 did not fall during the transfer nor was he/she dropped. During additional interview with LPN #1 on 02/21/2024 at 11:52 AM, she stated Resident #39 had been transferred with a lift before but then was changed to extensive assist with two (2) staff. She stated she was told after the incident that the care plan was changed to mechanical lift for transfers in late January 2024, but she had not been aware of this. During interview with Registered Nurse (RN) #3 on 02/21/2024 at 10:50 AM, she stated she saw Resident #39 on the Monday prior to the incident, and his/her status remained at baseline, with no evidence of pain or external rotation. During interview on 02/22/2024 at 9:09 AM with Occupational Therapist (OT) #1, she stated if a resident was being transferred from the bed to a Geri chair, it should be done using a mechanical lift device or some type of a slider board for assistance to ensure the safety of the residents. During interview with the Minimum Data Set (MDS) Coordinator on 02/22/2024 at 10:59 AM, she stated Resident #39 had been placed on Hospice care in January 2024 and that led to the Significant Change assessment on 02/01/2024. She stated the expectation was that any changes on the MDS assessment from the previous one would be updated on the care plan. During interview with the Director of Nursing (DON) on 02/21/2024 at 3:16 PM, she stated newly admitted residents received therapy screening and that helped determine their activities of daily living (ADL) abilities. She also stated safe transfers could be based on nursing judgment as well. The DON stated nurses built the baseline care plan at admission, and the ADLs transferred automatically from the care plan to the [NAME] if the nurse tagged it. The DON stated her expectation was that staff reviewed care plans prior to a shift. She stated the care plan was key to providing guidance on care, and the care plan should be updated with changes. The DON stated SRNA #8 knew he/she was supposed to use the mechanical lift. She also stated her expectation was that staff would check the [NAME] to confirm transfer status prior to transferring. During interview with the Administrator on 02/21/2024 at 3:51 PM, she stated nurses used their judgment in assessing residents' needs, such as transfers. She stated it was possible for staff to print the [NAME] to one (1) page in order to have a reference in hand. The Administrator stated she expected nurses to update care plans in real time and add an intervention that staff reviewed the next day in morning meeting. She stated the bottom line was nursing staff members were expected to look at the care plan. The Administrator stated updates to the care plan went to the [NAME] immediately, if the nurse tagged the update. She stated the elements marked with a K in the care plan had been tagged for the [NAME]. She stated following the care plan was important because it protected the residents. During subsequent interview with the Administrator on 02/22/2024 at 8:43 AM, she stated the shower sheet or hall sheet listed transfer status and other ADL requirements. She stated there were separate sheets for aides and nurses, and they could use the sheets but were supposed to go to the care plan or [NAME]. Also, she stated nurses could run a multiple day report on their residents, and the aides had a dashboard on Point Click Care (PCC, a software program) and could print those. She stated aides could also print their task sheets to have a paper guide as well as the computer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the use of assistance devices to prevent injury for one (1) of three (3) sampled residents (Residents #39). On 02/06/2024 staff transferred Resident #39 from the bed to chair then back to bed without using a mechanical lift (an assistance device used to transfer residents from one (1) surface to another who required support more than the manual support provided by caregivers alone). Resident #39 sustained an intertrochanteric comminuted fracture (the bone was broken in at least two (2) places) to the right proximal femur and a fracture to the thoracic (T)11 vertebrae. The findings include: Review of the facility's policy, untitled, revised 12/17/2023, revealed it was the facility's policy to assess and help to accommodate residents with activities of daily living (ADL). Further review revealed ADLs would be assessed and documented according to the needs of the individual resident, and ADLs would be care planned and updated as needed. Continued review revealed staff would accommodate the resident with ADLs based on needs. Review of the facility's policy titled, Care Plan Policy & Procedure, reviewed 01/31/2024, revealed care plans were put in place to ensure safety, quality, and individual care for residents. Per policy review, staff members were expected to follow the resident's care plan when providing care. Review of Resident #39's admission Record revealed the facility admitted the resident on 10/05/2022 with diagnoses including unspecified sequelae of cerebral infarction, muscle weakness, and unspecified dementia. Review of Resident #39's Quarterly Minimum Data Set (MDS) Assessment, dated 01/04/2024, Section GG, Functional Abilities and Goals, Subsection E Mobility, revealed chair/bed-to-chair transfer was rated as not attempted due to medical condition or safety concerns. Review of Resident #39's Significant Change in Status MDS Assessment, dated 02/01/2024, Section GG, Functional Abilities and Goals, Subsection E Mobility, revealed chair/bed-to-chair transfer was rated dependent. Review of Resident #39's care plan revealed transfers required total care with a two (2) staff assist with a mechanical lift to the Geri-chair (geriatric, a large padded chair with a wheeled base designed to assist patients with limited mobility). The intervention was added by the Minimum Data Set (MDS) Coordinator on 01/22/2024. Review of Resident #39's [NAME] (nurse aide care plan) revealed under Transferring, that transfers required total care with a two (2) staff assist with a mechanical lift to the Geri-chair. This intervention was tagged to the [NAME] from Resident #39's care plan intervention added by the MDS Coordinator on 01/22/2024. Review of Resident #39's Point Click Care (PCC, a software program used for charting) record, dated 02/06/2024 at 3:37 PM, revealed documentation that Resident #39 was transferred with total dependence-full staff performance. Review of Resident #39's Progress Note, dated 02/07/2024 at 10:45 AM, revealed the Hospice State Registered Nurse Aide (SRNA) asked Licensed Practical Nurse (LPN) #2 to look at the resident due to the resident's right leg looking abnormal during his/her bath. LPN #2 stated she went immediately to the room and performed an assessment and noted Resident #39 had facial grimacing and moaning when the right leg was moved. Per the note, the resident's right leg appeared to be rotated outwardly. The nurse stated she notified the Advanced Practice Registered Nurse (APRN), obtained instructions to send the resident to the emergency department for X-Rays if the family was agreeable. The note stated the Director of Nursing (DON) notified Resident #39's family, and Emergency Medical Services (EMS) transported the resident to the hospital. Further review of Resident #39's Progress Note, dated 02/07/2024 at 3:32 PM and written by LPN #2, stated the hospital had informed LPN #2 that Resident #39 had a right femur fracture and was awaiting a treatment decision from the family. Continued review of a note, dated 02/07/2024 at 5:16 PM, revealed the ED staff called report to the facility, which included Resident #39 had a T11 (thoracic eleven) vertebral compression fracture and a comminuted intertrochanteric fracture of the right proximal femur. In addition, a note, dated 02/07/2024 at 5:48 PM, revealed Resident #39 was returned to the facility by ambulance. Review of Resident #39's Emergency Department Discharge summary, dated [DATE], revealed he/she had sustained an intertrochanteric comminuted fracture to the right proximal femur and a T11 fracture. Further review revealed the age of the T11 fracture was indeterminate, although it was new since the last image (no date) he/she had undergone. In an interview with State Registered Nurse Aide (SRNA) #8 on 02/20/2024 at 2:34 PM, she stated she started at the facility in January 2024. She stated in the beginning of employment she would ask the previous aide how a resident transferred. SRNA #8 stated she would be told by the nurse, or she would check the care plan for information on what the resident required for transfers. She stated most residents were either a one (1) or two (2) person assist. She stated she would ask another aide if there was a question about how to care for a resident. In another interview with SRNA #8 on 02/20/2024 at 5:10 PM, she stated she got Resident #39 up with Licensed Practical Nurse (LPN) #1 on 02/06/2024. She further stated they got the resident up on the side of the bed, and the Geri-chair was pulled up to the side of the bed. She stated she could not say they stood the resident up with the resident bearing weight. She stated she did not think Resident #39 moved his/her feet. The SRNA stated they lifted under Resident #39's arms and by his/her pants, with up, over, and turn movements. SRNA #8 stated it was like stand and pivot, but she and LPN #1 bore the weight. She stated they did not use a gait belt. The SRNA denied that Resident #39 was dropped or hit his/her leg on anything. She stated she and the Quality Assurance Manager transferred Resident #39 back to bed the same way. SRNA #8 stated the Quality Assurance Manager was passing by the room and tried to help her situate Resident #39 with pillows, then they reported the discomfort to LPN #1 at the nurse's station. SRNA #8 stated she later learned Resident #39 was supposed to be transferred by the mechanical lift. In an interview with Licensed Practical Nurse (LPN) #1 on 02/20/2024 at 3:13 PM, She stated when determining a resident's transfer status, she looked at the [NAME]. She stated on admission she did an assessment and got a Physical Therapy (PT) consult. In additional interview with LPN #1 on 02/20/2024 at 5:47 PM, she stated SRNA #8 came to her for help with transferring Resident #39 on 02/06/2024. She stated Resident #39 was being moved out of the room so the room could be deep cleaned. She stated Resident #39 was prone to lean and did not ambulate, and Resident #39 used the Geri chair when out of bed. She stated that day, they just picked him/her up from the bed by his/her pants and moved the resident over to the chair. She stated she and the aide bore the resident's weight. She stated she frequently used the [NAME] because it was a quick view. She stated Resident #39 was not fussy or agitated until going to the dining room later that day. She stated the agitation occurred after Resident #39 was sat up vertically to eat. She stated once the resident was taken out of the dining room and tilted back in the chair, he/she was quiet as a mouse and did not seem to be in pain. She stated she thought