**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #14 was admitted to the facility in September 2018 and has the following diagnoses: Parkinson's disease, Diabetes mellitus type 2 and gastro-esophageal reflux disease (a condition in which stomach contents move up into the esophagus). Review of the most recent BIMS for Resident #14 indicated he/she was moderately cognitively impaired with a score of 11 out of 15 and his/her healthcare proxy (HCP) was invoked. During a telephone interview on 3/12/24 at 12:38 P.M., Family Member #3 said he doesn't get to come by much but there are issues with the Resident eating meals and another family member comes to the facility weekly to make sure the Resident gets the help he/she needs since the facility does not help him. During a telephone interview on 3/21/24 at 2:31 P.M., Family Member #4 said he specifically comes to visit Resident #14 at least weekly at meal time to help the Resident consume his/her meal. He said most of the time the Resident struggles to get the food from the spoon to his/her mouth and more than half the meal usually ends up on the Resident's lap or table and causes the Resident frustration. He said he doesn't know if the facility staff don't have the time or if the Resident is ineligible for assistance at meals, but the Resident grew up with his/her entire family running a restaurant business and food brings him/her lots of joy. He said he would be grateful if the facility would provide the Resident with more assistance during meals because he/she loves to eat and the entire experience of having a meal. He said he comes in to assist the Resident, who needs to be reminded not to rush because he/she is a choking risk and gets pneumonia. He said the Resident is not always capable of completing the task of eating independently and they leave the Resident alone to do so and that is his only concern. Review of the current care plans for Resident #14 indicated, but were not limited to the following: Focus: Resident has a self care deficit secondary to limited physical mobility related to Parkinson's disease and impaired vision (revised: 5/31/22) Goal: Resident will safely perform to maximum ability with self care activities through target date (revised: 3/12/4) Interventions: Eating: Continual supervision; aspiration risk (revised: 1/22/24) The surveyor made the following observations and had the following interactions with Resident #14: - 3/12/24 at 8:39 A.M., Resident in bed with breakfast in front of him/her. Resident was using a weighted spoon and attempting to eat his/her puree pancakes. The spoon was half empty or empty once the Resident got the food to his/her mouth landing on the Resident's shirt and overbed table. Resident #14 said, I'm doing poorly, I can't get this, and continued to attempt to scoop a spoon of scrambled egg into his/her mouth, but the food was dropping off the spoon and the Resident placed an empty spoon into their mouth. There was no staff in the room providing supervision or assistance to the Resident. - 3/12/24 at 8:49 A.M., Resident attempting to eat breakfast with the weighted spoon. Resident got approximately a half spoon full of egg into his/her mouth and said, Got some. Egg and pancake were observed on the Resident's clothing and table. There was no staff in the room providing continual supervision or assisting the Resident. - 3/12/24 at 8:53 A.M., Resident eating egg and pancake mixture with weighted spoon, but the Resident's hands were shaking hands as he/she attempted to scoop them into his/her mouth. There were no staff in the room providing supervision or assistance, Resident #14 said: I need help, I can't get it all. - 3/12/24 at 12:23 P.M., Sitting in high back wheelchair in his/her room leaning slightly forward to the right. Lunch was in front of the Resident and he/she appeared to be struggling while attempting to scoop ground meat with tomato sauce on it into his/her mouth with the weighted spoon. The Resident said, It's a bit hard. There were no staff members providing supervision or assistance to the Resident. The surveyor observed three Certified nurse assistants (CNA) standing at the opposite end of the hall socializing. - 3/12/24 at 12:36 P.M., CNA #8 entered Resident #14's room and asked the Resident if he/she was done eating lunch. The Resident replied, I'm hungry still and the CNA replied, Ok, well go ahead and eat then and left the room without providing the Resident any assistance or supervision. Only about 25% of the lunch meal was observed to be missing from the lunch tray at this time. - 3/12/24 at 12:47 P.M., CNA #8 re-entered Resident #14's room and asked if the Resident was still eating or if she could take the lunch tray. The Resident replied: ok can I just have a little something and the CNA offered the Resident a pudding dessert and milk. CNA #8 said the Resident ate about 50% of his/her meal. Food was observed on the Resident's lap. She did not remain with the Resident while he/she consumed their pudding and milk. - 3/13/24 at 8:03 A.M., CNA #7 repositioned Resident #14 in his/her bed and provided him/her their breakfast tray. The tray consisted of scrambled eggs and moist puree appearing pancakes and the Resident was left alone to consume it. CNA #7 did not stay in the room to provide the Resident with supervision or assistance if needed. - 3/13/24 at 8:20 A.M., Resident was struggling to use the weighted spoon to bring a scoop of eggs to his/her mouth. Food was falling off the spoon as it made its way to the Resident's mouth. There were no staff in the room providing supervision to the Resident. - 3/13/24 at 8:49 A.M., Resident observed to have eggs on their lap/clothing. There was no staff in the room to supervise or assist the Resident. Resident #14 said, I'm trying to get more and thank you for checking on me. - 3/13/24 at 12:23 P.M., Sitting up in the bed with lunch meal in front of him/her and the weighted spoon in his/her right hand. The Resident was attempting to scoop a spoonful of ground meat with tomato sauce into his/her mouth and some food was falling off the spoon as he/she reached their mouth landing on his/her lap. The Resident said, I'm having a problem and was observed to be having difficulty consuming their meal. There were no staff in the room providing supervision. -3/14/23 at 8:30 A.M., Sitting in bed, using the weighted spoon to bring scrambled egg to his/her mouth with shaking hands. The Resident was observed to cough following a full spoon of eggs making it into his/her mouth. A second attempt of bringing a scoop of egg to his/her mouth resulted in egg being spilled on the Resident's chest. There was no staff in the room to supervise the Resident. 3/14/24 at 12:24 P.M., Sitting in high back wheelchair in his/her room consuming his/her lunch. There were no staff in the room providing supervision to the Resident. 3/15/24 at 8:39 A.M., Sitting in bed attempting to eat scrambled eggs with a weighted spoon, there is egg observed on the Resident's chest, there are no staff in the room supervising the Resident. Review of the medical record for Resident #14 indicated a Speech Language Pathology (SLP) skilled therapy Discharge summary dated : 9/6/23, that indicated, but was limited to the following information: - Resident is at elevated risk for aspiration with all by mouth (PO); Resident is receptive to cues for small bites, slow rate of intake. - Resident requires supervision or assistance at meal time due to safe swallowing 76 - 90% of the time During an interview on 3/13/24 at 1:52 P.M., the SLP said she knew Resident #14 and had treated him/her. She said Resident #14 is very high risk for aspiration and should be supervised for meals to ensure he/she is safe from aspiration. During an interview on 3/14/24 at 8:37 A.M., CNA #5 said Resident #14 is well known to her and requires supervision with all meals. She said the staff are not constantly supervising because they have been told they can no longer use the lounge to supervise and assist resident's with meals and it is not possible to supervise all the residents on the unit as they are supposed to. She said Resident #14 does require assistance with meals at times, but she felt the Resident was reluctant to accept the help. During an interview on 3/14/24 at 8:39 A.M., CNA #3 said Resident #14 requires supervision for all meals related to shaky hands and risk of aspiration. She said the residents on the unit who require supervision are not supervised because the staff are no longer allowed to use the lounge for residents to have meals and be supervised or receive assistance and therefore the staff can only intermittently check in on the residents on the unit while eating. She said they really need the room back to help supervise the residents on the unit and keep them safe. Review of the February and March 2024 CNA documentation for the task of eating for Resident #14 indicated, but was not limited to the following: February 2024: - 60 of 87 meal opportunities were not documented - of the 27 documented opportunities: the Resident received set-up eight times, supervision six times, substantial assistance once, moderate assistance once and was documented as independent 11 times. March 2024: - 35 of 41 meal opportunities were not documented - of the 6 documented opportunities: the Resident received supervision twice and was documented as independent four times. During an interview on 3/14/24 at 11:38 A.M., the Administrator said the staff have not been allowed to use the dining area on the unit for the last two to three weeks related to a COVID-19 outbreak in the facility. He said since the numbers are improving he will likely open up that room again for the residents in the facility to be able to have their meals and receive the necessary supervision or assistance they require in the next few days. He said the expectation is that the staff would provide supervision and assistance to the residents in their rooms as required in the interim. He could not explain how seven staff members could assist an entire unit with meals, supervise those who required it and pass meals all at the same time. He was made aware of the surveyor's concerns and observations and said residents requiring meal supervision should be receiving it in accordance with their care plans and orders and it appeared they were not. During an interview on 3/14/24 at 12:41 P.M., the surveyor observed CNA #5 supervising Resident #14 during the lunchtime meal in his/her room. She said Resident #14 is an aspiration risk and requires constant supervision because at times the Resident struggles to feed him/herself. She said the Resident did not receive constant supervision at meals in the last week or so since the dining room had been closed. She said the unit has two residents who are full assist for meals and about 15 who require supervision so it was not possible to supervise them all at once but now that they are able to have communal dining again it should be possible. During an interview on 3/14/24 at 12:44 P.M., Nurse #1 said Resident #14 is suppose to be supervised at all times with meals related to an aspiration risk, but when all the residents are in their rooms they do not have the staff to accomplish this. She reviewed the care plan and said Resident #14 has not been receiving the continual supervision as the care plan indicated is required. During an interview on 3/14/24 at 3:12 P.M., the DON said the Resident should have been supervised in accordance with the plan of care and in these circumstances that appears to not have occurred. 5. Resident #26 was admitted in December 2020 and has diagnoses including: hemiplegia and hemiparesis (one-sided muscle weakness or paralysis) affecting the left non-dominant hand and polyneuropathy (the damage of multiple peripheral nerves resulting in problems with sensation, coordination, and/or function). Review of the most recent BIMS for Resident #26, dated 12/6/2023, indicated Resident #26 was cognitively intact with a score of 15 out of 15 and made his/her own decisions. During an observation with interview on 3/12/24 at 8:59 A.M., the surveyor observed Resident #26 to have a contracted left hand with no splint or device in place. The Resident said his/her left hand was contracted and he/she used to have a splint he/she wore but the device doesn't work and was broken. The Resident said now it just sits in his/her bottom drawer. The Resident showed the surveyor a printout hanging on their bedroom wall about the splint and how long it was supposed to be worn. The Resident said it hasn't been worn in probably one or two months and they are afraid the hand will freeze closed and they will never be able to use it again. The Resident said, No one notices or seems to care. The Resident said that they told the nursing staff he/she had issues with their splint but nothing had been done about it. Review of the posted paper on Resident #26's wall titled Wearing Your Splint, undated, indicated but was not limited to the following: - Wearing your splint was highlighted on as needed for your comfort / between A.M. and P.M. care about four to six hours. - May remove for hand washing, bath and shower, wound care or exercises - Contact your therapist if you have any questions or any of the following happen: your splint is not comfortable, or you feel your splint needs to be fixed During an interview on 3/13/24 at 8:56 A.M., CNA #4 said the Resident chooses not to wear his/her left hand splint and she hasn't seen the splint in a while. During an interview on 3/13/24 at 10:16 A.M., CNA #7 said he has not seen the Resident wear his/her hand splint in a while. He said he has seen him/her exercise and open his/her hand, but not wear the splint. During an interview on 3/14/24 at 10:05 A.M., CNA #6 said Resident #26 is his/her own person and chooses not to wear the left hand splint because they don't like it and thinks it is not the right one for them. She said she has not seen the splint on the Resident for quite a while. During an interview on 3/13/24 at 10:11 A.M., Nurse #2 said the Resident #26 does not wear the splint. She said she does not know why the Resident chooses not to wear it and she has not asked the Resident or notified the rehab department or therapist of the issue. Review of the current physician orders for Resident #26 as of 3/14/24 indicated, but were not limited to the following: - Nursing staff to assist to don (put on) hand/wrist orthosis (splint) daily between A.M. and P.M. care, as tolerated for four to six hours a day. Care also includes hourly skin checks to assess for areas of redness, blanched skin, pain, pressure, tingling or soreness and to ensure proper