the resident did not want to eat in the dining room, as he/she normally took meals in his/her room. She stated Resident #39 did not fall during the transfer nor was he/she dropped. In additional interview with LPN #1 on 02/21/2024 at 11:52 AM, she stated Resident #39 had been transferred with a lift before and then was changed to extensive assist with two (2) staff. She stated she was told after the incident that the care plan had been changed to requiring a mechanical lift for transfers in late January 2024, but she had not been aware of this. In an interview with the Hospice Registered Nurse (RN) on 02/21/2024 at 10:50 AM, she stated she saw Resident #39 on the Monday prior to the incident, and all Resident #39's assessments remained baseline, with no evidence of pain or external rotation of the right leg. The Hospice RN further stated Resident #39 was frequently agitated during any care, and they had a conference about interventions for this incident but had not had evidence of chronic pain or anxiety aside from that. Observation of Resident #39's skin on his/her right side with the Hospice Nurse on 02/21/2024 at 10:50 AM, revealed no signs of new or healing bruising. In an interview with the Occupational Therapist (OT) on 02/21/2024 at 12:38 PM, she stated she had been an OT for seventeen (17) years and had worked at the facility since April 2023. She stated all residents got an evaluation upon admission, depending on the admission criteria and the discharging facility. The OT stated if the family was in the room, she would ask them the residents. She stated the OT determined if they needed a walker, wheelchair, bedside commode, raised toilet seat, a reacher, and how many assists they needed to move. She stated if the residents needed equipment, the OT could get the equipment for them immediately if it was in the supply shed. She stated she also made recommendations on the assist level. During the interview, the OT stated that she evaluated how many assists the residents needed and if they needed cueing. The OT stated she scored the residents on each section evaluated. She stated extensive assist meant the resident could only assist twenty-five percent (25%) to help move him/her or complete the activity; moderate assist was fifty percent (50%). The OT stated if the residents were a maximum assist with two (2) staff, then they needed a mechanical device because they could not help or complete at all without totally relying on aid. In another interview with the OT on 02/22/2024 at 9:09 AM, she stated there had been a few instances where the OT would recommend a Geri chair for a resident's use. The OT stated the determination for need was based on how dependent the resident was; if the resident was having difficulty sitting up or could not use his/her arms to push up; and if the resident had rigidity in his/her lower body. She stated the resident must be dependent on assistance to have a Geri chair recommended. The OT stated, in her opinion as an OT, if a resident was being transferred from the bed to a Geri chair, it should be done using a mechanical lift device or some type of a slider board for assistance. In an interview with the Minimum Data Set (MDS) Coordinator on 02/22/2024 at 10:59 AM, she stated she had been the MDS Coordinator for about a month. She stated Resident #39 had been placed on Hospice care in January 2024, but the Significant Change in Status Assessment had not been completed by staff. She stated the Regional MDS Nurse and the facility's Director of Nursing (DON) had informed her it was missed in January 2024, so she completed it on 02/01/2024. In an interview with the Emergency Department Physician on 02/20/2024 at 2:35 PM, he stated he felt Resident #39's fractures were not from physical abuse as there was no bruising. He stated the ED's call to Adult Protective Services (APS) was because the resident was non-ambulatory, bedridden, and sustained a hip fracture. He stated his best guess was that somebody was trying to transfer the resident and just dropped him/her on the hip; or, he/she slipped, based on the hip fracture and thoracic spine fracture. He stated an acute axial load on the pelvis/bottom went straight up the spine and was the most common source of a vertebral thoracic fracture. In an interview with the Medical Director on 02/20/2024 at 4:06 PM, he stated he had talked to the Hospice Nurse, who found Resident #39 with a shortened right leg, and the Director of Nursing (DON), whom the nurse/aide told that they had the resident stand and pivot rather than use the lift. He stated he did not know if there was any withheld information, but Resident #39 did sustain a compression fracture. He stated Resident #39's fracture looked more like a high energy impact, but the resident was frail, and there was no other evidence of a fall. In an interview with the Director of Nursing (DON) on 02/21/2024 at 3:16 PM, she stated newly admitted residents received therapy screening and that helped determine activities of daily living (ADL) abilities. She also stated what defined a safe transfer could be based on nursing judgment as well. The DON stated SRNA #8 knew he/she was supposed to use the lift. The DON stated she suspected when staff members transferred Resident #39 that the resident's right leg did not pivot. She also stated her expectation was that staff would check the [NAME] to confirm transfer status prior to transferring the resident. In an interview with the Administrator on 02/21/2024 at 3:51 PM, she stated nursing judgment was used for assessing residents' needs, such as transfers. She stated therapy conducted screening for newly admitted residents, and therapy might bring evaluations to the interdisciplinary team (IDT) to make a recommendation for a resident to use a lift for transfers. She stated the IDT included the Administrator, Director of Nursing, Quality Assurance Manager, Social Services Director, and Minimum Data Set Coordinator. In additional interview with the Administrator on 02/22/2024 at 8:43 AM, she stated the shower sheet/hall sheet would list things like transfer status, whether residents required feeding assistance or other ADL requirements. She stated leaders used these for training new employees. She stated active employees used the sheet but were supposed to go to the care plan/[NAME] for information on resident care. The Administrator stated there was a different sheet for aides or nurses that they could make notes on and carry with them. She stated the nurses' sheet was kept on the medication cart, as well as the 24 hour report. Also, she stated nurses could run a multiple day report on their residents, and the aides had a dashboard on Point Click Care (PCC) and could print those. She stated aides could also print their task sheets to have a paper guide as well as the computer. The Administrator stated staff could not use mechanical lifts with residents until they had taken and passed a skill competency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #26's Face Sheet revealed the facility admitted the resident on 07/02/2020 with diagnoses including hemiplegia (paralysis) of left side of the body, chronic kidney disease, and type 2 diabetes. Review of Resident #26's Quarterly MDS Assessment, dated 11/30/2023, revealed the facility assessed the resident's cognition with a BIMS score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. a. Review of Resident #26's Care Plan, dated 12/03/2023, revealed the facility assessed the resident as having left sided paralysis and listed interventions including: reposition as tolerated with every care round and encourage the resident to be up in a chair daily. Observation on 01/09/2024 from 9:30 AM to 11:45 AM revealed no staff entered Resident #26's room during this time to reposition Resident #26. Observation on 01/07/2024 at 2:43 PM of Resident #26's room revealed there was no chair available for the resident to sit in. In an interview on 01/07/2024 at 2:43 PM, Resident #26 stated staff did not routinely reposition him/her, but occasionally a staff member would place a pillow in different positions for offloading. Per interview, Resident #26 stated he/she did not refuse repositioning as long as he/she could still reach his/her personal items. In further interview, Resident #26 stated he/she would like to sit in a recliner on the days he/she did not go to dialysis, but the facility told him/her that he/she could not have a recliner due to not having enough space in his/her room. b. Review of Resident #26's Care Plan, dated 12/03/2023, revealed the facility identified the resident had a left hand contracture and listed the intervention to place a splint to the left hand for up to four (4) hours per day as tolerated. Review of the facility's document Nursing Rehab, dated 12/13/2023 through 01/11/2024, revealed staff members charted they applied the splint on three (3) occasions during that time frame. The rest of the days, staff marked not applicable for this task. Observation on 01/07/2024 at 2:43 PM revealed the splint was available on Resident #26's bedside table. In an interview on 01/07/2024 at 2:43 PM, Resident #26 stated staff had only applied the splint to his/her left hand contracture two (2) or three (3) times in the last month. In an interview on 01/10/2024 at 1:15 PM, State Registered Nurse Aide (SRNA) #4 stated she did not know Resident #26 had a splint that staff members were to apply to his/her contracted hand every day. In an interview on 01/10/2024 at 3:31 PM, LPN #2 stated she was not aware of Resident #26's need for a splint and had not applied it to the resident at any time. In an interview on 01/11/2024 at 4:08 PM, the DON stated Resident #26 reported to her on 01/09/2024 that staff had not applied his/her brace to his/her contracture. Per interview, the DON stated she believed staff members needed additional education to ensure they knew how to access residents' care plans. In an interview on 01/11/2024 at 5:30 PM, the Administrator stated she did not know why staff failed to apply the splint as described in Resident #26's Care Plan but stated she did expect staff to implement care planned interventions. Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for three (3) of thirty-seven (37) sampled residents (Residents #29, #12, and #26). Resident #29 sustained a laceration to the chin requiring six (6) sutures on 02/21/2023 when the bed the resident was in was not locked and rolled causing the resident to fall while receiving care per one (1) persons assistance when the resident was assessed and care planned for two (2) person assist. Resident #12 sustained nine (9) documented falls from 09/24/2023-01/05/2024 with six (6) documented active interventions on his/her fall care plan, none of which were dated. There was no care plan for monitoring psychotropic medications for side effects. Resident #26's care plan was not specific regarding how often staff should round. Resident #26 was ordered and care planned a splint for his/her left hand, which was not observed, and the resident reported it had not been applied in months. The findings include: Review of the facility's policy, Care Plan Policy and Procedure, dated 08/13/2023, revealed the facility would maintain an up-to-date plan of care on each resident with a procedure to include the Interdisciplinary Team (IDT) or Licensed Nurse to be responsible for updating the plan of care as changes in individual care needs occurred. Further review revealed the care plan was the primary instrument used to meet the objectives for each resident, and the focused approach sought favorable outcomes. 1. Review of Resident #29's Electronic Health Record (EHR) revealed the facility admitted the resident on 03/04/2022 with diagnoses that included unspecified dementia without behavioral disturbance, need for assistance with personal care, and other reduced mobility. The facility assessed Resident #29, in a Quarterly Minimum Data Set (MDS) Assessment, dated 07/20/2023, as severely cognitively impaired and requiring extensive assist of two (2) with bed mobility and with incontinence care. Review of Resident #29's Comprehensive Care Plan, last reviewed 10/17/2023, revealed the resident was care planned for two (2) person assist with toileting and bed mobility, but these interventions were undated. Resident #29 was also care planned for transfers with a mechanical lift, which was also undated. Review of Resident #29's Fall Report, dated 12/21/2023, revealed Resident #29 had a fall with injury on 12/21/2023 at 7:00 PM while a State Registered Nurse Aide (SRNA) was assisting the resident with incontinence care. Per the report, the resident rolled out of bed before the SRNA could stop the resident. The report stated Resident #29 was sent to the emergency room and required six (6) stitches to repair a laceration to his/her chin. Interview on 01/11/2024 at 8:01 AM with SRNA #6, she stated she was working on 12/21/2023 with Resident #29. She stated she was going to give Resident #29 care and had never had any problem changing him/her before. SRNA #6 stated she was changing Resident #29 and did not realize the bed was not locked. She stated in her four (4) years working at the facility, nothing like that had ever happened. The SRNA stated the bed rolled when she turned to get wipes, Resident #29 became unstable, and the resident fell too fast for her to prevent the fall. SRNA #6 stated Resident #29 immediately became a two (2) person assist after that. She also stated she now always checked to ensure beds were in the locked position before providing any kind of care. SRNA #6 was unaware of Resident #29 being assessed as requiring extensive assist of two (2) with bed mobility and with incontinence care previously. In an interview with SRNA #4 on 01/10/2024 at 1:15 PM, she stated resident care plans or the [NAME] were not documented in the SRNA care plans on the computer, and usually the nurses just told the SRNAs about resident care during shift change report. SRNA #4 stated she had been informed Resident #29 was a one (1) person assist, and was unaware of Resident #29 being assessed and care planned as two (2) assist prior to the 12/21/2023 fall. In an interview with SRNA #23 on 01/10/2024 at 2:48 PM, she stated if she had questions about how a resident transferred or toileted, she either asked the other SRNAs or the charge nurse. She stated there was an aid [NAME] on the computer where she did her charting. However, she stated she had never seen it but knew where to look for it. She stated she mainly got her resident information on rounds from the previous shift staff. During an interview with Licensed Practical Nurse (LPN) #2 on 01/10/2024 at 3:32 PM, she stated she believed Resident #29 was a one (1) person assist with changing, but was not certain as she had not worked with Resident #29 recently. In interview with the Director of Nursing (DON) on 01/11/2024 at 4:18 PM, she stated she would expect staff to ensure care plan interventions were implemented and care plans would be referenced by all staff before providing care. She state, she noted the intervention for two (2) person assistance in the notes section and SRNA #6 should have asked for assistance prior to providing toileting care and bed mobility for Resident #29. 2. Review of Resident #12's Face Sheet revealed the facility admitted the resident on 08/08/2023 with diagnoses of unspecified dementia with agitation, muscle weakness, and unsteadiness on his feet. Review of Resident #12's admission Minimum Data Set (MDS) Assessment, section C for cognition, dated 08/15/2023, revealed a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15), indicating severe cognitive impairment. Review of Resident #12's admission MDS Assessment, dated 08/08/2023, section GG, revealed Resident #12 used a walker and a wheelchair for mobility; and needed assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury. Resident #12 also needed assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury; and as needing assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury. Review of Resident #12's Quarterly MDS Assessment, section C for cognition, dated 11/15/2023, revealed a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating severe cognitive impairment. Review of Resident #12's Quarterly MDS Assessment, dated 11/15/2023, section GG, revealed there were no changes to Resident #12's functional ability since the admission MDS Assessment, dated 08/08/2023. Review of Resident # 12's Comprehensive Care Plan (CCP) for falls, last reviewed 11/16/2023, revealed Resident #12 was at risk for and had falls related to gait and balance problems, psychoactive drug use, decreased safety awareness, and cognitive impairment. The documented goal was for Resident #12 to be free of injury from falls through the target date of 02/14/2024. Documented active interventions, all undated and unclear as to which fall the interventions were in response to, included encourage resident to use the call light for assistance as needed, encourage resident to wear non-skid footwear when ambulating as the resident allowed, encourage resident to toilet before/after meals, encourage use of assistive device, walker to promote independence when ambulating, physical therapy as ordered, and Resident #12 needed a safe environment with floors free from spills and/or clutter, adequate glare free lighting, a working and reachable call light, the bed in low position at night and personal items within reach. Three (3) additional undated interventions included: follow the facility's fall protocol, encourage Resident #12 to participate in activities that promoted exercise, physical activity for strengthening and improved mobility such as Sittercise. Resident #12 needed activities that minimized the potential for falls while providing diversion and distraction were marked as resolved on 12/10/2023. Review of Resident #12's Clinical Orders, dated 08/08/2023, revealed an active order for Seroquel (an antipsychotic medication which side effects included dizziness and faintness and lightheadedness when getting up from a lying or a sitting position). The order was for a Seroquel twenty-five milligram (25 mg) tablet to be given by mouth two (2) times a day and a Seroquel three-hundred milligrams (300 mg) tablet to be given by mouth at bedtime. Review of Resident #12's CCP revealed no care plan had been developed for the use of a psychoactive medication and the monitoring for adverse side effects. Review of the facility's document Incidents by Incident Type, printed on 01/09/2024, revealed Resident #12 sustained nine (9) falls on the following dates: 09/24/2023 at 10:58 PM, 09/24/2023 at 11:53 PM, 10/15/2023 at 7:28 PM, 10/28/2023 at 8:25 AM, 12/05/2023 at 5:55 PM, 12/30/2023 at 2:04 AM, 01/01/2024 at 9:44 AM, 01/03/2024 at 7:45 AM, and 01/05/2024 at 1:05 PM. a. Review of Resident #12's Fall Incident Report, dated 09/24/2023 at 10:58 PM, revealed Resident #12 was found kneeling at the bedside. Resident #12 was documented to have stated he/she was trying to get up and here I am on the floor. No injuries were observed, and it was documented no witnesses were found. No immediate intervention was identified to place on the CCP. b. Review of Resident #12's Fall Incident Report, dated 09/24/2023 at 11:53 PM, revealed Resident #12 was found sitting on the floor in front of the sink and had stated he/she was walking to the sink to empty a pitcher of water, lost his/her balance, and fell hitting the wall with his/her left arm. No injury was documented, and it was documented no witnesses were found. No immediate intervention was identified to place on the care plan. c. Review of Resident #12's Fall Incident Report, dated 10/15/2023 at 7:28 AM, revealed Resident #12 was found on the floor beside the bed, and the resident stated he/she rolled out of bed. A small abrasion was noted to the back, left side of Resident #12's head. No immediate intervention was identified to place on the care plan. d. Review of Resident #12's Fall Incident Report, dated 10/28/2023 at 7:28 AM, revealed Resident #12 was found with his/her head on a pillow on the floor, and the resident's waist/legs remained on the bed. Resident #12 stated he/she leaned over and rolled off the bed. No injuries were noted. No immediate intervention was identified to place on the care plan. e. Review of Resident #12's Fall Incident Report, dated 12/05/2023 at 5:55 PM, revealed Resident #12 was found sitting on the floor beside the bathroom door. Resident #12 stated he/she was coming from the bathroom and lost his/her balance. Resident #12 had his/her walker nearby but did not have shoes on. No injuries were noted. No immediate intervention was identified to place on the care plan. f. Review of Resident #12's Fall Incident Report, dated 12/30/2023 at 2:04 PM, revealed Resident #12 was lying on the floor next to the bed with his/her head toward the foot of the bed and facing the wall, and it appeared his/her feet were tangled up in the blanket. No injuries were noted. No immediate intervention was identified to place on the care plan. g. Review of Resident #12's Fall Incident Report, dated 01/01/2024 at 9:44 AM, revealed Resident #12 attempted to get out of bed without assistance, did not use the call light, had regular socks on, and stated he/she slid out of the bed. No injuries were noted. No immediate intervention was identified to place on the care plan. h. Review of Resident #12's Fall Incident Report, dated 01/03/2024 at 7:45 AM, revealed Resident #12 was found lying on the floor next to his/her bed on his/her left side. Resident #12 was unable to give a description of what happened. No injuries were noted. No immediate intervention was identified to place on the care plan. Further review of Resident #12's Fall Incident Report, the notes section dated 01/04/2024, revealed Resident #12's recent increase in falls was discussed and therapy would assess and adjust the plan of care accordingly to decrease the risk of future falls. However, no adjustments to the plan of care were observed on Resident #12's CCP for Falls. i. Review of Resident #12's Fall Incident Report, dated 01/05/2024 at 1:05 PM, revealed Resident #12 was found lying on