fit of orthosis. If patient experiences any of the above symptoms remove orthosis and contact occupational therapy department. (9/7/23) Review of the CNA Visual bedside Kardex (summary of resident's care and preferences) for Resident #26 as of 3/14/24 failed to indicate the Resident wore a splint on his/her left hand or required staff assistance with putting the splint on daily. Review of the current care plans in place for Resident #26 as of 3/14/24 indicated but were not limited to the following: Focus: - Hemiplegia/hemiparesis related to stroke (10/13/22) Goal: - Will remain free of complications or discomfort related to hemiplegia/hemiparesis through review date (revised: 1/9/24) Interventions: - Discuss with Resident and family any concerns, fears, issues regarding diagnosis and treatments; give medications as ordered (revised: 12/20/23) - Obtain and monitor diagnostics and labs work as ordered; pain management as needed (revised: 12/20/23) - Provide referrals to community resources as needed (PRN) (revised: 12/20/23) - Physical therapy (PT), Occupational therapy (OT), Speech therapy (ST) evaluate and treat as ordered (12/20/23) The care plan failed to indicate Resident #26 should wear a orthosis/splint on his/her left hand or that nursing staff should assist the Resident with putting the device on daily. During an interview on 3/14/24 at 12:35 P.M., Unit Manager #1 said Resident #26 should have a care plan for use of the left hand splint and does not. During an interview on 3/14/23 at 3:12 P.M., the DON said care plans should be developed in accordance with the facility policy and in these circumstances that expectation was not met. 6. Resident #58 was admitted to the facility in October 2023 and has diagnoses including: Alzheimer's dementia and depression. Review of the most BIMS for Resident #58 indicated he/she was severely cognitively impaired with a score of 1 out of 15 and his/her healthcare proxy (HCP) was invoked. a. On 3/12/24 at 8:21 A.M., the surveyor observed a sign posted over Resident #58's bed that indicated the following: Resident's geri sleeves is to stay on at all times. Remove only for hygiene. Please and thank you. [sic] During a telephone interview on 3/12/24 at 4:48 P.M., Family Member #1 said that she believes the Resident wears geri-sleeves as a preventative for skin tears. She said she has not seen the geri-sleeves on her family member in quite some time and does not know why. Review of the most recent [NAME] plus score assessment for skin risk, dated 2/5/24, indicated a final assessment score of seven, indicating the Resident was high risk for skin break down. (A score under 10 indicates high risk) Review of the progress notes from 1/1/24 to 3/13/24 indicated but were not limited to the following: -1/18/24: Skin to bilateral upper extremities (BUE) very fragile, geri-sleeves at all times, remove only for hygiene Review of the current Physician's Orders for Resident #58, dated 3/13/24, indicated but were not limited to the following: -Geri-sleeves at all times, every shift for skin protection (11/15/23) Review of the CNA visual/bedside Kardex, dated 3/14/24, failed to indicate the Resident required bilateral geri-sleeves be worn. Review of the current care plans for Resident #58 indicated but were not limited to the following: Focus: Potential skin: potential alteration in skin integrity (revised: 2/9/24) Goal: Skin will remain intact through next review (revised: 1/9/24) Interventions: Complete skin condition check weekly (11/24/23) Follow MD orders for skin care and treatments (11/24/23) Pressure redistribution cushion to chair and mattress to bed (11/24/23) Inspect feet daily with care and moisturize and protect skin with barrier cream following incontinent care (11/24/23) Turn and reposition every two hours as needed (2/9/24) Off-load heels when in bed (2/9/24) Dietary intervention/evaluation and pressure ulcer risk assessments (2/9/24) The care plan failed to indicate Resident #58 was to wear geri-sleeves to both arms at all times, every shift for skin protection or that the devices should only be removed for care and hygiene. During an interview on 3/13/24 at 12:34 P.M., CNA #3 said Resident #58 did not have a pair of geri-sleeves available for use in the Resident's room. During an interview on 3/13/24 at 12:41 P.M., Unit Manager #1 said Resident #58 had an active order to wear geri-sleeves and should have a care plan in place to help direct the staff in their use and did not. During an interview on 3/14/24 at 3:17 P.M., the DON said care plans should be individualized, developed and implemented to meet each individual resident's needs and the policy was not met. b. Review of the medical record indicated the Resident's last Activity assessment and documentation was completed on 10/31/23 and indicated but was not limited to the following information: - Religious/Spiritual information: Resident #58 is Catholic and would be interested in attending religious services and receiving religious visits. - Interests/Preferences: gardening, music, Boston sports, movies, newspapers, cats and being with people is number one thing he/she enjoys - Participation Expectations: Family would like the Resident to attend groups, although he/she cannot partake, they believe the stimulation of being near other people would be beneficial. Unable to be independent in any situation but the staff can put on a television (TV) for sports, news or music. - Summary/Comments: Resident #58's family assisted with the assessment and want him/her to be at scheduled programs, they are aware of the inability to interact, but wish for attendance for the audio stimulation. Resident will be offered groups when out of bed and staff will assist with putting the TV on for him/her when in his/her room. During a telephone interview on 3/12/24 at 4:48 P.M., Family Member #1 said Resident #58 was very social in his/her life and enjoys being around people. She said she usually finds the Resident sitting in the hallway when she arrives for a visit. She said it doesn't seem the Resident attends many activities but indicated it would be nice for him/her to attend even though they cannot participate related to their cognitive status, just to be there and receive the stimulation and be around his/her peers. Review of the progress notes for Resident #58 from 11/1/23 through 3/13/24 indicated but was not limited to the following: 11/2/23: Risk meeting note: Long term care with severe dementia. Needs a more structured activity plan. Nursing will get Resident out of bed daily so he/she can be brought to activities programming. 11/15/23: Care plan meeting note: Family would like Resident to be up early so he/she can attend activities and report the Resident was always a people person. 2/20/24: Quarterly Note/review: Resident is alert, forgetful and confused and out of bed daily to a Broda chair [positioning chair]. Enjoys interacting with staff and peers especially one to one visits and small group activities due to advanced dementia. Review of the current care plans for Resident #58 failed to indicate a care plan addressing leisurely pursuits, activity involvement or methods to enrich the Resident's life through social interaction or stimulation, as indicated in the October 2023 activity assessment. During an interview on 3/14/24 at 2:08 P.M., Activity Assistant (AA) #1 said Resident #58 does not attend activities and usually just sits in a chair in the hallway. She said the Resident isn't capable of participating in any groups and is confused so the activity staff would not approach the Resident or transport him/her to activities, since they can't understand. She said she does not make the care plans and was not aware Resident #58 did not have a care plan for activities or a recent activity assessment completed. She said those tasks are completed by the Activity Director. The facility has not had an Activity Director in place since November 2023 or at the time of the survey. During an interview on 3/15/24 at 11:35 A.M., Unit Manager #1 said she is newer to the facility and learning the residents and their interests and is not aware of what Resident #58 may be interested in or capable of benefiting from in activities. She said the Resident should have a care plan for activities and social interaction but does not. 7. Resident #94 was admitted to the facility in May 2021 and had the following diagnoses: Unspecified dementia, moderate with other behavioral disturbances and major depressive disorder. Review of the most recent BIMS, dated 1/19/24, indicated he/she was severely cognitively impaired with a score of 3 out of 15 and he/she had a family guardian in place. Review of the medical record for Resident #94 indicated the last quarterly recreational (activity) assessment and note was completed on 5/17/23 and indicated, but was not limited to the following: Activity participation: - Resident participated in 1:1 activities, out of room activities less than weekly and religious activities when available - Resident has entertainment appliances in the room consisting of TV and family visits Additional comments: Resident attends 4-5 activities weekly, his/her family visits regularly Limitations and accommodations: - Activities are modified to accommodate cognitive deficit - Assistance is provided to get to the activity Additional comments: Resident is pleasantly forgetful and needs reminders to when activities are starting and assistance to get to activities. During activities he/she requires cues to stay on task. Comments and Plan of Care: Resident #94 is alert and social with others and likes to attend activities weekly. Pleasantly forgetful and needs reminders and cues to help during activity to remember what he/she is doing. Family visits regularly. Activity department will continue to provide Resident with friendly reminders when an activity is starting and assistance to get to the activity and back to his/her room after the activity is over. Review of Resident #94's current care plan for activity involvement included but was not limited to the following: Focus: Resident is alert with the ability to express themselves and needs time to process and respond to questions asked; he doesn't always like the group setting and sometimes likes alone time; he/she is Catholic, was a teacher, and served in the Coast Guard, at home the Resident used to paint, read, watch TV, watch sports and listen to music, also enjoys conversing with people one on one (10/9/22) Goals: Will watch football and hockey games in the lounge throughout the season; be independently active by painting, coloring, reading and watching TV; will attend events of interest four times weekly with active participation and socialization (revised: 9/13/23) Interventions: Assist with watching hockey and football, provide a schedule of games to see if he/she would like to watch; set up with books, adult coloring books and painting opportunities, put on the list for communion, see if another resident would like to play checkers (revised: 10/5/23) Provide calendar of events; invite to groups; assist with transport to and from groups; introduce to his/her neighbors they are sitting with and assist with program as needed; praise all efforts to attend (revised 10/5/23) During an interview on 3/14/24 at 9:26 A.M., CNA #5 said Resident #94 does not usually attend activities that she is aware of. The surveyor made the following observations of Resident #94 and had the following interactions: - 3/13/24 at 11:50 A.M., Sitting in wheelchair (wc) at the nurses' station, not being engaged by staff, no music playing, just sitting in the hallway alert with their head down, there are no activities occurring on the unit - 3/14/24 at 8:42 A.M., Sitting in bed, eating breakfast, there is no TV on or music playing in the room. Resident #94 said he/she would like to go to an activity and cannot recall the last time he/she went - 3/14/24 at 10:39 A.M., Sitting in bed, there is no staff engagement, no TV or music playing in the room and Resident #94 is just looking at the curtain in between the two beds which is partially pulled shut, he/she said they were just waiting - 3/14/24 at 10:46 A.M., CNA #6 entered the room and offered to get Resident out of bed, he/she declined and the CNA offered to put the TV on for the Resident who with a big smile said yes, thank you - 3/14/24 at 2:04 P.M., Sitting in bed, there are no staff in the room engaging with the Resident and there is no TV or music playing, Resident #94 is staring towards the obstructed view of the window, there is no activity program taking place on the unit at this time - 3/14/24 at 2:34 P.M., Lying in bed, no music or TV on in the room, there is an ice cream social and karaoke activity taking place on the unit - 3/15/24 at 11:11 A.M., Sitting in wc in the hallway outside of his/her room, there is no staff engagement and no music playing, the Resident said he/she was bored and no one offered to bring them to activities down the hall, there was a 10:30 A.M. trivia activity and an 11:00 A.M., sittercise activity in the main dining room down the hall occurring at this time During an interview on 3/14/24 at 10:18 A.M., AA #2 said Resident #94 does not attend activities or bring themselves to the activity area. She said activity staff are responsible for bringing residents to activities if they want to attend, but it is usually the same residents who attend all the time and they know the schedule and bring themselves down. She said Resident #94 does not usually attend and she has not offered any activities to the Resident. The facility failed to implement the activity care plan.Based on observations, interview, policy review, and record review, the facility failed for nine Residents (#24, #226, #49, #14, #26, #58, #94, #44, and #114), out of a total sample of 24 residents, to develop and implement individualized person-centered care plans to meet the resident's physical, psychosocial and functional needs. Specifically, the facility failed: 1a. For Resident #24, to develop and implement a care plan that identified risk factors as well as interventions designed to reduce or prevent the development of pressure related ulcers/injuries upon which the Resident developed a facility acquired full thickness unstageable (actual depth of ulcer is completely obscured by slough and/or eschar in the wound bed) left heel ulcer; and b. to develop and implement a care plan that identified risk factors as well as interventions designed to help prevent incidents/accidents upon which the Resident who had six total falls, one of which resulted in an acute left-sided 7th rib fracture, healing 5th and 6th rib fractures, and a closed head injury; 2a. For Resident #226, to develop and implement a care plan to help prevent incidents/accidents; and b. to develop and implement a care plan to address the Resident's physical, psychosocial, and functional needs while receiving dialysis services; 3. For Resident #49, to develop a care plan for activities; 4. For Resident #14, to implement a care plan intervention of continual supervision during meals for the Resident's high risk for aspiration (the drawing of food or fluid into the lungs while eating); 5. For Resident #26, to develop a person-centered care plan for the use and care of a splint device to help prevent the worsening of a left hand contracture; 6a. For Resident #58, to develop and implement a person-centered care plan to ensure the use of physician ordered Geri-sleeves to help protect the Resident from skin tears on his/her bilateral arms, and b. to ensure the Resident was engaged in leisurely activities to help enhance his/her quality of life and had an individualized care plan indicating what types of leisurely pursuits the Resident may enjoy within their cognitive abilities; 7. For Resident #94, to implement the activities person-centered care plan; 8. For Resident #44, to develop and implement an individualized care plan for this Resident who would take their bedroom furniture apart; and 9. For Resident #114, to develop a care plan for activities. Findings include: Review of the facility's policy titled Care Plans Comprehensive, dated as revised 10/2022, indicated but was not limited to the following: -a comprehensive, person-centered care plan that includes measurable objectives, and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment -the comprehensive person centered care plan will: describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; include resident preferences and goals; incorporate identified problem areas and risk factors; reflect the r[TRUNCATED]

Based on observation, interview, record review, and policy review, the facility failed to ensure one Resident (#24), out of a total sample of 24 residents, received care and treatment per professional standards of practice to promote optimal wound healing and to prevent the development of a facility acquired unstageable (actual depth of ulcer is completely obscured by slough and/or eschar in the wound bed) left heel ulcer, full thickness. Specifically, the facility failed to conduct a timely Braden risk assessment upon admission to predict the Resident's level of risk for pressure ulcer development, complete an admission comprehensive skin assessment documented in the Resident's electronic health record (EHR), develop and implement a care plan that identified risk factors as well as interventions designed to reduce or prevent the development of pressure related ulcers/injuries, obtain orders and provide wound care treatments per wound consultant recommendations, and consistently off-load the Resident's heels and ensure weekly skin checks were completed per physician's orders. Findings include: Review of the facility's policy titled Pressure Wound Prevention, revised February 2022, indicated but was not limited to the following: -Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. -Assess the resident on admission for existing pressure ulcer/injury risk factors. Repeat the Braden risk assessment weekly for 4 weeks then quarterly, annually or any significant change in resident condition. -Conduct a comprehensive skin assessment upon admission including: a. skin integrity - any evidence of existing or developing pressure ulcers or injuries; b. tissue tolerance; and c. areas of impaired circulation due to pressure from positioning or medical devices. -Identify any signs of developing pressure injuries and inspect pressure points. -Evaluate, report, and document potential changes in the skin. -Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's policy titled Protocol - Wound Care and Rounds, revised January 2023, indicated but was not limited to the following: New Wound Identified in House: -Licensed nurse should complete an assessment of the wound including shape, size, depth, staging (if applicable) and condition of wound. -Licensed nurse/manager/supervisor will notify the physician and obtain a treatment order and an order for pain medication 30 minutes prior to treatment. -An Incident Report and Facility Acquired Pressure Ulcer Investigative Tool will be initiated. -Interdisciplinary team should review and revise the care plan for new interventions, during morning meeting the following day as applicable. -A comprehensive nurse's note will be completed identifying the wound as unavoidable/ avoidable with documentation including co-morbidities, risk factors and interventions. -Weekly rounds should take place on the same day each week Review of the facility's policy titled Wound - Ulcer, dated January 2023, indicated but was not limited to the following: -Nurses may not diagnose, just describe -Staff will institute a plan for any resident who has potential for skin breakdown or whose condition is deteriorating. This may include: d. floating areas of concern such as heels when appropriate f. use of elbow or heel protectors when appropriate Resident #24 was admitted to the facility in December 2023 with diagnoses including encephalopathy (any brain disease that alters brain function or structure), diabetes mellitus type 2, cognitive communication deficit, unsteadiness on feet, and lack of coordination. Review of the Minimum Data Set (MDS) assessment, dated 12/28/23, indicated Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was at risk for developing pressure ulcers, and had no unhealed pressure ulcers. The MDS also indicated skin and ulcer treatments of ointments/medications were being applied other than to the feet. During an interview on 3/12/24 at 9:17 A.M., Resident #24 said he/she had a hematoma (pool of clotted blood) on his/her left heel from three to four weeks ago, was not sure how he/she got it, but it was very painful. The Resident said he/she was being followed by the wound doctor. December 2023 Review of the admission Physician's Progress Note, dated 12/23/23, indicated the Resident's skin was warm and dry and had chronic lower extremity edema versus lymphedema. There was no mention of an alteration in skin integrity. Review of the medical record for Resident #24 failed to indicate a comprehensive care plan was developed on admission for the prevention of skin breakdown and pressure injuries despite the MDS indicating the Resident was at risk for developing pressure injuries. Review of Physician's Orders indicated the following: -Weekly skin assessment by a licensed nurse (documented in Point Click Care (PCC), electronic health record) every evening shift every Monday, 12/25/23 January 2024 Review of a Physician's Progress Note, dated 1/1/24, indicated Resident #24's skin was warm and dry with an erythematous patch on very low back and upper buttock and had a shingles rash. There was no mention of an alteration in skin integrity to the Resident's left heel. Review of a nursing Skilled Evaluation, dated 1/5/24, indicated the Resident's skin was warm and dry, skin color within normal limits and turgor was normal. There was no mention of an alteration in skin integrity to the Resident's left heel. Review of a Physician's Progress Note, dated 1/8/24, indicated Resident #24 reported left heel pain. His/her extremities were edematous and swollen and a left heel blister was noted with some darkened fluid as if there was mild bleeding within; no erythema or induration to suggest infection. Review of Physician's Orders indicated the following: -Mupirocin External Ointment 2%, apply to left heel topically two times a day for blister, wash with normal saline, pat dry, apply Mupirocin two times daily, start 1/9/24, stop 1/11/24 -Mupirocin External Ointment 2%, apply to left heel topically every day and evening shift for wound care, wash with normal saline, pat dry, apply Mupirocin two times daily, start 1/12/24, stop 3/14/24 Review of the medical record indicated a Norton Scale for Predicting Risk of Pressure Ulcer assessment was completed on 1/12/24, three days after the identification of a left heel blister and three weeks after admission, indicating Resident #24 was at high risk for developing pressure injuries. Review of the medical record indicated a care plan was developed on 1/12/24 for an Alteration in Skin Integrity related to diabetes, edema, urinary incontinence, and a left heel unstageable wound and was as follows: -Goal: Resident's skin would show improved healing through the next review date -Interventions: complete skin condition check weekly, dietary intervention/evaluation, follow MD orders for skin care and treatment, seen by wound MD, heels off-loaded when in bed, inspect feet daily and report changes to nurse, pressure ulcer risk assessment weekly x 4 weeks upon admission then quarterly and with change in condition, and to protect the skin with incontinent care, 1/12/24. Further review of the medical record indicated a care plan was developed on 1/12/24 for Diabetes Mellitus and was as follows: -Goal: Resident will have no complications related to diabetes through the review date -Interventions: Check all of the body for breaks in skin and treat promptly as ordered by doctor, inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness, and monitor/document/report to MD as needed for signs and symptoms of infection to any open areas: redness, pain, heat, swelling or pus formation, 1/12/24 Review of the January 2024 Treatment Administration Record (TAR) failed to indicate a weekly skin assessment was conducted on 1/24/24 and failed to indicate the Mupirocin external ointment 2% was documented as being applied topically to the Resident's left heel every day and evening shift for wound care for 8 out of 26 shifts from 1/12/24-1/24/24. Review of a nurse's Clinical admission Note, dated as a late entry on 1/24/24, 33 days after admission, indicated Resident #24 had a left heel diabetic foot ulcer with slough present in the wound bed, purulent wound exudate, fragile skin peri wound, minimal dressing saturation, boggy skin, pain, and was receiving daily wound treatments. Review of the Initial Wound Evaluation and Management Summary for Resident #24, dated 1/25/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicted the wound was a new injury, greater than 11 days in duration, measured 4.3 x 2.5 x 0.1 centimeters (cm) and was a pressure wound. Recommendations included: Primary Dressing - normal saline wash apply once daily for 30 days, Iodosorb gel, apply once daily for 30 days Secondary Dressing - abdominal pad apply once daily for 30 days, gauze roll (stretch) 4 apply once daily for 30 days, tape (waterproof adhesive) apply once daily for 30 days -Peri-wound Treatment - skin prep apply once daily for 30 days Plan of Care Recommendations - elevate legs, float heels in bed, off-load wound, reposition per facility protocol, pillows, booties Review of Resident #24's care plan indicated the recommended intervention for booties was not implemented until 2/6/24, 12 days after the wound doctor assessed the Resident. Review of a Nurse's Progress Note, dated 1/25/24, indicated the Resident presented with a wound on the left lower extremity (heel) at the time of bilateral leg wrapping treatment. The patient complained of having lots of pain coming from the heel. The wound was 4 x 6, red color around it with a small amount of slug (Sic). The patient was seen that day by the wound doctor. New orders in place and started today on the 3-11 shift. Review of the January 2024 TAR and Medication Administration Record (MAR) failed to indicate a treatment order was obtained for the Iodosorb gel, abdominal dressing, gauze roll stretch, and skin prep dressing to the left heel per the Wound Physician's recommendations. Further review of the January 2024 TAR indicated the Mupirocin external ointment 2% continued to be applied topically to the Resident's left heel every day and evening shift for wound care for 8 out of 12 shifts from 1/26/24-1/31/24. February 2024 Review of the Wound Evaluation and Management Summary for Resident #24, dated 2/1/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicated the wound size was 4.3 x 2.6 x 0.1 cm and was not at goal. Surgical excisional debridement (dead or unhealthy tissue removed) was performed. The Wound Physician recommended the same treatment as indicated in the previous 1/25/24 visit. The Resident's Alteration in Skin Integrity care plan was revised to include a left heel bootie on while in bed as tolerated, initiated 2/6/24. Review of the Wound Evaluation and Management Summary for Resident #24, dated 2/8/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicated the wound size was 4.7 x 2.8 x 0.1 cm and was not at goal. Surgical excisional debridement was performed. The Wound Physician recommended the same treatment as indicated in the previous 1/25/24 and 2/1/24 visits. Review of the Wound Evaluation and Management Summary for Resident #24, dated 2/15/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicated the wound size was 4.7 x 3.2 x 0.1 cm and was not at goal. Surgical excisional debridement was performed. The Wound Physician recommended the same treatment as indicated in the previous 1/25/24, 2/1/24, and 2/8/24 visits. Review of the Wound Evaluation and Management Summary for Resident #24, dated 2/22/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicated the wound size was 4.7 x 3.3 x 0.1 cm and was not at goal. Sharp selective debridement was performed. The Wound Physician recommended the same treatment as indicated in the previous 1/25/24, 2/1/24, 2/8/24, and 2/15/24 visits. Review of the Wound Evaluation and Management Summary for Resident #24, dated 2/29/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicated the wound size was 4.4 x 3.5 x 0.1 cm and was not at goal. Surgical excisional debridement was performed. The Wound Physician recommended the same treatment as indicated in the previous 1/25/24, 2/1/24, 2/8/24, 2/15/24, and 2/22/24 visits. Review of the February 2024 TAR and MAR failed to indicate a treatment order was obtained for the Iodosorb gel, abdominal dressing, gauze roll stretch, and skin prep dressing to the left heel per the Wound Physician's recommendations and no documentation was found in nurse progress notes to suggest the specific wound treatment recommendations were being followed. Further review of the February 2024 TAR indicated the following: -weekly skin assessments not conducted on 2/12/24 and 2/19/24 -left foot bootie/heel protector not