the floor in front of the nurses' station on his/her right side with his/her right arm at a natural angle behind his/her head and both legs bent at the knees. Resident #12 stated that he/she did not know why he/she fell. Further review of Resident #12's Fall Incident Report, the notes section dated 01/08/2024, revealed Resident #12 was sent to the hospital emergency department for evaluation related to complaints of neck pain and returned with no new orders or acute injury notes. The note further documented, upon review of Resident #12's fall history, it was noted the majority of his/her falls occurred during or within an hour or two (2) of mealtimes, so staff would encourage Resident #12 to toilet before/after meals in an attempt to decrease falls. This intervention appeared on Resident #12's CCP but was undated and unclear as to which fall it was in response to. In an interview on 01/10/2024 at 3:31 PM with Licensed Practical Nurse (LPN) #2, she stated an intervention was put in place after each fall on the resident's care plan and asked, Isn't that an MDS kind of thing? When asked if she knew how to tell if a resident was care planned as a fall risk, she stated she would have to look that up. LPN #2 stated nurses were made aware of resident care needs through verbal report and through the care plans which were on the computer. She stated if something changed with a resident's care, she communicated that to the staff on the floor verbally. In an interview on 01/11/2024 at 3:30 PM with the MDS Nurse, she stated she had been in that role since Monday but had been with the facility as a floor nurse since 01/17/2023. The MDS Nurse stated she was scheduled for MDS training in February 2024 and had just begun working on care plan updates. She stated she was aware care plans needed to be developed/updated after each fall with a new intervention as soon as possible. The MDS Nurse stated she was not aware the system did not date the care plan entries. In an interview on 01/10/2024 at 8:10 AM with the Director of Nursing (DON), she stated she currently had a process improvement plan in progress for fall investigations and care plans because she saw that there were concerns in those areas. The DON stated her expectation would be a new fall intervention would be placed on the resident's care plan, which she had explained to floor staff. In an additional interview on 01/10/2024 at 12:40 PM with the DON, she stated the Seroquel was being used off label (the practice of using a drug for a different purpose then what the Food and Drug Administration (FDA) approved) to manage Resident #12's dementia with agitation, and there was no approved diagnosis for the use of this medication for Resident #12. She further stated it was her expectation the use of any psychoactive medication be on the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #5's medical record revealed the facility admitted the resident on 03/04/2022 with diagnoses to include muscle weakness, reduced mobility, dementia, and difficulty in walking. Continued review revealed the facility assessed Resident #5 on 12/18/2023 to be severely cognitively impaired with a score of three (3) of fifteen (15) on the Brief Interview for Mental Status (BIMS). Review of Resident #5's Annual Minimum Data Set (MDS) Assessment, dated 12/18/2023, revealed the resident required moderate to partial assistance with Activities of Daily Living (ADL) and utilized a walker as an assistive device. Review of Resident #5's Care Plan, no date given for creation, revealed a focus as a fall risk related to confusion, gait and balance problems, incontinence, and impaired safety awareness. Further review revealed a goal included the resident was to be free of falls with a resolved date of 11/23/2022. Continued review revealed Resident #5 would not sustain further serious injury through the review date given as 04/07/2024. Further review revealed interventions placed were to have a safe environment with a resolved date of 02/13/2023. Additional interventions included: signage on walker as a reminder to use; bed to be at appropriate height; encourage to use call light; wear appropriate footwear; and encourage to toilet every day at 6:00 AM and 4:00 PM. However, there was no date given for revisions or creations. Additional review revealed a resolved date of 01/12/2023 for observation of appropriate use of walker with frequent reminders to use it. Additional review of Resident #5's Care Plan revealed a focus of impaired cognitive function/dementia/impaired thought processes related to dementia. Interventions placed included the resident required verbal cues, reminders, and redirection for safety with a resolved date of 01/07/2024. However, no creation or revision date was given. Review of Resident #5's Progress Notes, revealed nine (9) falls from 01/12/2023 through 11/02/2023. 1a. On 01/12/2023 at 6:20 AM, Resident #5 was found sitting on the bathroom floor. The facility assessed Resident #5 to have no injuries. b. On 01/30/2023 at 11:10 AM, Resident #5 was found lying on his/her back in his/her room. Resident #5 was assessed without any injuries noted. c. On 02/11/2023 at 4:56 PM, Resident #5 was found sitting in the bathroom doorway. Resident #5 was assessed with no injuries noted. d. On 02/24/2023 at 8:08 AM, Resident #5 was found in his/her room on the floor to the right side of the chair. An assessment revealed Resident #5 complained of right foot pain without bruising or redness noted. e. On 03/21/2023 at 11:13 PM, Resident #5 was found sitting on the floor in his/her room between the bed and the chair. Resident #5 was assessed without any injuries noted. f. On 05/30/2023 at 7:46 PM, Resident #5 was ambulating behind staff in the hallway without using a walker. Staff left Resident #5 to get the walker from the dining room, but before they returned, Resident #5 had fallen in the hallway. An assessment was performed revealing a reddened area noted to the right elbow and knee and no complaint of pain. g. On 08/24/2023 at 2:35 PM, Resident #5 was found leaning against the wall in front of the lounge. An assessment was performed with moderate swelling to the resident's left wrist; the resident had complaints of pain to that area. The facility transferred Resident #5 to a local hospital per Emergency Services. Per Resident #5's hospital record, dated 08/24/2023, the resident sustained a left distal radial (wrist) fracture. In an interview with Licensed Practical Nurse (LPN) #2 on 01/11/2024 at 8:10 AM, she stated, after the 08/24/2023 fall, she added a small basket to Resident #5's walker for his/her stuffed cats to cue the resident not to leave the walker since he/she was so fond of stuffed cats. However, review of Resident #5's care plan revealed it did not include this intervention. h. On 09/18/2023 at 1:21 AM a notation was made in the medical record for follow-up on fall. However, no notation was found for this fall other than entry for no injuries. i. On 11/02/2023 at 5:40 PM, Resident #5 was found on the bathroom floor. Resident #5 was assessed without injuries noted. However, review of Resident #5's care plan revealed no dates for the interventions or revision dates. Observation on 01/07/2024 at 1:15 PM revealed Resident #5 sitting at a table in the dining room with two (2) other residents. Resident #5's walker was sitting to the right of him/her within reach. No signage for a reminder to use the walker was observed. Further observation revealed a small white plastic basket was attached to the top frame of the walker with two (2) stuffed cats inside the basket. In an interview with State Registered Nurse Aide (SRNA) #2 on 01/11/2024 at 8:45 AM, she stated, when asked how she knew if any new interventions were placed for a resident on the care plan, she stated staff got information in report from the nurses. She added that the facility's system did not transfer any new information about a resident. In an interview with SRNA #5 on 01/11/2024 at 8:30 AM, she stated she was providing care for Resident #5 today and knew he/she was a fall risk. She stated she got that information from shift report and did not look at the Care Plan or [NAME]. In an interview with SRNA #4 on 01/09/2024 at 3:40 PM, she stated she would refer to the Care Plan Book for any new information for any resident. However, upon observation SRNA #4 was unable to locate the book. In an interview on 01/11/2024 at 9:20 AM with the Director of Nursing (DON), she stated she had held that title since November of 2023. The DON stated the nurses should be placing immediate interventions to care plans when there was an incident including falls. She stated if there were no interventions placed on the care plans after a fall, staff should be passing information on in report to the next shift. During the interview, the DON stated she had identified problems with the whole care plan process saying there was no process for nurses to place immediate interventions after a fall. The DON stated, at this time, nurses were not allowed to add interventions to care plans. When asked whose responsibility that was, she said that she, the DON was responsible. She stated she was putting a Process Improvement Plan (PIP) program in place for falls and care plans. She stated the process should be when a resident fell, an assessment should be done and immediate interventions placed at that time by that nurse. When asked to find the interventions placed in the medical record/care plan for Resident #5's falls, the DON replied she could not locate them. Based on interview and record review it was determined the facility failed to revise the Care Plan for two (2) of thirty-seven (37) residents (Residents #5 and #39). Resident #39 was care planned to be nutritionally at risk. However, care plan interventions were not updated following a significant weight loss. Resident #5 experienced nine (9) falls from 01/12/2023 through 11/02/2023. One fall resulted in a fractured wrist. There was no evidence that interventions following the falls were placed on the care plan or dated. (See F689 and F692) The findings include: Review of the facility's policy, Care Plan Policy and Procedure, dated 08/13/2023, revealed the Interdisciplinary Team (IDT), which included the Dietician, Dietary Manager, nursing staff, and the Director of Nursing, or Licensed Nurse were responsible for updating the resident's care plan when there were changes in the resident's care needs. 