documented as being applied for 21 out of 87 shifts -Mupirocin external ointment 2% continued to be applied topically to the Resident's left heel every day and evening shift for wound care for 29 out of 58 shifts March 2024 Review of the Wound Evaluation and Management Summary for Resident #24, dated 3/7/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicated the wound size was 3.7 x 2.8 x 0.1 cm and improved. Surgical excisional debridement was performed. The Wound Physician recommended the same treatment as indicated in the previous 1/25/24, 2/1/24, 2/8/24, 2/15/24, 2/22/24, and 2/29/24 visits. Review of Physical Therapy Treatment Encounter Notes, dated 1/24/24, 1/30/24, 2/1/24, 2/6/24, and 2/7/24, indicated the patient denied gait training and/or transferring due to pain in the left heel, increased sensitivity, and/or due to wound. Review of the Resident's Alteration in Skin Integrity care plan indicated it was revised to include a consultation with the vascular surgeon, initiated 3/14/24. Review of the March 2024 TAR and MAR failed to indicate a treatment order was obtained for the Iodosorb gel, abdominal dressing, gauze roll stretch, and skin prep dressing to the left heel per the Wound Physician's recommendations until 3/14/24. Further review of the March 2024 TAR indicated the following: -weekly skin assessments not conducted on 3/11/24 -Mupirocin external ointment 2% continued to be applied topically to the Resident's left heel every day and evening shift for wound care for 24 out of 26 shifts During an interview on 3/14/24 at 10:42 A.M., the surveyor observed Resident #24 lying in bed. The Resident did not have a foam bootie on his/her left foot as recommended by the wound doctor. He/she said the last time it was applied was maybe last week, but lately never. The Resident said he/she started with a blister on his/her left heel which had gotten worse since then, hurt more, and felt like it was infected. During an interview on 3/14/24 at 11:00 A.M., Certified Nursing Assistant (CNA) #11 said she was assigned to the Resident that day and was familiar with him/her. She said the Resident had no pressure areas she was aware of or skin issues but should have a pillow under his/her heels. She said she didn't know if he/she was supposed to have a foam bootie on. During an interview on 3/14/24 at 3:18 P.M., Nurse #9 said Resident #24 was at risk for developing pressures and had a stage 2 pressure ulcer on his/her left heel. During an observation with interview on 3/14/24 at 4:05 P.M., the surveyor observed the Resident's left heel wound with the Wound Physician and Nurse #9. The Wound Physician said the left heel was an unstageable necrosis pressure injury and the Resident came in with it. He said it was much better this day and getting a lot smaller. The wound, per surveyor observation, was approximately 2 cm x 2 cm x unstageable. The wound had a dark center and small area of detached necrotic tissue from the wound bed which was removed by the physician. Once removed, the wound bed was red in color with scant sero-sanguinous drainage. The surrounding skin was pink. The Wound Physician said they were originally using betadine (used to treat or prevent skin infection) products but the Resident was still in pain, so the new treatment was to use Iodosorb gel (gel that's applied to the skin to treat wet ulcers and wounds). The surveyor informed the Wound Physician that there was no order for the Iodosorb gel dressing treatment since the initial visit recommendation on 1/25/24 and that staff had been documenting on the TARs the mupirocin ointment application to the left heel since early January. The Wound Physician said the mupirocin treatment shouldn't have been continued as it was an antibiotic and would have needed to be monitored. He said there had been a lot of turnover with the Director of Nurses (DON) position and there was no designated wound nurse, but wound recommendations should be followed. The Wound Physician further said because the Resident crossed his/her left leg over his/her right, staff needed to off-load both. He said the Resident had bilateral lower extremity circulation issues so that may be a factor in his/her wound healing. During an interview on 3/18/24 at 11:17 A.M., Unit Manager (UM) #1 said she was not the designated wound nurse. She said sometimes the Infection Preventionist would round but whoever was available to help would help. On 3/18/24 at 11:20 A.M., the surveyor observed Resident #24 lying in bed. The Resident's heels were not elevated off the mattress and a foam bootie was not observed on the Resident's left heel in accordance with the Resident's plan of care. On 3/19/24 at 7:50 A.M., the surveyor observed Resident #24 lying sideways in bed awake with his/her feet on the ground. No foam bootie was observed in the Resident's room. During an interview on 3/19/24 at 10:26 A.M., Nurse #13 said Resident #24 was at risk for developing pressures, had pressure sites on his/her feet, and had basic bootie and heel protection orders. She said the 1/25/24 wound note indicated an unstageable pressure wound of the left heel that was new and greater than 11 days old. She said a new treatment was recommended on that visit and subsequent visits for a normal saline wash and Iodosorb dressing daily along with to float the Resident's heels while in bed, elevate the legs, and use pillows and booties, but the order was not entered until 3/14/24. She said there was no designated wound nurse but if recommendations are made by the wound physician, she wasn't sure who would take and implement them. She said there was no admission skin evaluation, no Braden risk assessment (Norton Scale) completed until 1/12/24, and a care plan for skin integrity was not developed or implemented until 1/12/24. She said interventions and treatments should have been implemented consistently to improve skin and to prevent/avoid any pressure related injuries. During an interview on 3/19/24 at 1:35 P.M., the surveyor reviewed the medical record with the DON and Consulting Staff #1. Consulting Staff #1 said the Resident was not admitted with a left heel wound. She said physician's notes, dated 12/23/23 (admission note) and 1/1/24, did not mention anything about the Resident's heels until the 1/9/24 note. She said the first skin evaluation was not conducted until 1/24/24 but should have been done upon admission and weekly. Consulting Staff #1 said the initial wound note on 1/25/24 indicated the left heel was a new pressure wound. She said if there's a wound physician recommendation, it gets printed and placed in the physician's book. If there's a change, then the nurse should call the physician to get orders and any interventions completed consistently without blank holes to prevent a pressure ulcer from forming or worsening. Consulting Staff #1 said there was no care plan in place for skin integrity until 1/12/24 and care planned interventions should be reviewed and revised quarterly and with any changes.

Based on observations, interviews, record reviews, and policy review, the facility failed to notify the physician about a change in condition in order to re-evaluate the potential need to alter the treatment plan for two Residents (#2, #61), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #2, to notify the physician regarding a 12.66% severe significant weight loss in three months (11/21/23 to 2/3/24) and 5.39% in one month (2/3/24 to 3/8/24); and 2. For Resident #61, to notify the physician regarding a 6.95% (10/21/23 to 11/21/23) severe significant weight loss in one month, as well as a 10.54% (10/21/23 to 1/25/24) severe significant weight loss in three months and an additional 10.74% severe significant weight loss in three months (11/30/23 to 3/18/24). Findings include: Review of the facility's policy titled Weight Assessment and Interventions, revised May 2019, included but was not limited to: - The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents. - Monthly weights will be obtained each month or as ordered by physician. - Weights will be recorded in the medical record (electronic health record where available) for each resident. - Any weight change of five pounds (lbs.) in a month or three pounds in a week since their last weight assessment should be retaken within 72 hours for confirmation and verified by Nursing. - Re-weigh should be reviewed by the Licensed Nurse. - Licensed Nurses should notify Dietician of identified weight change once reviewed. - Dietician notification should be documented within Resident's medical record. - Dietician or diet technician should respond within 72 hours of receipt of notification. - The threshold for significant unplanned and undesired weight change will be based on the following criteria: (a) one month: 5% weight change is significant, greater than 5% is severe; (b) three months: 7.5% weight change is significant; greater than 7.5% is severe; (c) six months: 10% weight change is significant; greater than 10% is severe. 1. Resident #2 was admitted to the facility in February 2021 with diagnoses including schizoaffective disorder and type II diabetes. Review of the Minimum Data Set (MDS) assessment, dated 1/24/24, indicated Resident #2 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Further review of Section K of the MDS assessment indicated Resident #2 had a weight loss of 5% or more in the last month or 10% or more in the last six months. Section K of the MDS assessment indicated Resident #2 was not on a prescribed weight loss regimen. Review of Resident #2's active Physician's Orders included but were not limited to: - 2/26/24: Weekly Weight - weekly weight secondary to weight loss every day shift every seven days Review of Resident #2's weights in the electronic medical record indicated the following weights: - 11/21/23: 191.2 lbs. - 12/2023: not obtained - 01/23/24: 172.2 lbs. - 02/03/24: 167.0 lbs. - 03/08/24: 160.0 lbs. Review of Resident #2's weights indicated he/she had a 12.66% severe significant weight loss in three months. Further review of Resident #2's weights indicated a 5.39% significant weight loss in one month (2/3/24 and 3/8/24). Review of Resident #2's nutritional care plan indicate interventions included but were not limited to: - Obtain weight per physician (MD) order on same scale. Notify MD/Nurse Practitioner (NP)/Registered Dietician (RD) of significant weight changes (revised 11/14/23). Review of a dietary progress note, dated 2/12/24, indicated Resident #2 had a 12.7% significant weight loss over the past three months. The RD recommended the facility obtain a reweight of Resident #2 prior to any further intervention changes. Further review indicated the RD recommended Resident #2 to have weekly weights, sugar free house supplement (four ounces twice daily) and change to regular size portions (versus the previously recommended large portions). Documentation failed to indicate MD/NP notification of continued significant weight loss was completed. Review of MD/NP notes failed to indicate MD/NP documentation related to Resident #2's significant weight loss. During an interview on 3/18/24 at 1:58 P.M., Nurse #4 said when weights are input into the electronic medical record they populate red for a significant change. Nurse #4 said the Dietitian would notify the MD directly of any new recommendations or changes. During an interview on 3/18/24 at 3:13 P.M., Unit Manager (UM) #1 said she and the RD should be reviewing weights of all residents on the unit. UM #1 said she was uncertain if Resident #2's MD was aware of their significant weight loss. UM #1 said she would be responsible for notifying the MD of changes in weight. UM #1 said staff should be notifying the MD of changes in weight to ensure the interdisciplinary team are aware. During an interview on 3/18/24 at 4:09 P.M., the RD said she reviews weights for significant weight loss when they are obtained by staff at the facility. The RD said she then determines an individualized plan for each resident to address the weight loss. The RD said the goal is to review each resident in the facility quarterly, or more often if a significant weight loss is identified. The RD said Resident #2 has had a continued significant weight loss. The RD said she notifies nursing staff of recommendations to notify the MD. The RD said she does not notify the MD of significant weight loss or recommendations herself. During an interview on 3/18/24 at 4:27 P.M., the Director of Nurses (DON) said her expectation would be for the RD to identify a significant weight loss for any residents in the building. The DON said she would expect the nursing staff and/or the RD to notify the MD regarding the changes identified. The DON said the UM should be looking at changes to identify risk factors for residents on each unit. 2. Resident #61 was admitted to the facility in December 2021 with diagnoses including hypertension, atrial fibrillation (abnormal heart rhythm), and cerebral infarction (stroke). Review of the MDS assessment, dated 2/21/24, specified a BIMS score of 14 out of 15, indicating he/she had intact cognition. Further review of Section K of the MDS assessment indicated Resident #61 had a weight loss of 5% or more in the last month or 10% or more in the last 6 months. Section K of the MDS assessment indicated Resident #61 was not on a prescribed weight loss regimen. Review of Resident #61's weights in the electronic documentation system indicated the following weights: - 9/2023: not obtained - 10/21/23: 178.4 lbs. - 11/21/23: 166.0 lbs. - 11/30/23: 169.4 lbs. - 12/2023: not obtained - 1/25/24: 159.6 lbs. - 2/2024: not obtained - 3/18/24: 151.2 lbs. Review of Resident #61's weight indicated that Resident #61 had a 6.95% severe significant weight loss between 10/21/23 and 11/21/23. Further review indicated Resident #61 had a 10.54% severe significant weight loss in three months (10/21/23 to 1/25/24). Additionally, a second severe significant weight loss of 10.74% was identified in three months (11/30/23 to 3/18/24). Review of Resident #61's nutritional care plan indicated interventions included but were not limited to: - Obtain weight per physician (MD) order on same scale. Notify MD/Nurse Practitioner (NP)/Registered Dietician (RD) of significant weight changes (revised 10/5/23). Review of MD/NP progress note documentation, dated 3/5/24, indicated the Resident was seen for family concerns related to weight loss and poor appetite. Further review of the documentation indicated Resident #61's weight was down but failed to address the significant weight loss. Documentation indicated Resident #61 may benefit from house supplement shakes three times per day. Further review of the medical record failed to indicate the MD was notified of the Resident's severe significant weight loss between 10/21/23 to 11/21/23 (6.95%), 10/21/23 to 1/25/24 (10.54%) and 11/30/23 to 3/18/24 (10.74%). During an interview on 3/18/24 at 1:58 P.M., Nurse #4 said when weights are input into the electronic medical record they populate red for a significant change. Nurse #4 said the Dietitian would notify the MD directly of any new recommendations or changes. During an interview on 3/18/24 at 3:25 P.M., UM #1 said she and the RD should be reviewing weights of all residents on the unit. UM #1 said she was uncertain if Resident #61's MD was aware of their significant weight loss. UM #1 said she would be responsible for notifying the MD of changes in weight. UM #1 said staff should be notifying the MD of changes in weight to ensure the interdisciplinary team are aware. During an interview on 3/18/24 at 4:09 P.M., the RD said she reviews weights for significant weight loss when they are obtained by staff at the facility. The RD said she then determines an individualized plan for each resident to address the weight loss. The RD said she pulls a weight report for each resident when reviewing their documentation. The RD said the goal is to review each resident in the facility quarterly, or more often if a significant weight loss is identified. The RD said Resident #61 has had a continued significant weight loss and it needed to be addressed. The RD said she notifies nursing staff of recommendations to notify the MD. The RD said she does not notify the MD of significant weight loss or recommendations herself. During an interview on 3/18/24 at 4:27 P.M., the DON said her expectation would be for the RD to identify a significant weight loss for any residents in the building. The DON said she would expect the nursing staff and/or the RD to notify the MD regarding the changes identified. Refer to F692

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #2 was admitted to the facility in February 2021 with diagnoses including schizoaffective disorder, type II diabetes, hypertension, and depression. Review of the MDS assessment, dated 1/24/24, indicated Resident #2 had severe cognitive impairment as evidenced by a BIMS score of 6 out of 15. Further review of the MDS assessment indicated Resident #2 had a history of two or more falls and required assistance from staff for bed mobility, transfers, toileting, dressing and hygiene. On 3/12/24 at 10:17 A.M., the surveyor observed Resident #2 at the nurses' station seated in a high back wheelchair, leaning forward and to their right side. Resident #2 was observed to be restless in his/her wheelchair and continuously calling out I am going to fall. The surveyor observed Nurse #4 completing her morning medication pass down the hall from the Resident and then returning to the nurses' station. Nurse #4 was observed to approach Resident #2 and reassure them that they were safe in the wheelchair. On 3/12/24 at 10:30 A.M., the surveyor observed Resident #2 seated in a wheelchair in their room. Resident #2 was observed to be seated in their high back wheelchair, leaning forward and to their right side. Resident #2 was observed to be continuously calling out Help me Resident #2 was observed to be in his/her room without a staff member present. Resident #2 was later observed to be brought back to the nurses' station by a staff member. Review of the medical record indicated Resident #2 had two falls in December 2023. Review of Resident #2's Incident Report, dated 12/1/23, indicated: - On 12/1/23 at 9:00 A.M., Resident #2 was observed by staff in the dining room on the North 2 Unit attempting to get up out of his/her wheelchair. Resident #2 was observed by staff getting out of wheelchair and falling onto his/her right side. No injuries were noted. The incident report indicated factors to the fall included Resident #2 being incontinent, agitated, and anxious. - Review of the nursing documentation indicated the Resident remained agitated in the dining room post fall. The facility failed to provide a Post Fall Evaluation Assessment for the incident on 12/1/23 which would have indicated interventions put in place and updates to the care plan after the Resident's fall. Review of the medical record failed to indicate a Rehab screen was completed post incident on 12/1/23. Review of Resident #2's interdisciplinary care plan for falls failed to indicate any interventions were developed or implemented post fall. Review of Resident #2's Incident Report, dated 12/9/23, indicated: - On 12/9/23 at 2:59 P.M., Resident #2 was found by staff in the dining room on the North 2 Unit on the ground. Staff indicated in the report the Resident was found screaming for help and a standard chair was noted to be on the ground next to him/her. The report indicated the Resident was confused and had decreased safety awareness. - The incident report indicated the Resident was assessed for injuries (none noted), taken to the bathroom and assisted into a recliner chair. Review of the Post Fall Evaluation assessment, dated 12/9/23, failed to indicate any interventions were developed or implemented post fall, as well as failed to indicate any updates were made to the Resident's care plan. Review of the medical record indicated a Rehab screen was completed post fall on 1/18/24, 40 days after the original fall. The Rehab screen indicated recommendations included for the Resident to be supervised when out of bed secondary to fall history related to behaviors and for continued assistance with transfers by staff. Review of Resident #2's interdisciplinary care plan for falls failed to indicate any interventions were developed or implemented post fall. The interdisciplinary care plan also failed to indicate implementation or development of the Rehab screen recommendations from 1/18/24. During an interview on 3/19/24 at 8:24 A.M., the Director of Rehabilitation (DOR) said the facility's process after a resident falls is for a Rehab screen to be completed. The DOR said they are notified by nursing either through a daily clinical meeting or through a screen when a resident falls. The DOR reviewed therapy documentation for Resident #2 and said he/she was not receiving therapy services in December 2023. The DOR said she had documentation a Rehab screen was completed after Resident #2's fall on 12/1/23. The DOR said Resident #2 was screened post fall on 12/9/23 by therapy services but was not picked up on caseload. During an interview on 3/19/24 at 9:57 A.M., Nurse #5 said when a resident falls an evaluation is completed including an assessment of vitals and pain. Nurse #5 said if a resident is injured or in significant pain they are transferred to the hospital. Nurse #5 said notification to the physician and resident's family is completed. Nurse #5 said a fall monitoring sheet is completed post fall. Nurse #5 said they were unsure of who was responsible for updating care plans and developing interventions to the fall. Nurse #5 and the surveyor reviewed the medical record for Resident #2. Nurse #5 said they attempt to keep Resident #2 in line of sight once he/she is out of bed for the day related to their history of falls. Nurse #5 said Resident #2 is often found close to the nurses' station or in the dining room with supervision. During an interview on 3/19/24 at 11:00 A.M., Unit Manager (UM) #1 said when a resident falls an evaluation is completed to assess for injury and pain. UM #1 said fall packets are completed post assessment to indicate the circumstances surrounding the fall. UM #1 said fall packets should include information regarding immediate interventions put in place to prevent further falls. UM #1 said information regarding falls is brought to clinical meeting the next day to keep the interdisciplinary team up to date. UM #1 said Rehab would be notified in clinical meetings or by screen from nursing about a resident's fall. UM #1 and the surveyor reviewed the medical record findings for Resident #2. UM #1 said care plans should have been updated after each fall, including interventions put into place to prevent further incidents. During an interview on 3/19/24 at 2:56 P.M., the Regional Clinical Director said an assessment is completed after each fall to identify the incident. The Regional Clinical Director said an immediate intervention should be documented and updated in the care plan after resident fall. The Regional Clinical Director said Rehab screens should be completed after each fall. The Regional Clinical Director and the surveyor reviewed the findings of Resident #2's falls. The Regional Clinical Director said screens from Rehab services should be completed timely, within a few days. The Regional Clinical Director said each fall should have had an intervention put in place post incident and been reflected in an updated care plan. 2. Resident #70 was admitted to the facility in April 2023 with diagnoses which included Alzheimer's disease, anemia, orthostatic hypotension (low blood pressure that happens when standing up from sitting or lying down), difficulty walking, syncope (fainting or sudden temporary loss of consciousness) and collapse, and a history of falls. Review of the MDS assessment, dated 12/19/23, indicated Resident #70 had a score of 3 out of 15 on the BIMS, indicating severe cognitive impairment, needed supervision/assistance with ADLs, was occasionally incontinent of urine, and had a history of falls. Review of Resident #70's medical record indicated he/she had sustained four falls between October 2023 and March 2024 (10/26/23, 10/27/23, 12/10/23, and 3/1/24). FALL #1 on 10/26/23: Review of the progress note, dated 10/26/23 at 6:41 P.M., indicated Resident #70 was alert and confused at baseline, Resident was noted on the floor with a small area to left side of temple. Additionally, the note indicated the Resident had received new glasses yesterday after not having them for a while. Nurse will monitor to ensure he/she is adjusting to having the glasses on again. Review of Incident Report, dated 10/26/23, indicated the nurse heard Resident #70 call out and upon entering the room, Resident was noted to be on the floor on his/her left side with a 1x1x0.1 centimeter (cm) cut to the left temple from his/her glasses. Additionally, a 3x3 cm bruise was noted to the left elbow. The Resident did not know how he/she fell, however stated he/she hit his/her back on the footboard of the roommate's bed. The Mental Status section indicated he/she had memory impairment. The notes section indicated Resident complained of discomfort related to the fall, no visible injuries, ice applied, MD notified, leg equal in length will continue to monitor. The Predisposing Environmental Factors section and the Predisposing Physiological Factors section were not completed. The Predisposing Situation Factors section had other checked off and the comment noted the Resident had new glasses. Review of the care plans for Resident #70 indicated but were not limited to the following: Review of the Fall Risk Care Plan for Resident #70 indicated: FOCUS: Resident #70 is at risk for falls related to deconditioning, history of fall secondary to syncope and collapse (4/11/23). GOAL: He/she will be free of falls through review date (4/11/23). INTERVENTIONS: -Be sure Resident #70's call light is within reach and encourage him/her to use it for assistance as needed. He/she needs prompt response to all requests for assistance (4/11/23) -Ensure Resident #70 is wearing appropriate footwear when ambulating or mobilizing in wheelchair (4/11/23). -Follow facility fall protocol. (4/11/23) -Physical Therapy evaluate and treat as ordered or as needed (4/11/23) The facility failed to update the Fall Risk care plan or initiate a new intervention to keep the Resident safe/prevent a repeat fall per facility policy and Fall Packet procedure guide. Review of the Activities of Daily Living (ADL) Care Plan prior to the fall on 10/26/23, indicated Resident #70 needed supervision with transfers, ambulation, and toileting. Review of the Vision Care plan for Resident #70, indicated the following: FOCUS: Resident #70 has impaired visual function related to age (8/12/23) GOAL: Resident #70 will show no decline in visual function through the review date (8/23/23) INTERVENTIONS: -Ensure appropriate visual aids (eyeglasses) are available to support his/her participation in activities (8/12/23) -Remind him/her to wear glasses when up. Ensure resident is wearing glasses which are clean, free from scratches, and in good repair. Report any damage to nurse/family. (8/12/23) There were no additional interventions on the vision care plan, current or historical. The facility failed to note the Resident had been without glasses for a while, had new glasses, or needed additional monitoring for adjustment to the new glasses status post fall. Review of the most recent Fall Risk Evaluation indicated an evaluation was done on 10/17/23 as part of the quarterly MDS schedule, and the total score was 9. The Fall Risk Evaluation determines the level of fall risk based on questions pertaining to current health status, recent fall history, ambulation status, blood pressure, vision, diagnosis/predisposing conditions, recent change in condition, and recent hospitalization. A score of 10 of greater would indicate HIGH risk for potential falls and prevention protocol should be initiated immediately and documented on the care plan. The facility failed to complete a Fall Risk Evaluation after the fall on 10/26/23 per policy. Further review of Resident #70's medical record, including progress notes, medication administration records (MAR), treatment administration records (TAR), and physician's orders failed to indicate any new intervention had been implemented to prevent additional falls/injury. FALL #2 on 10/27/23: Review of the progress note, dated 10/27/24 at 6:24 A.M., indicated at 4:15 A.M., staff heard a loud noise down the hall and found Resident #70 lying on the floor on his/her right side. Resident said he/she was coming out of the bathroom. The Resident was assisted back to bed and complained left hip was sore. Review of the Incident Report, dated 10/27/23, indicated staff heard a loud noise down the hall, and found Resident #70 lying on the floor in his/her room. The Resident said he/she was coming back from the bathroom. Resident #70 was wearing regular socks, not slipper socks and complained left hip was sore. The Mental Status section indicated he/she was memory impaired and decision making impaired. The notes section indicated the Resident had his/her walker with them. Predisposing Environmental Factor included poor