1. Review of Resident #39's Face Sheet revealed the facility admitted the resident on 10/05/2022 with diagnoses that included unspecified dementia and major depressive disorder. Further review revealed the facility updated the diagnosis list to include cerebral infarction (stroke) and aphasia (inability to speak) on 12/02/2022. Review of Resident #39's Annual Minimum Data Set (MDS) Assessment, dated 10/05/2023, revealed the facility assessed the resident as not able to be understood and assessed the resident's memory, decision making, and attention to be severely impaired. Further review revealed the facility assessed Resident #39 as dependent on staff for eating and requiring a mechanically altered diet. Review of Resident #39's Quarterly MDS Assessment, dated 07/13/2023, revealed the facility assessed the resident as having lost ten percent (10%) or more of his/her body weight in the last six (6) months while not on an intended weight-loss program. Review of Resident #39's Care Plan, dated 04/19/2023, revealed the facility identified that Resident #39 lost eighteen percent (18%) of his/her body weight in the previous six (6) months and set a goal of no further significant weight loss. Further review of the care plan revealed the facility identified further weight loss on 07/13/2023 of ten and nine-tenths percent (10.9%) in six (6) months; and on 01/03/2024 a loss of ten and one-half percent (10.5%) of his/her body weight in the past six (6) months. Continued review revealed the interventions listed were to provide diet and supplements per physician's order, to assist the resident with the meal tray as needed, to obtain meal preferences, encourage food and fluids, and monitor weights as needed. Per review, the facility failed to date the interventions and failed to make the interventions resident specific. In the section of the care plan describing Activities of Daily Living (ADL), the intervention for eating described Resident #39 as able to feed himself/herself after the tray was set up. However, the resident was no longer able to perform this activity. Review of Resident #39's nutrition orders, dated 10/10/2023, revealed the facility prescribed a fortified foods diet with pureed texture for Resident #39. Observation of the meal service on 01/10/2024 at 12:35 PM revealed State Registered Nurse Aide (SRNA) #4 assisted Resident #39 with eating. Per observation, Resident #39 ate fifty percent (50%) of the mashed potatoes and pureed chicken in gravy and drank twenty-five percent (25%) of the sweet tea. Further observation revealed SRNA #4 had not opened the fortified pudding container. In an interview on 01/09/2024 at 6:03 PM, Resident #39's resident representative stated the facility never asked her what Resident #39's food preferences were. However, the representative told several aides that Resident #39 disliked sweet tea, which the facility continued to serve Resident #39 at every lunch and dinner. In interview on 01/10/2024 at 12:35 PM, SRNA #4 stated she did not know what Resident #39's care plan contained about Resident #39's dietary needs such as food preferences. She further stated she was not aware if anyone had asked the resident's representative about Resident #39's food preferences or if staff members documented their observations about which foods Resident #39 demonstrated preferences for based on his/her consumption. In an interview on 01/11/2024 at 10:07 AM, the Registered Dietician (RD) stated she made recommendations for Resident #39 and gave them to the nursing management team to enter as orders in the electronic medical record. She further stated she did not know if those interventions also went on the resident's care plan. In an interview on 01/11/2024 at 4:08 PM, the Director of Nursing (DON) stated she was aware the facility had failed to keep resident care plans up to date with resident specific interventions. Per interview, it was the DON's expectation that resident-specific interventions to address a resident's unplanned weight loss were up-to-date and followed. In an interview with the Director of Nursing (DON) on 01/11/2024 at 1:25 PM, she stated there had not been a process in place to review or revise care plans. In an interview with the Administrator on 01/11/2024 at 5:10 PM, she stated the care plans were a mess and that they failed to be resident-specific. She stated the new DON had implemented a process to improve care plans including that the nurses could now place immediate interventions after an incident. She stated her expectation for a care plan was it should be updated as needed with specific interventions to reflect resident care needs. She stated staff should be able to look at a care plan and know the plan of care. She added the former DON had created care plans but had not done anything about them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #12's medical record revealed the facility admitted the resident on 08/08/2023 with diagnoses of unspecified dementia with muscle weakness, unsteadiness on feet, and chronic obstructive pulmonary disease. Review of Resident #12's admission Minimum Data Set (MDS) Assessment, dated 08/08/2023 and the Quarterly MDS Assessment, dated 11/15/2023, section GG revealed Resident #12 used a walker and a wheelchair for mobility and needed assistance with bathing, dressing, using the toilet, and eating. Resident #12 also needed assistance with walking from room to room (with or without a device such as cane, crutch, or walker). Further review of the MDS, section C for cognition dated, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15) which indicated severe cognitive impairment. Review of the Facility Resident Matrix dated 01/07/2024 revealed Resident #12 was coded for falls. Review of Resident #12's Comprehensive Care Plan (CCP) for falls, last reviewed 11/16/2023, revealed Resident #12 was at risk for and had falls related to gait and balance problems, psychoactive drug use, decreased safety awareness, and cognitive impairment. The documented goal was for Resident #12 to be free of injury from falls through the target date of 02/14/2024. Documented active interventions, all undated, included: encourage resident to use the call light for assistance as needed, encourage resident to wear non-skid footwear when ambulating as the resident allowed, encourage resident to toilet before/after meals, encourage use of assistive device, walker to promote independence when ambulating, physical therapy as ordered, and Resident #12 needed a safe environment with floors free from spills and/or clutter, adequate glare free lighting, a working and reachable call light, the bed in low position at night, and personal items within reach. Three (3) additional undated interventions were follow facility fall protocol; encourage Resident #12 to participate in activities that promoted exercise and physical activity for strengthening and improved mobility such as Sittercise; and Resident #12 needed activities that minimized the potential for falls while providing diversion and distraction. These were marked as resolved on 12/10/2023. Review of Resident # 12's Comprehensive Care Plan (CCP) for Activities of Daily Living, last review date 11/16/2023, revealed Resident #12 required assistance with activities of daily living related to dementia, impaired balance, and limited mobility. The documented goal, undated, was Resident #12 would maintain his/her current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene through the target date of 02/14/2024. Documented active interventions, all undated, included encourage Resident #12 to use the call bell for assistance, make sure shoes were comfortable and fit properly, assist with eating as needed, and Resident #12 required cueing, encouragement, and limited assist with transferring. Review of the facility's document, Incidents by Incident Type, printed on 01/09/2024, revealed Resident #12 sustained a fall on the following dates: 09/24/2023 at 10:58 PM, 09/24/2023 at 11:53 PM, 10/15/2023 at 7:28 PM, 10/28/2023 at 8:25 AM, 12/05/2023 at 5:55 PM, 12/30/2023 at 2:04 AM, 01/01/2024 at 9:44 AM, 01/03/2024 at 7:45 AM, and 01/05/2024 at 1:05 PM. a. Review of Resident #12's Fall Incident Report, dated 09/24/2023 at 10:58 PM and written by Licensed Practical Nurse (LPN) #4, revealed staff (not identified) was called to the room where Resident #12 was found kneeling at the bedside. Resident #12 was documented to have stated he/she was trying to get up and here I am on the floor. No injuries were observed, and it was documented no witnesses to the fall could be identified. Review of Resident #12's Health Status Note, dated 09/24/2023 at 10:58 PM and written by LPN #4, revealed she was called to the room by staff, and Resident #12 was found kneeling on the floor beside the bed and had stated he/she fell out of the bed. An assessment was documented as completed, and Resident #12 was transferred to the bed with no injury noted. However, there was no documented evidence the facility performed neuro/cranial check assessment, initiated by the nurse at the time of the fall as the fall was unwitnessed, and continued for twenty-four (24) hours as per the facility's policy. b. Review of Resident #12's Fall Incident Report, dated 09/24/2023 at 11:53 PM by LPN #4, revealed she was called to the room by staff, and Resident #12 was found sitting on the floor in front of the sink and had stated he/she was walking to the sink to empty a pitcher of water, lost his/her balance, and fell hitting the wall with his/her left arm. An assessment was documented as completed, and Resident #12 was assisted up by staff and ambulated back to bed. No injury was documented, and no witnesses to the fall were identified. Review of Resident #12's Health Status Note, dated 09/24/2023 at 11:53 PM and written by LPN #4, revealed she was called to the resident's room by staff, and Resident #12 was found sitting on the floor in front of the sink. LPN #4 further documented an assessment was done per the nurse, Resident #12 was able to move his/her extremities on his/her own. Staff lifted the resident to his/her feet. The resident was able to ambulate to bed, and a bruise was noted to the resident's posterior left upper arm. However, there was no documented evidence the facility performed a neuro/cranial check assessment, initiated by the nurse at the time of the fall as the fall was unwitnessed, and continued for twenty-four (24) hours as per the facility's policy. c. Review of Resident #12's Fall Incident Report, dated 10/15/2023 at 7:28 AM by LPN #5, revealed a SRNA, unidentified, observed Resident #12 on the floor beside the bed and documented the resident had stated he/she rolled out of bed. LPN #5 documented a small abrasion was noted to the back and left side of Resident #12's head, and Resident #12 denied pain. LPN #5 further documented range of motion to all extremities and neurological checks were within normal limits. Review of Resident #12's Incident Note, dated 10/15/2023 at 10:43 AM, revealed an SRNA observed Resident #12 lying on the floor beside the bed. LPN #5 documented Resident #12 stated he/she rolled out of bed. LPN #5 assessed Resident #12, and noted a small abrasion to the back of Resident #12's head on the left side. Continued review revealed Resident #12 denied any pain to any extremities, and range of motion to all extremities was within normal limits. LPN #5 further noted a skin assessment was completed and vital signs and neurological checks were obtained and were also within normal limits. However there was no documented evidence the facility continued to performed neuro/cranial check assessment for twenty-four (24) hours as the fall was unwitnessed and the resident had an abrasion to the head. d. Review of Resident #12's Fall Incident