lighting and adaptive equipment. Predisposing Physiological Factors included confusion, decreased safety awareness, impaired memory, and decreased strength and endurance. Predisposing Situation Factors included using a walker, side rails up, and improper footwear. Further review of the Complete Incident Report, dated 10/27/23, failed to include witness statements. Review of the Reportable Incident Folder indicated but was not limited to the following: -Date of Incident: 10/27/23 at 4:15 A.M. -There were three witness statements dated 10/26/23, all three staff members indicated they saw the resident ambulating prior to the fall the evening of 10/26/23. None of the statements indicated the staff had intervened or provided assistance/supervision. None of the statements indicated when the resident was last toileted. (One response was not sure and the other two were N/A (not applicable) to the question regarding when the resident was last toileted. The resident required supervision/assistance with toileting. -There were not any witness statements related to the fall on 10/27/23. The facility failed to provide supervision with transfers and ambulation on 10/26/23, resulting in the Resident falling in his/her room striking head, elbow, and back and failed ensure a new intervention had been implemented to prevent additional falls/injury, resulting in Resident #70 falling again, less than 12 hours later while ambulating in room and toileting self. The facility failed to update the Fall Risk care plan or initiate a new intervention to keep the resident safe/prevent a repeat fall per facility policy and Fall Packet procedure guide. Further review of Resident #70's medical record, including progress notes, and physician's orders failed to indicate any new intervention had been implemented to prevent additional falls. Review of the progress note, dated 10/27/23 at 11:51 A.M., indicated Resident #70 complained of increased pain to the left hip, had compromised circulation, sensation, and motion (CSM) to left lower extremity, had a bruise to left hip, and was grimacing in pain. An order was obtained to transfer Resident #70 to the emergency room for evaluation. Review of the Discharge Summary from the hospital, dated 10/30/23, indicated but was not limited to the following: -Resident #70 had a left displaced (the bones are not in alignment) femoral neck (hip) fracture. -Resident #70 underwent a left hip hemiarthroplasty (surgery to replace half of the hip joint with an artificial one). The facility failed to provide supervision with transfers, ambulation, and toileting, and failed to ensure Resident #70 had proper footwear on while ambulating, resulting in the Resident falling in his/her room and fracturing his/her hip. The facility failed to complete a Fall Risk Evaluation after the fall on 10/27/23 per policy. FALL #3 on 12/10/23: Review of the progress note, dated 12/10/23 at 3:59 A.M., indicated a loud noise was heard coming from the room. The Resident was observed on the bathroom floor with a hematoma to the right side of his/her head and a skin tear to the right arm. The resident was assisted from the floor and into the wheelchair and then transferred to the emergency room for further evaluation. There was no incident report completed for this fall on 12/10/23 per policy. Review of the most recent Fall Risk Evaluation indicated an evaluation was done on 10/30/23 as part of the Admission/re-admission MDS schedule, the total score was 12, indicating the Resident was a HIGH RISK for potential falls and prevention protocol should be initiated immediately and documented on the care plan. The facility failed to complete a Fall Risk Evaluation after the fall on 12/10/23 per policy. Review of the ADL Care Plan prior to the fall 12/10/23, indicated Resident #70 needed assistance with transfers, ambulation, toileting, and dressing. Review of the Fall Risk care plan failed to indicate it had been updated with a new intervention to prevent further falls/injury and an actual Fall care plan had not been initiated, per policy. Further review of Resident #70's medical record, including progress notes, and physician's orders failed to indicate any intervention had been implemented to prevent additional falls. The Resident was sent to the hospital on [DATE] for further evaluation after the fall with head strike, he/she was treated at the hospital and subsequently diagnosed with a UTI while inpatient, returned to the facility on [DATE] and was admitted to hospice services. Review of the care plans failed to indicate any new interventions were implemented upon return to the facility. The facility failed to provide assistance with transfers, ambulation, and toileting resulting in the Resident falling in his/her room and sustaining a hematoma to the right side of the head and skin tear to the right arm. FALL #4 on 3/1/24: Review of the progress note, dated 3/1/24 at 2:52 P.M., indicated Resident #70 fell in the lobby; he/she was observed sitting on the floor and was assisted back into wheelchair by a visitor. Review of the Incident Report, dated 3/1/24, indicated the Resident fell after getting up from wheelchair without assistance. The Mental Status section indicated he/she was memory impaired, confused, oriented to person and decision making impaired. Predisposing Environmental Factor indicated none. Predisposing Physiological Factors included confusion, incontinent, and impaired memory. Predisposing Situation Factors included incident during unassisted self-transfer from chair and wheelchair wheels unlocked. Further review of the Complete Incident Report, dated 3/1/24, failed to include witness statements. Review of the Fall Risk Care Plan for Resident #70 indicated the following: FOCUS: Resident #70 is at risk for falls related to deconditioning, history of fall secondary to syncope and collapse. (4/11/23) GOAL: He/she will be free of falls through review date. (4/11/23) INTERVENTIONS: -Be sure Resident #70's call light is within reach and encourage him/her to use it for assistance as needed. He/she needs prompt response to all requests for assistance. (4/11/23) -Ensure Resident #70 is wearing appropriate footwear when ambulating or mobilizing in wheelchair. (4/11/23) -Follow facility fall protocol. (4/11/23) -Physical Therapy evaluate and treat as ordered or as needed. (4/11/23) -Provide frequent safety checks when Resident #70 is in his/her room. (1/1/24) -Provide Resident #70 with frequent reminders to use the call light. (1/1/24) Further review of the Fall Risk Care plan indicated a revision had been done on 1/1/24 after a Significant Change MDS was completed, related to hospice status, and not in direct response to the fall on 12/10/23. Review of the ADL Care Plan prior to the fall 3/1/24, indicated Resident #70 needed assistance with bed mobility, transfers, ambulation/wheelchair use, toileting, and dressing. Review of the most recent Fall Risk Evaluation indicated an evaluation was done on 12/19/23 as part of the Significant Change MDS schedule, the total score was 14, indicating the Resident was a HIGH RISK for potential falls and prevention protocol should be initiated immediately and documented on the care plan. The facility failed to complete a Fall Risk Evaluation after the fall on 3/1/24 per policy. The facility failed to provide assistance with transfers resulting in the Resident falling while self-transferring in the lobby. During an interview on 3/18/24 at 12:37 P.M., Nurse #1 said after a fall an incident report is done, the fall packet is completed, and the care plan should be updated. During an interview on 3/19/24 at 9:18 A.M., Unit Manager #1 said after a fall, an incident report should be completed. She said the process includes obtaining statements from everyone working, neurological assessment, a rehab screen and updating the care plan with a new intervention to prevent further falls. She said her expectation is that staff are following the care plan. Additionally, Unit Manager #1 said she could not speak to the falls on 10/26/23, 10/27/23 and 12/10/23 as she had not been employed at the facility at that time. During an interview on 3/19/24 at 11:55 A.M., the Rehab Director said rehab screens are done after every fall and there was no fall screen done after the 12/10/23 fall as she was not aware of that fall. The Director of Nurses was not available for interview on 3/18/24 or 3/19/24. The Staff Development Coordinator was not available for interview on 3/19/24. During an interview on 3/19/24 at 3:26 P.M., Consulting Staff #1 said the falls process includes immediate evaluation and assessment after the fall, completing an incident report, root cause analysis for new interventions, updating the care plan with the new intervention, therapy screen, notes for 72 hours after the fall, and completing a fall risk evaluation. She said she would expect to see a new intervention with every fall and the care plan updated and it was not done after the falls on 10/26/23, 10/27/23, and 12/10/23. She said she thought it was passed on in report about the new glasses on 10/26/23, but it should have been noted in the medical record and care plan updated after the fall and it was not. Additionally, she did not know why an incident report was not done after the fall on 12/10/23 as it should have been. She said her expectation is for staff to follow the Resident's care plans and policies of the facility and they were not. 3. Resident #226 was admitted to the facility in February 2024 with diagnoses including fracture of right neck of femur, reduced mobility, dependence on renal dialysis, symptoms and signs involving cognitive functions and awareness, difficulty in walking, muscle wasting and atrophy, and end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 2/24/24, indicated Resident #226 had moderate cognitive impairment as evidence by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, required dialysis, used a walker, car transfer in/out of car or van was not attempted due to safety or medical concerns, walking 10 feet and 50 feet required supervision or touch assist, and walking 150 feet was not attempted. Review of the Patient Care Referral Form, dated 2/18/24, indicated Resident #226 presented to the ED on 1/26/24 after a mechanical fall at home. The Resident sustained a right femoral subcapital fracture (occurs in the neck of the thighbone) and underwent hemiarthroplasty (partial hip replacement) on 1/27/24. He/she was transferred to a short-term rehab facility on 2/2/24 through 2/18/24. The Resident's family was unable to provide the level of assistance needed for safe discharge home and ongoing rehab was recommended. The Resident was then transferred to the current nursing facility to continue to receive therapy services. Review of the medical record failed to indicate an admission Fall Risk Evaluation had been completed to determine the Resident's history of falls and risk factors to help prevent subsequent falls. Further review of the medical record failed to indicate the interdisciplinary team (IDT) had identified and implemented appropriate care planned interventions to help reduce the risk of falls or injuries and the level of assistance required for activities of daily living (ADLs) per facility policy. Review of current Physician's Orders indicated the following: -Resident to attend dialysis 3 times a week on Monday, Wednesday, and Friday. Pick up time at 10:30 A.M., by Cape Cod Regional Transit Authority (CCRTA) bus for a chair time of 12:00 P.M. - 5:00 P.M. for dialysis, 2/19/24 Review of a Social Services Note, dated 3/13/24, indicated the Resident ambulated 300 feet with a rolling walker and moderate to maximum assist, performed sit to stand with supervision, and needed assist with ADLs and toileting. During an interview on 3/14/24 at 8:17 A.M., Nurse #6 said Resident #226 was arranged to take a bus to and from dialysis, but the bus driver yesterday just dropped him/her off and did not wheel him/her in like they usually do. Nurse #6 and Nurse #10 said they both saw the Resident just walking in to the facility's main lobby. When asked what action was taken, they said they didn't know. During an interview on 3/14/24 at 11:06 A.M., CNA #11 said she believed physical therapy (PT) had cleared the Resident to walk independently but felt the Resident should be supervised to be on the safe side. During an interview on 3/14/24 at 1:00 P.M., the Rehab Director said Resident #226 was currently receiving therapy services and ambulated with a rolling walker and standby assist. During an observation with interview on 3/14/24 at 2:25 P.M., the surveyor observed Resident #226 sitting in a wheelchair in the day room on the Southwest Unit with his/her spouse. While returning to his/her room, the surveyor observed Resident #226 stand up independently from the wheelchair and ambulate towards the surveyor grabbing her shoulder. The Resident was observed to be unsteady on his/her feet. No staff were present. The Resident's spouse brought the wheelchair over to the Resident and asked him/her to sit down. The Resident self-propelled back to his/her room. His/her spouse said the Resident had had recent right hip surgery and took the CCRTA bus to and from dialysis but had never actually seen him/her getting on or off the bus. The Resident was unable to recall events from the previous day but said this was a major surgery for him/her and didn't want any issues. During an interview on 3/14/24 at 3:30 P.M., Nurse #9 said the Resident was steady on his/her feet and could walk independently. She said the Resident was receiving therapy services and had had hip surgery but was no longer on hip precautions. Nurse #9 said the Resident regularly took the CCRTA bus and staff brings him/her back inside. She said the bus usually drops him/her off at the nursing facility around 6:00 P.M. and staff will usually see it pull in to know when to go out there. She said yesterday she saw the Resident walking independently from the bus but was already in the lobby by the time she saw him/her. She said the Resident never should have come in alone. During an interview on 3/14/24 at 4:45 P.M., the Rehab Director said the Resident had not been cleared by PT to ambulate independently and was still on hip precautions requiring supervision to maintain safety. During an interview on 3/18/24 at 10:51 A.M., Rehab Staff #4 said she went out to the bus this day with the Resident on his/her way to dialysis and spoke to the bus driver who said sometimes the Resident stayed in his/her wheelchair and sometimes he/she did not. Rehab Staff #4 said the bus driver didn't know the Resident wasn't supposed to be walking by his/herself but could not be sure if it was the same bus driver. Rehab Staff #4 said she was unaware of the incident that occurred the previous week. During an interview on 3/19/24 at 9:10 A.M., the surveyor reviewed the medical record with Nurse #6 who said the Resident did not have a comprehensive, person-centered care plan that included risk factors for identified problem areas such as PT/rehab status post hip surgery, ADLs, and fall risk interventions to ensure the Resident's safety and maintain hip precautions. Nurse #6 said an admission Fall Risk Evaluation was not done and was unsure of the arrangement between the nursing facility and the bus to and from dialysis. She said last week the Resident went to dialysis then she saw him/her in the lobby walking independently with a walker, I guess the driver just dropped him/her off, there was no one with him/her. During an interview on 3/19/24 at 12:44 P.M., the DON and Consulting Staff #1 said they were not sure how the Resident's transport was set up but would find out and get back to the surveyor. Consulting Staff #1 said there should be communication between the facility and bus driver but was not aware of the process. She said nursing should have communicated the incident to the rehab staff and the DON. The DON said she wasn't made aware. Consulting Staff #1 said the Resident should not have been ambulating independently and nursing staff should be aware of any precautions in place and the Resident's ambulatory status. She further said the Resident's care plan was not comprehensive for ADLs, PT/OT/rehab, and fall risk, and there was no fall risk evaluation completed upon admission but should have been. Based on observation, record review, policy review, and interview, the facility failed to ensure that four Residents (#24, #70, #226, and #2), out of a total sample of 24 residents, were provided an environment free from accident hazards. Specifically, the facility failed to ensure staff: Provided adequate supervision and/or followed their Falls Prevention and Management policy of investigating falls and initiating fall prevention interventions for: 1. Resident #24, who had six total falls, all related to toileting, one of which consisted of an acute left-sided 7th rib fracture, healing 5th and 6th rib fractures, and a closed head injury; 2. Resident #70, who had two falls, less than 12 hours apart, one resulting in a fracture of the left femoral neck (left hip fracture) requiring inpatient hospital stay and surgical repair; and the other resulting in a hematoma to the right side of the head and a skin tear to the right arm; 3. Resident #226, to ensure adequate supervision and the appropriate level of staff assistance after the Resident was observed by staff to be ambulating independently with his/her walker into the facility's main lobby from a transit bus upon his/her return from dialysis; and 4. Resident #2, to ensure that falls were thoroughly investigated, and interventions were implemented to prevent further falls. Findings include: Review of the facility Fall Prevention and Management Policy, dated as last revised January 2023, indicated but was not limited to the following: -Fall Risk Evaluation will determine fall risk factors. The interdisciplinary team (IDT) identifies and implements appropriate interventions to reduce the risk of falls or injury while maximizing dignity and independence. ASSESSMENT AND PREVENTION -Fall risk assessments will be completed for all residents; initially on admission / readmission, quarterly, significant change and after an identified fall. -As part of the assessment, the nurse will help identify individuals with a history of falls and risk factors for subsequent falling. a. History of falling. b. History of one or more recent falls. c. Root cause for fall history will be identified. -The staff will implement goals and interventions based on the resident's individual needs. -Communicate interventions to care givers. -Review and revise IDT care plan when a change is identified, after an event. -If the resident continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions. [TRUNCATED]

Based on observations, interviews, record review, and policy review, the facility failed to monitor the nutritional status for two Residents (#2, #61) with an unplanned significant weight loss, out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #2, to continue to monitor the Resident's nutritional status after they experienced a severe significant weight loss of 12.66% in three months (11/21/23 to 2/3/24), resulting in a continued significant weight loss of 5.39% in one month (2/3/24 to 3/8/24) which the facility did not identify or address; and 2. For Resident #61, to continue to monitor the Resident's nutritional status after they experienced a severe significant weight loss of 6.95% in one month (10/21/23 to 11/21/23), resulting in a 10.54% severe significant weight loss in three months (10/21/23 to 1/25/24) and a 10.74% severe significant weight loss in three months (11/30/23 to 3/18/23) which the facility did not identify or address. Findings include: Review of the facility's policy titled Weight Assessment and Interventions, revised May 2019, included but was not limited to: - The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents. - Monthly weights will be obtained each month or as ordered by physician. - Weights will be recorded in the medical record (electronic health record where available) for each resident. - Any weight change of five pounds (lbs) in a month or three pounds in a week since their last weight assessment should be retaken within 72 hours for confirmation and verified by Nursing. - Re-weigh should be reviewed by the Licensed Nurse. - Licensed Nurses should notify Dietician of identified weight change once reviewed. - Dietician notification should be documented within Resident's medical record. - Dietician or diet technician should respond within 72 hours of receipt of notification. - The threshold for significant unplanned and undesired weight change will be based on the following criteria: (a) one month: 5% weight change is significant, greater than 5% is severe; (b) three months: 7.5% weight change is significant; greater than 7.5% is severe; (c) six months: 10% weight change is significant; greater than 10% is severe. 1. Resident #2 was admitted to the facility in February 2021 with diagnoses including schizoaffective disorder and type II diabetes. Review of the Minimum Data Set (MDS) assessment, dated 1/24/24, indicated Resident #2 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Further review of Section K of the MDS assessment indicated Resident #2 had a weight loss of 5% or more in the last month or 10% or more in the last 6 months. Section K of the MDS assessment indicated Resident #2 was not on a prescribed weight loss regimen. Further review of the MDS assessment indicated Resident #2 required set-up assistance for meals. On 3/12/24 at 12:05 P.M., the surveyor observed Resident #2 eating his/her lunch meal in the dining room on the North Two Unit. Resident #2 was seated at a table with other residents and his/her meal was set-up by staff. Staff were observed to assist by cutting Resident #2's meal and opening drinks. Staff were not observed to provide any additional assistance with feeding to the Resident. The surveyor observed Resident #2 leaning to the right side in their wheelchair and gripping onto the table with both hands throughout the meal. The surveyor observed Resident #2 consume a few bites of his/her meal before fluctuating between sleeping and calling out to staff. On 3/13/24 at 12:12 P.M., the surveyor observed Resident #2 brought into the North Two Unit dining room for lunch. Resident #2 was positioned at a table with other residents and set up by staff members for the meal. Staff were observed to assist by cutting Resident #2's meal and opening drinks. Staff were not observed to provide any additional assistance with feeding to the Resident. The surveyor observed Resident #2 asleep throughout the meal. Staff members were observed to encourage the Resident to initiate eating by tapping him/her on the shoulder and saying, it is time to eat. Resident #2 was observed to be asleep without initiating feeding throughout the mealtime. The surveyor did not observe Resident #2 consume any food during the lunch meal. Review of Resident #2's active Physician's Orders included but were not limited to: - 11/20/23: DIET - Regular Texture, Thin Liquid Consistency, Consistent/Controlled Carbohydrate (CCHO) Diet - 2/21/24: House Diabetic Supplement - two four-ounce supplements per day - 2/26/24: Weekly Weight - weekly weight secondary to weight loss every day shift every seven days Review of Resident #2's Medication Administration Record (MAR) indicated a House Diabetic Supplement was provided to him/her twice daily from 2/21/24 through 3/17/24. Further review of the MAR indicated failed to indicate a percentage value of amount consumed on 15 out of 51 opportunities. Furthermore, the MAR indicated the Resident drank less than or equal to 50% of the house supplement provided on 23 of 51 opportunities. Review of Resident #2's weights in the electronic medical record indicated the following weights: - 09/2023: not obtained - 10/2023: not obtained - 11/21/23: 191.2 lbs. - 12/2023: not obtained - 01/23/24: 172.2 lbs. - 02/03/24: 167.0 lbs. - 02/26/24: not obtained - 03/04/24: not obtained - 03/08/24: 160.0 lbs. Review of Resident #2's weights indicated he/she had a 12.66% severe weight loss in three months. Further review of Resident #2's weights indicated a 5.39% significant weight loss in one month (2/3/24 and 3/8/24). A significant and/or severe weight loss value for six months was unable to be calculated due to failure of the facility to obtain a monthly weight value in 9/2023. Review of Resident #2's nutritional care plan failed to indicate he/she was at risk for nutritional decline. Interventions for Resident #2's nutritional care plan included but were not limited to: - Obtain weight per physician (MD) order on same scale. Notify MD/Nurse Practitioner (NP)/Registered Dietician (RD) of significant weight changes (revised 11/14/23). Review of Resident #2's Comprehensive Nutrition Assessment, dated 11/9/23, indicated his/her weight history was not stable. The RD recommended continued monthly weights and diet as ordered. No new interventions were recommended. Review of RD documentation failed to indicate any further assessment of Resident #2's weights until 2/12/24, three months after the Comprehensive Nutrition Assessment. Dietary progress note documentation, dated 2/12/24, indicated Resident #2 had a 12.7% significant weight loss over the past three months. The RD recommended the facility obtain a reweigh of Resident #2 prior to any further intervention changes. Further review of RD documentation on 2/21/24 indicated Resident #2 had triggered for significant weight loss of 12.7% over the past three months. The RD recommended Resident #2 to have weekly weights, sugar free house supplement (four ounces twice daily) and change to regular size portions (versus the previously recommended large portions). Further review of the RD documentation failed to indicate the RD identified the significant weight loss of 5.39% in one month (2/3/24 to 3/8/24). Review of nursing notes failed to indicate documentation related to Resident #2's weight loss. Nursing documentation failed to indicate refusal or inability to obtain weekly weights on 3/4/24 and 2/26/24, as well for monthly weights in 12/2023, 10/2023, and 9/2023. Nursing documentation failed to indicate the RD or MD were notified of weight loss. Review of MD/NP notes failed to indicate documentation related to Resident #2's significant weight loss. During an interview on 3/18/24 at 9:42 A.M., Nurse #4 said staff try to obtain weights for all residents on the unit on the first Monday of each new month. Nurse #4 said staff go down the list until each resident's weight is obtained. Nurse #4 said sometimes it takes a while for weights to be obtained. Nurse #4 said some residents have orders to be weighed weekly and those orders come over on a specific day. Nurse #4 said residents with monthly weights do not necessarily have orders to be weighed on a specific day. Nurse #4 said monthly weights do not come up on the Medication Administration Record (MAR) for a specific date to obtain. During an interview on 3/18/24 at 10:20 A.M., Unit Manager (UM) #1 said weights are obtained monthly for most residents on the unit. UM #1 said weights should have a standard order to be obtained and the order would generate a date and shift to be inputted. UM #1 said refusal of weights should be documented in the medical record. During an interview on 3/18/24 at 1:58 P.M., Nurse #4 said when weights are input into the electronic medical record they populate red for a significant change. Nurse #4 said Resident #2 did populate on her MAR to obtain a weekly weight. Nurse #4 said she was unsure of weekly weights being obtained by other nursing staff. Nurse #4 said the Dietitian would notify the MD directly of any new recommendations or changes. During an interview on 3/18/24 at 3:13 P.M., UM #1 said she and the RD should be reviewing weights of all residents on the unit. UM #1 said she was uncertain if Resident #2's MD was aware of their significant weight loss. UM #1 said she would be responsible for notifying the MD of changes in weight. UM #1 said staff should be notifying the MD of changes in weight to ensure the interdisciplinary team are aware. UM #1 said Resident #2 should not have any missing weekly or monthly weights. During an interview on 3/18/24 at 4:09 P.M., the RD said she reviews weights for significant weight loss when they are obtained by staff at the facility. The RD said she then determines an individualized plan for each resident to address the weight loss. The RD said she pulls a weight report for each resident when reviewing their documentation. The RD said she typically pulls a weight report to review resident trends in weight loss. The RD said if weights are not obtained in greater than or equal to 30 days, the resident would not populate on the weight report. The RD said she does her best to compare weight reports monthly to not miss any resident weights. The RD said because weights are missing, she is patching together assessments. The RD said the goal is to review each resident in the facility quarterly, or more often if a significant weight loss is identified. The RD said she was behind on quarterly assessments. The RD said Resident #2 has had a continued significant weight loss. The RD said she