Report, dated 10/28/2023 at 7:28 AM by LPN #5 revealed she was in the hallway administering medications and heard Resident #12 yell out, Help Me. She documented she turned to observe Resident #12 with his/her head on a pillow on the floor, and the resident's waist/legs remained on the bed. LPN #5 documented Resident #12 stated he/she had leaned over and rolled off the bed. The LPN documented no apparent injury was visualized; range of motion was normal for all four (4) extremities; a skin assessment and neurological checks were completed and were within normal limits. Per the report, Resident #5's fall was unwitnessed. Review of Resident #12's Incident Note dated 10/28/2023 at 10:01 AM, revealed the same information as Resident #12's Fall Incident Report, dated 10/28/2023 at 7:28 AM, but it added that no new orders were received from the APRN. However, there was no documented evidence the facility performed neuro/cranial check assessment, as the fall was unwitnessed, and continued for twenty-four (24) hours as per the facility's policy. e. Review of Resident #12's Fall Incident Report, dated 12/05/2023 at 5:55 PM by LPN #5, revealed she observed Resident #12 sitting on the floor beside the bathroom door, and Resident #12 stated he/she was coming from the bathroom and lost his/her balance. LPN #5 documented Resident #12 denied hitting his/her head, no injury was noted, and Resident #12's roommate stated Resident #12 slid down the wall to the floor. LPN #5 further documented range of motion to all extremities and a skin assessment and vital signs were all within normal limits. Resident #12 denied pain or discomfort, and LPN #5 observed Resident #12 had his/her walker nearby but did not have shoes on. Review of Resident #12's Incident Note dated 12/05/2023 at 6:03 PM, detailed the same information about the fall as the Fall Incident Report, dated 12/05/2023 at 5:55 PM. However, there was no documented evidence the facility performed a neuro/cranial check assessment, initiated by the nurse at the time of the fall as the fall was unwitnessed, and continued for twenty-four (24) hours as per the facility's policy. f. Review of Resident #12's Fall Incident Report, dated 12/30/2023 at 2:04 PM by the MDS Nurse revealed Resident #12 was laying on the floor next to the bed with his/her head toward the foot of the bed and facing the wall. The report stated it appeared his/her feet were tangled up in the blanket, and the resident stated he/she was just trying to get up. The MDS Nurse documented the bed was in the lowest position. Resident #12 was alert and oriented to person which was normal, and a head-to-toe assessment was completed with no injury found. The MDS Nurse further documented neurological checks were initiated as the fall was unwitnessed, vital signs were stable, and Resident #12's daughter and the APRN were notified. Review of Resident #12's Incident Note dated 12/30/2023 at 4:21 PM by the MDS Nurse, revealed the same information as Resident #12's Fall Incident Report, dated 12/30/2023 at 2:04 PM. However, there was no documented evidence the facility performed neuro/cranial check assessment, as the fall was unwitnessed, were continued for twenty-four (24) hours as per the facility's policy. g. Review of Resident #12's Fall Incident Report, dated 01/01/2024 at 9:44 AM by LPN #6, revealed Resident #12 attempted to get out of bed without assistance, did not use the call light, had regular socks on with the bed in the lowest position. The resident stated he/she slid out of the bed. LPN #6 documented she assisted Resident #12 back to bed, completed a full skin assessment, put shoes on the resident, and brought him/her to the nurses' station in a wheelchair. LPN #6 further documented Resident #12 denied pain, no injuries were observed at the time of the incident, with no witnesses to the fall were identified. Review of Resident #12's Health Status Note, dated 01/01/2024 at 10:01 AM, revealed Resident #12 slid out of bed that morning with the bed in the lowest position and the call light in easy reach, but he/she did not use it. LPN #6 further documented no injuries were noted and Resident #12 was sitting at the nurses' station. However, there was no documented evidence the facility performed neuro/cranial check assessment, initiated by the nurse at the time of the fall as the fall was unwitnessed, and continued for twenty-four (24) hours as per the facility's policy. h. Review of Resident #12's Fall Incident Report, dated 01/03/2024 at 7:45 AM by LPN #7, revealed she was called to Resident #12's room by an unidentified SRNA. Per the report, upon entering the room, LPN #7 observed Resident #12 lying on the floor next to the bed on his/her left side. The report stated Resident #12 denied pain, no injuries were noted, vital signs were stable, and Resident #12 was unable to give a description of what happened. Per the report no witnesses to the fall were identified. Review of Resident #12's Health Status Note, dated 01/03/2024 at 8:00 AM, revealed Resident #12 was found by an SRNA lying on the floor next to his/her bed. The note stated an assessment was completed, vital signs were stable, and no injuries were noted. Continued review revealed Resident #12 denied pain or discomfort, the bed was in the lowest position and the call light was in reach. LPN #7 further documented Resident #12 was encouraged to use the call light for assistance, to continue to wear non slip socks, and that he/she voiced understanding at the time. However, there was no documented evidence the facility performed neuro/cranial check assessment, initiated by the nurse at the time of the fall as the fall was unwitnessed, and continued for twenty-four (24) hours as per the facility's policy. i. Review of Resident #12's Fall Incident Report, dated 01/05/2024 at 1:05 PM by LPN #3, revealed Resident #12 was found lying on the floor in front of the nurses' station on his/her right side with his/her right arm at a natural angle behind his/her head and both legs bent at the knees. Per the report, Resident #12 stated, I fell I don't know. LPN #3 documented a head to toe assessment was completed, and Resident #12 complained of neck, right arm, and right hip pain. Resident #12's head and neck were stabilized to prevent movement, neurological checks were completed, and Resident #12 was assessed to be at his/her baseline for orientation. The facility assessed Resident #12 as being able to move all extremities, hand grasps were equal and strong, speech was clear, but pupils measured four (4) millimeters with sluggish reaction. Vital signs were stable with no obvious injuries noted. Per the report, 911 was called for transport to the hospital for evaluation. No witnesses to the fall were identified. Further review of Resident #12's Fall Incident Report dated 01/05/2024, in the notes section dated 01/08/2024, revealed Resident #12 was noted lying on his/her right side on the floor by the nurses' station on 01/05/2024. The facility assessed Resident #12 and noted the resident had no obvious injury. However, the resident was sent to the hospital emergency department (ED) for evaluation related to complaints of neck pain and returned with no new orders or acute injuries notes. Review of Resident #12's Health Status Note dated 01/05/2024 at 1:30 PM, revealed the intervention to be put in place when Resident #12 returned to the facility would be proper footwear, shoes or nonskid socks to be in place. Review of Resident #12's Health Status Note dated 01/06/2024 at 4:32 AM, revealed Resident #12 returned from the ED on 01/05/2024 at 8:10 PM with no new orders and diagnostic tests negative for acute injuries. In an interview on 01/10/2024 at 10:10 AM with SRNA #3, she stated for Resident #12, he/she was very forgetful and needed frequent redirection. She further stated it seemed to her when Resident #12 got up he/she was either trying to get to the bathroom or stated he/she was looking for a little white dog. When asked if staff had tried providing him/her with a stuffed white dog to see if that helped at all, she stated not that she was aware of. In an interview with SRNA #4 on 01/09/2024 at 3:40 PM, she stated she would refer to the Care Plan Book for any new information for any resident. However, upon observation SRNA #4 was unable to locate the book. She stated if a resident fell she would get the nurse immediately. In another interview on 01/10/2024 at 1:15 PM with SRNA #4, she stated she had been at the facility for almost eleven (11) years. She stated she knew Resident #12 had fallen several times because he/she kept trying to get up. She stated in order to try and keep Resident #12 from trying to stand up, they placed him/her behind the nurses' station for the whole shift, basically doing one-to-one (1:1) supervision with the resident. She further stated that even then, staff had to keep reminding Resident #12 to sit down. SRNA #4 stated residents' care plans or the [NAME] were not documented in the SRNA care plans on the computer, and usually the nurses just told the SRNAs about resident care during shift change report. She further stated she did not necessarily hear of a new intervention for each fall. She stated Resident #12 used to walk with a walker when he/she first came to the facility, and staff tried to use distraction and redirection with Resident #12, but it did not always work. In an interview on 01/10/2024 at 2:48 PM with SRNA #5 she stated she had worked at the facility since October 2023. SRNA #5 stated Resident #12's most recent fall was last week and he/she used to use a walker and was now in a wheelchair when up. She stated she did not know if Resident #12 had certain behaviors that were repeating like looking for something or going to the bathroom. SRNA #5 stated a resident's method of toileting and mobility were on the care plan/[NAME], and she could see that where she charted in the computer. She stated the resident information was also relayed in the morning report or rounds. SRNA #5 further stated she did not hear of specific interventions added for each resident's fall during report. She stated she just heard the resident fell and was okay. In an interview on 01/10/2023 at 12:55 PM with LPN #3, she stated she had worked at the facility on an as needed basis for sixteen (16) years. She stated after a resident fell, and after the resident was assessed and safe, she would fill out an incident report. However, she stated the Director of Nursing (DON) finished the report and filled in the intervention on the resident's care plan. She stated she did not attend Interdisciplinary Team (IDT) meetings. In an interview on 01/10/2023 at 3:31 PM with LPN #2, she stated she had worked for the facility from 2012 to 2021, left, and returned in August 2023. She stated an intervention was put in place after each fall on the resident's care plan and asked, isn't that an MDS kind of thing? When asked if she knew how to tell if a resident was care planned as a fall risk she stated she would have to look that up. LPN #2 stated nurses were made aware of resident care needs through verbal report and through the care plans which were on the computer. She stated if something changed with a resident's care, she communicated that to the staff on the floor verbally. LPN #2 stated Resident #12 was confused and required frequent redirection, had an unsteady gait, had a walker and a wheelchair which he/she frequently forgot to use, his/her bed was kept in low position, and staff tried to ensure he/she was assisted with toileting and getting up. She also stated Resident #12 was rounded on more frequently than the standard every two (2) hours, and his/her room was located closer to the nurses' station. LPN #2 further stated her job was safety, and she did not touch care plans. She stated she filled out the incident report, and when her part was done, there was a spot where she could put an immediate intervention in. The LPN stated the incident report stayed open until the DON completed and closed it during the Interdisciplinary Team (IDT) meeting. LPN #2 stated she did not know when IDT met or how often and that she had never been to an IDT meeting. When asked what her expectation was for residents with multiple and repeated falls, she stated if she was in charge, she would utilize pressure alarms for the high-risk residents, so she would know if a resident was trying to get up. In an interview on 01/11/2024 at 3:30 PM with the MDS Nurse, she stated she had been the MDS Nurse since Monday but had been with the facility as a floor nurse since 01/17/2023. She stated she was scheduled for MDS training in February 2024 and had just begun working on care plan updates. She stated she was aware care plans needed to be updated with each new intervention as soon as possible. However, she was not aware the system did not date the care plan entries. She stated it was her expectation every resident's fall be investigated and the cause addressed to promote resident safety. In an interview on 01/10/2024 at 8:10 AM with the DON (Director of Nursing) she stated when she did a fall investigation, she typically put the investigation, interventions, and the Root Cause Analysis under the notes section of the investigation report. She stated she did not know how they were doing it prior to her coming to the facility. The DON stated she currently had a process improvement plan in progress for fall investigations and care plans because she saw that there were concerns in those areas. She also stated typically fall investigations were covered under Quality Analysis, and she thought the previous DON, who was no longer at the facility, had been doing Quality Analysis. The DON stated she had done education with floor staff members in December 2023 with interventions for falls when they occurred, their role in determining the root cause, and trying to gather all the information they could at the time. She stated she started as DON at the facility on the first Monday in November 2023, and her process would be the IDT team would be involved in the investigation and root cause analysis of a fall, and all falls would be reviewed weekly on Fridays. The DON stated her expectation would be a new fall intervention would placed on the resident's care plan, which she had explained to floor staff, and the investigation would also be checked to ensure a new intervention was placed there. In continued interview on 01/11/2024 at 9:20 AM with the DON, she stated her tasks included offering oversight of the nursing clinical area, assuring staff members were performing their tasks including nurse aides. The DON added the nurses should be placing immediate interventions to care plans when there was an incident including falls and a neuro/cranial check assessment was to be initiated by the nurse at the time of the falL. She stated neuro checks had to be done if the fall was unwitnessed, or if the resident hit his/her head. The DON stated this should be done for twenty-four (24) hours as per the facility's policy. She added she had identified problems with the whole care plan process, saying there was no process for nurses to place immediate interventions after a fall. The DON stated, at this time, nurses were not allowed to add interventions to care plans. When asked whose responsibility that was, she said the DON. She added that she was putting in place a Process Improvement Plan (PIP) program for falls and care plans. She stated the process should be when a resident fell, an assessment should be done and immediate interventions placed at that time by the nurse. She also stated that nurse would fill out an incident report, which right now was not always performed. In an interview on 01/11/2024 at 8:25 AM with the Administrator, she stated the facility's fall process was the nurse on duty assessed the resident and the situation and responded with an intervention. She stated the doctor and the resident's representative were notified, but the DON was not notified unless it was a fall with a major injury. Then, she stated in the morning meeting/stand up, the fall was reviewed. She stated the appropriateness of the intervention should also be should reviewed and changes should be made as appropriate. She stated the root cause of the fall was determined in the weekly IDT meeting (she stated the members were nursing leadership, MDS Nurse, the Dietician via phone, the Infection Preventionist, the Quality/Staff Development Nurse, and sometimes the Social Services Director). She stated she did not typically attend the weekly IDT meeting. The Administrator further stated the floor/charge nurses did not add interventions on the care plan and that sometimes the DON did it. She stated it had been the MDS Nurse's responsibility but going forward it would be a team effort. The Administrator stated it was her expectation every employee do their job and that included investigating falls, updating care plans, and ensuring every resident's safety. In another interview with the Administrator on 01/11/2024 at 5:10 PM, she added that the facility had identified falls were occurring at mealtimes, and the process was to have a staff member in the hallway during mealtimes. She stated that had decreased incidents for awhile but did not say if the process was ongoing. Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure adequate supervision and assistance devices to prevent falls for two (2) of thirty-seven (37) sampled residents (Residents #29 and #12). Resident #29 sustained a laceration to the chin requiring six (6) sutures on 02/21/2023 when the bed the resident was in was not locked and rolled causing the resident to fall while receiving care with only one (1) person assistance when the facility had assessed and care planned Resident #29 to require the assistance of two (2) person for toileting and bed mobility. Resident #12 sustained nine (9) documented falls from 09/24/2023 to 01/05/2024, none with injuries. The findings include: Review of the facility's policy, Resident Fall Protocol, dated 09/01/2023, revealed it was the policy of the facility to attempt to eliminate falls from occurring and/or to prevent residents from falls with major injuries. Review of the procedure section of the policy revealed the facility was to include interventions as indicated. Further review of the policy, under the note section, revealed a neuro/cranial check assessment was to be initiated by the nurse at the time of the fall, had to be done if the fall was unwitnessed, or the resident hit his/her head. It stated this assessment was to be done for twenty-four (24) hours. 1. Review of Resident #29's Electronic Health Record (EHR) revealed the facility admitted the resident on 03/04/2022 with diagnoses to include unspecified dementia without behavioral disturbance, need for assistance with personal care, and other reduced mobility. The facility assessed Resident #29, in a Quarterly Minimum Data Set (MDS) Assessment, dated 07/20/2023, as severely cognitively impaired and requiring extensive assist of two (2) with bed mobility and with incontinence care. Review of Resident #29's Comprehensive Care Plan, last reviewed 10/17/2023, revealed the resident was care planned for two (2) person assist with toileting and bed mobility, but these interventions were undated. Resident #29 was also care planned for transfers with a mechanical lift, which was also undated. Review of Resident #29's Fall Report, dated 12/21/2023, revealed Resident #29 had a fall with injury on 12/21/2023 at 7:00 PM while a State Registered Nurse Aide (SRNA) was assisting the resident with incontinence care. Per the report, the resident rolled out of bed before the SRNA could stop the resident. The report stated Resident #29 was sent to the emergency room and required six (6) stitches repair a laceration to his/her chin. Review of Resident #29's Root Cause Analysis document, not dated, revealed Resident #29 would be changed with the assist of two (2) with bed mobility/incontinence care to prevent the resident from rolling out of bed in the future. However, review of the MDS and Comprehensive Care Plan revealed the facility had already assessed and care planned the resident to require two (2) person assist with toileting and bed mobility. Interview on 01/11/24 at 8:01 AM with SRNA #6 revealed she was working on 12/21/2023 with Resident #29. She stated she was going to give Resident #29 care and had never had any problem changing him/her before. She stated she was changing Resident #29 and did not realize the bed was not locked. She stated in her four (4) years working at the facility, nothing like that had ever happened. She stated the bed rolled while she turned to get wipes, Resident #29 became unstable, and the resident fell too fast for SRNA #6 to prevent the fall. SRNA #6 stated Resident #29 immediately became a two (2) person assist after that. She also stated she now always checked to ensure beds were in the locked position before providing any kind of care. In an interview on 01/10/2024 at 1:13 PM with State Registered Nurse Aide (SRNA) #4, she thought Resident #29 was a one (1) person assist with care prior to the fall on 12/21/2023. In another interview on 01/10/2024 at 1:15 PM with SRNA #4, she stated she had been at the facility for almost eleven (11) years. SRNA #4 stated resident care plans or the [NAME] were not documented in the SRNA care plans on the computer, and usually the nurses just told the SRNAs about resident care during shift change report. She further stated she did not necessarily hear of a new intervention for each fall. In an interview with SRNA #5 on 01/10/2024 at 2:48 PM, she thought Resident #29 was a one (1) person assist prior to the fall on 12/21/2023. In an interview on 01/10/2024 at 10:10 AM with SRNA #3, she stated she had been at the facility for two (2) years. SRNA #3 stated if she had questions about how a resident transferred or toileted, she either asked the other SRNAs or the charge nurse. She stated there was an aide [NAME] on the computer where she did her charting, but she admitted she had never seen it but knew where to look for it. She stated she mainly got her resident information on rounds from the previous shift staff, In an interview on 01/10/2024 at 3:32 PM with Licensed Practical Nurse (LPN) #2, she stated she believed Resident #29 was a one (1) person assist with changing but had not worked with the resident recently. In an interview with the Director of Nursing (DON) on 01/11/2024 at 4:18 PM, she stated she would expect staff to ensure care plan interventions were implemented and care plans would be referenced by all staff before providing care. She went on to state, she would expected staff to ensure the bed was locked prior to providing resident care. She stated when she conducted a fall investigation, she noted the intervention for two (2) person assistance in the notes section and SRNA #6 should have asked for assistance prior to providing toileting care and bed mobility for Resident #29.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain acceptable parameters of nutritional status for one (1) of thirty-seven (37) sampled residents (Resident #39). Resident #39 lost greater than ten percent (10%) of his/her body weight in the past six (6) months and over twenty percent (20%) in a year. The facility failed to ensure that interventions were implemented timely to prevent the weight loss. The findings include: Review of the facility's policy, Weight Monitoring Procedure, dated 12/03/2023, revealed the facility weighed residents once per month, unless the resident unexpectedly lost greater than five percent (5%) of his/her body weight in one (1) month; greater than seven and a half percent (7.5%) in three (3) months; or greater than ten percent (10%) in six (6) months. Review of Resident #39's Face Sheet revealed the facility admitted the resident on 10/05/2022 with diagnoses that included unspecified dementia and major depressive disorder. Further review revealed the facility updated the diagnosis list to include cerebral infarction (stroke) and aphasia (inability to speak) on 12/02/2022. Review of Resident #39's Quarterly Minimum Data Set (MDS) Assessment, dated 07/13/2023, revealed the facility assessed the resident as having lost ten percent (10%) or more of his/her body weight in the last six (6) months while not on an intended weight-loss program. Review of Resident #39's Annual Minimum Data Set (MDS) Assessment, dated 10/05/2023, revealed the facility assessed the resident as not able to be understood and assessed the resident's memory, decision making, and attention to be severely impaired. Further review revealed the facility assessed Resident #39 as being dependent on staff for eating and as requiring a mechanically altered diet. Review of Resident #39's Care Plan, dated 04/19/2023, revealed the facility identified that Resident #39 lost eighteen percent (18%) of his/her body weight in the previous six (6) months and set a goal of no further significant weight loss. Further review of the care plan revealed the facility identified further weight loss of 10.9% in six (6) months on 07/13/2023, and on 01/03/2024 a loss of 10.5% of his/her body weight in the past six (6) months. Continued review revealed the interventions listed included: provide diet and supplements per physician's order; assist the resident with meal tray as needed; obtain meal preferences; encourage food and fluids; and monitor weights as needed. Additional review revealed the facility did not date the interventions. Per review of the section of the care plan describing Activities of Daily Living (ADLs), the intervention for eating described Resident #39 as able to feed himself/herself after the tray was set up. However, the resident was no longer able to perform this activity. Review of the facility's document Weight Summary, dated 01/01/2024, revealed Resident #39 weighed one hundred one (101) pounds on 01/01/2024, down from one hundred thirteen (113) pounds on 07/02/2023, for a loss of over ten percent (10.6%) in six (6) months. Further review revealed Resident #39 weighed one hundred twenty-eight (128) pounds on 01/02/2023, for a loss of over twenty-one percent (21.1%) of his/her body weight in one (1) year. Review of the facility's document Progress Note-NAR (Nutrition at Risk), dated 05/17/2023, revealed the dietician discharged Resident #39 from the NAR focus group, despite noting a four percent (4%) weight loss during the four (4) weeks the facility was following the resident for significant weight loss. Review of Resident #39's Physician's Order for nutrition, dated 10/10/2023, revealed the resident was prescribed a fortified foods diet with pureed texture. Review of the facility's document Nutrition: Amount Eaten, dated 12/12/2023 through 01/10/2024, revealed Resident #39 ate fifty percent (50%) or less of sixty (60) of the ninety-one (91) meals documented. Review of the facility's document Nutrition: Snacks, dated 12/14/2023 through 01/10/2024, revealed the facility failed to offer snacks to Resident #39 during daytime hours. Record of Resident #39's food preferences was requested by the State Survey Agency (SSA) on 01/10/2024 at 1:45 PM and on 01/11/2024 at 2:30 PM. However, the facility failed to provide this documentation by the time of exit on 01/11/2024 at 7:30 PM. Observation of the meal service on 01/10/2024 at 12:35 PM revealed State Registered Nurse Aide (SRNA) #4 assisted Resident #39 with eating, starting with the mashed potatoes. Observation revealed Resident #39 ate fifty percent (50%) of the mashed potatoes and pureed chicken in gravy and drank twenty-five percent (25%) of the sweet tea. Further observation revealed SRNA #4 had not opened the fortified pudding container. Observation on 01/08/2024 between 1:15 PM and 2:15 PM and on 01/09/2024 between 9:30 AM and 11:45 AM revealed staff failed to offer snacks and drinks throughout the day. In an interview on 01/09/2024 at 6:03 PM, Resident #39's resident representative stated the facility never asked her what Resident #39's food preferences were. However, the representative stated she told several aides that Resident #39 disliked sweet tea, which the facility continued to serve Resident #39 at every lunch and dinner. The resident's representative stated Resident #39 liked coffee with sweetened creamer and fruit juice, which could be a source of calories, but she did not see those offered to the resident consistently. Further, the resident's representative stated she had visited after a meal service and observed Resident #39 asleep in bed without any food being disturbed on the tray left at the bedside. Per interview, Resident #39 ate when the resident's representative fed her, and some staff members told her that Resident #39 ate well when they fed the resident. The resident's representative stated she believed when the resident did not eat the majority of a meal served, it was because his/her food preferences were not honored or the staff member assisting with feeding lacked skill in feeding. In interview on 01/10/2024 at 12:35 PM, SRNA #4 stated she did not know what Resident #39's food preferences were and was not aware if anyone had asked the resident's representative about Resident #39's food preferences. Further, SRNA #4 stated she attempted to feed the resident each meal, and if the resident started to refuse bites, she stopped trying to feed him/her and documented the amount eaten. SRNA #4 stated she did not regularly offer Resident #39 snacks. She stated she tried to offer him/her drinks through the day, but the resident would often refuse. In an interview on 01/11/2024 at 10:07 AM, the Registered Dietician (RD) stated she was aware Resident #39 had lost a significant amount of weight, and the resident was included in the Nutrition at Risk (NAR) intervention group. Per interview, the RD followed residents in the NAR program when they had lost more than five percent (5%) of their body weight in one (1) month or more than ten percent (10%) in six (6) months. The RD further stated Resident #39 had been part of the NAR program earlier in the year but was discharged when his/her weekly weights were stable for four (4) weeks. The RD stated that a stable weight was defined as within two and one-half percent (2.5%) of the previous weight; though if the weight slowly decreased over that amount of time, she considered it appropriate to continue to monitor the resident closely. The RD stated she made recommendations for Resident #39, such as adding fortified oats and/or pudding, when Resident #39 lost weight. However, she stated she was only in the facility one (1) day per week and did not know what foods Resident #39 was actually eating, nor had she identified if the technique of the aides feeding Resident #39 had contributed to his/her weight loss. Per interview, the RD stated she had not educated staff on techniques to use in assisting residents with eating, such as offering higher calorie foods first. Additionally, the RD stated she put her recommendations in her notes in the electronic medical record. However, she stated she did not know if those recommendations went on the resident's care plan. She further stated she did not assess resident's food preferences as a potential cause for a resident's weight loss as she believed that was the role of the Dietary Manager. In an interview on 01/11/2024 at 2:37 PM, the Dietary Manager (DM) stated each resident's food preferences were documented in the dietary computer system and could be obtained from interviewing the resident about his/her preferences or even from observing returned meal trays to see what the resident had eaten. Per interview, the DM stated she believed Resident #39 liked butterscotch flavored fortified pudding, but she did not know if that preference was documented in the computer system or if it was written on the resident's care plan. In an interview on 01/11/2024 at 4:08 PM, the Director of Nursing (DON) stated she was aware Resident #39 had been losing weight and that he/she had poor intake at meals. She further stated her expectations were for the facility to assess resident food preferences on admission and during quarterly care planning meetings. However, she stated she did not know when Resident #39's food preferences were updated due to the facility not communicating with the resident's representative due to difficulty contacting her via phone. Per interview, the facility had talked to the resident's representative about Resident #39's weight loss and that administration of an appetite stimulant might have increased the resident's food intake, but the DON stated she did not know if the resident's food preferences had been discussed at that time. In an interview on 01/11/2024 at 5:30 PM, the Administrator stated her expectations were for residents who had lost weight to have interventions implemented as recommended by the Dietician. Per interview, she did not conduct audits to ensure staff were implementing interventions and to try to identify any barriers to implementing recommendations. In further interview, the Administrator stated she was aware Resident #39 had lost weight over many months due to poor intake. She stated she did not believe the facility had tried to offer Resident #39 smaller, more frequent meals in an attempt to increase his/her caloric intake.