notifies nursing staff of recommendations to notify the MD. The RD said she does not notify the MD of significant weight loss or recommendations herself. During an interview on 3/18/24 at 4:27 P.M., the Director of Nurses (DON) said her expectation would be for the RD to identify a significant weight loss for any residents in the building. The DON said she would then expect the RD to make any recommendations to address the significant weight loss. The DON said she would expect the nursing staff and/or the RD to notify the MD regarding the changes identified. The DON said the UM should be looking at changes to identify risk factors for residents on each unit. 2. Resident #61 was admitted to the facility in December 2021 with diagnoses including hypertension, atrial fibrillation (abnormal heart rhythm), and cerebral infarction (stroke). Review of the MDS assessment, dated 2/21/24, specified a BIMS score of 14 out of 15, indicating he/she had intact cognition. Further review of Section K of the MDS assessment indicated Resident #61 had a weight loss of 5% or more in the last month or 10% or more in the last 6 months. Section K of the MDS assessment indicated Resident #61 was not on a prescribed weight loss regimen. The MDS assessment indicated Resident #61 had a mechanically altered diet and he/she required set-up feeding assistance. On 3/13/24 at 12:15 P.M., the surveyor observed Resident #61 in their room. Resident #61 said he/she did not want their lunch meal today. The surveyor did not observe as meal tray in Resident #61's room. Review of Resident #61's active Physician's Orders included but were not limited to: - 11/20/23: DIET - Regular Diet; Mechanical Soft Chopped Meat Texture; Thin Liquid Consistency - 6/6/23: REC - Aspiration Precautions; seated upright with head of bed (HOB) Raised for meals and for at least 45-60 minutes after meals; slow rate of intake; small bolus size; alternate solids and liquids - 3/5/24: House Supplement - three times per day for nutritional supplementation; eight ounces; prefers chocolate Ensure or clear supplement Further review of Resident #61's active Physician's Orders failed to include an order for monthly weights to be obtained. Review of Resident #61's Medication Administration Record (MAR) indicated a House Supplement was provided to him/her three times per day from 3/6/24 through 3/17/24. Further review of the MAR indicated the facility failed to document the percentage value consumed by Resident #61 as follows: - 3/6/24: 8:00 A.M. - 10:00 A.M. - 3/6/24: 12:00 P.M. - 2:00 P.M. - 3/6/24: 4:00 P.M. - 8:00 P.M. - 3/7/24: 8:00 A.M. - 10:00 A.M. - 3/7/24: 12:00 P.M. - 2:00 P.M. - 3/14/24: 12:00 P.M. - 2:00 P.M. Further review of the MAR indicated the Resident drank less than or equal to 50% of the house supplement provided on 10 of 36 opportunities. Review of Resident #61's weights in the electronic documentation system indicated the following weights: - 9/2023: not obtained - 10/21/23: 178.4 lbs. - 11/21/23: 166.0 lbs. - 11/30/23: 169.4 lbs. - 12/2023: not obtained - 1/25/24: 159.6 lbs. - 2/2024: not obtained - 3/18/24: 151.2 lbs. Review showed Resident #61 had a 6.95% severe significant weight loss in one month (10/21/23 to 11/21/23). Further review showed two additional severe significant weight losses in a three-month period between 10/21/23 through 1/25/24 (10.54%) and 11/30/23 through 3/18/24 (10.74%). Review of Resident #61's nutritional care plan indicated he/she was presenting with an undesired weight loss and further weight loss is not desired. Interventions for Resident #61's nutritional care plan included but were not limited to: - Obtain weight per physician (MD) order on same scale. Notify MD/Nurse Practitioner (NP)/Registered Dietician (RD) of significant weight changes (revised 10/5/23). Review of Resident #61's Comprehensive Nutrition Assessment, dated 11/30/23, indicated his/her weight history was not stable, and a significant weight loss was identified. The assessment indicated to continue with current diet as ordered, use of house supplements, and monitoring of intakes and weights. Review of a Dietary progress note, dated 1/26/24, indicated review of the Speech Therapy diet texture to meet house formulary diets. No indication of continued weight loss was addressed in the documentation. Further review of the Dietary progress notes failed to indicate the RD identified the Resident's 10.54% (10/21/23 to 1/25/24) and 10.74% (11/30/23 to 3/18/24) severe significant weight loss over three months and considered interventions to curb further weight loss. Review of nursing progress notes failed to indicate documentation related to Resident #61's weight loss. Nursing progress note documentation failed to indicate refusal or inability to obtain monthly weights in 2/2024, 12/2023, and 9/2023. Furthermore, nursing progress note documentation failed to indicate the RD or MD were notified of the severe significant weight loss. Review of MD/NP progress note documentation, dated 3/5/24, indicated the Resident was seen for family concerns related to weight loss and poor appetite. Further review of the documentation indicated Resident #61's weight was down. Documentation indicated Resident #61 may benefit from house supplement shakes three times per day. Further review of MD/NP progress note documentation indicated no weight changes addressed in reports dated 2/8/24, 2/6/24, 1/18/24, 1/2/24, and 11/30/23. During an interview on 3/12/24 at 11:11 A.M., Resident #61 said they prefer to eat their meals in their room. Resident #61 said they do not require assistance with meals. Resident #61 said they did not want breakfast this morning and did not eat. During an interview on 3/18/24 at 9:42 A.M., Nurse #4 said staff try to obtain weights for all residents on the unit on the first Monday of each new month. Nurse #4 said staff go down the list until each resident's weight is obtained. Nurse #4 said sometimes it takes a while for weights to be obtained. Nurse #4 said some residents have orders to be weighed weekly and those orders come over on a specific day. Nurse #4 said residents with monthly weights do not necessarily have orders to be weighed on a specific day. Nurse #4 said monthly weights do not come up on the Medication Administration Record (MAR) for a specific date to obtain. Nurse #4 said Resident #61 was on the list to obtain a weight today. Nurse #4 and the surveyor reviewed the most recent weights for Resident #61. Nurse #4 said she thought Resident #61 had been weighed in February but could not find the documentation. During an interview on 3/18/24 at 10:20 A.M., Unit Manager (UM) #1 said weights are obtained monthly for most residents on the unit. UM #1 said weights should have a standard order to be obtained and the order would generate a date and shift to be inputted. UM #1 said refusal of weights should be documented in the medical record. During an interview on 3/18/24 at 1:58 P.M., Nurse #4 said when weights are input into the electronic medical record they populate red for a significant change. Nurse #4 said the Dietitian would notify the MD directly of any new recommendations or changes. During an interview on 3/18/24 at 3:25 P.M., UM #1 said she and the RD should be reviewing weights of all residents on the unit. UM #1 said she was uncertain if Resident #61's MD was aware of their significant weight loss. UM #1 said she would be responsible for notifying the MD of changes in weight. UM #1 said staff should be notifying the MD of changes in weight to ensure the interdisciplinary team are on the same page. UM #1 and the surveyor reviewed the active physician orders for Resident #61. UM #1 said she could not see any weight orders for the Resident. UM #1 said Resident #61 should not have had any missing monthly weights. During an interview on 3/18/24 at 4:09 P.M., the RD said she reviews weights for significant weight loss when they are obtained by staff at the facility. The RD said she then determines an individualized plan for each resident to address the weight loss. The RD said she pulls a weight report for each resident when reviewing their documentation. The RD said she typically pulls a weight report to review resident trends in weight loss. The RD said if weights are not obtained in greater than or equal to 30 days, the resident would not populate on the weight report. The RD said she does her best to compare weight reports monthly to not miss any resident weights. The RD said because weights are missing, she is patching together assessments. The RD said the goal is to review each resident in the facility quarterly, or more often if a significant weight loss is identified. The RD said she was behind on quarterly assessments. The RD said Resident #61 has had a continued significant weight loss and it needed to be addressed. The RD said she notifies nursing staff of recommendations to notify the MD. The RD said she does not notify the MD of significant weight loss or recommendations herself. During an interview on 3/18/24 at 4:27 P.M., the Director of Nurses (DON) said her expectation would be for the RD to identify a significant weight loss for any residents in the building. The DON said she would then expect the RD to make any recommendations to address the significant weight loss. The DON said she would expect the nursing staff and/or the RD to notify the MD regarding the changes identified. The DON said the UM should be looking at changes to identify risk factors for residents on each unit.

Based on observation, record review, and interviews, the facility failed to follow their policy and implement an individualized comprehensive plan of care to promote optimal healing and the prevention of a facility acquired unstageable left heel ulcer for one Resident (#87), out of a total sample of 27 residents. Specifically, the facility failed to: 1) Reposition the Resident every two hours, correctly off-load the Resident's heels, and ensure the Resident wore bilateral Prevalon boots per physician's orders; 2) Ensure the air mattress is set to the Resident's correct weight; and 3) Perform weekly skin assessments. Findings include: Review of the facility's policy titled Pressure Ulcer Injury Prevention Program, dated 2/18/22, indicated but was not limited to the following: Policy: Point Group care shall have a system in place that assures observations are timely and appropriate interventions are implemented and monitored and revised as appropriate and changes in condition are recognized evaluated reported to the resident's attending practitioner and other health care professionals as appropriate. -The facility shall provide care and treatment and services to: -Promote the prevention of pressure ulcer development -Promote the healthy healing of pressure ulcers that are present including prevention of infection to the extent possible -Prevent development of additional pressure areas The facility's pressure ulcer injury prevention treatment program shall include: -Implementing individualized comprehensive plan of care interventions to help stabilize/ reduce underlining risk factors with each dressing change or at least weekly the pressure ulcer injury wound shall be assessed and documented: -Date, location of ulcer and staging, size, depth of the pressure ulcer injury wound, presence location, and extent of any undermining or tunneling sinus /tract and the presence of extradites the type, color, odor, amount, pain. -Description of the wound and edges and surrounding tissue rolled edges, redness, hardness, maceration, and description of healing pressure ulcer. Residents who are dependent on staff for repositioning: -Reposition the resident every two hours and as needed depending on the resident's condition -A turning schedule shall be followed and documented on the 24-hour flow sheet -Use pressure redistributing devices i.e., gels, air fluidized mattresses, low air mattresses, four-inch convoluted foam, when appropriate -To reduce pressure effectively always follow manufacturer's instructions for these devices. -Sheepskin heel and elbow protectors are not effective at redistributing pressure; they provide comfort and reduce friction and shearing forces; they may be used to prevent bony prominence's from rubbing together. -Place a pillow under the resident's lower leg suspending the heels to decrease the pressure placed on the resident's heels Resident #87 was admitted in April 2022 with diagnoses including cellulitis (skin infection) of the right lower limb, Pressure ulcer right heel stage three (full thickness deep skin wound), localized edema, and severe protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 7/28/22, indicated Resident #87 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. In addition, it indicated the Resident's height to be 69 inches and weight to be 114 pounds. Review of Resident #87's current Skin Care Plan indicated but was not limited to the following: Actual alteration in skin integrity related to unstageable wound right heel, excoriated coccyx (bottom), wounds bilateral lower extremities, and wound top of the left foot. -Resident will have improved skin integrity as evidenced by signs and symptoms of healing within the next 90 days. Interventions: -Assess for pain/comfort level as needed prior to dressing change and medicate per physician order -Consult and treatment by certified wound physician or nurse as needed -Dietary intervention -Follow physician orders for skin care and treatments -Monitor for signs of infection and report to physician and obtain treatment. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 5/23/22, indicated a new unstageable deep tissue injury was located on the left heel. The visit note further indicated the wound size was 2.9 cm length x 3.2 cm width with no depth measured. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 6/01/22, indicated an unstageable deep tissue injury was located on the left heel. The visit note further indicated the wound size was 4.0 cm length x 3.2 cm width with no depth measured. The wound was not improved. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 6/06/22, indicated an unstageable deep tissue injury was located on the left heel. The visit note further indicated the wound size was 4.0 cm length x 3.2 cm width with no depth measured. The wound was not improved. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 6/27/22, indicated an unstageable deep tissue injury was located on the left heel. The visit note further indicated the wound size was 4.4 cm length x 3.2 cm x 0.1 cm depth. Small amounts of serous exudate present. The wound was not improved. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 7/6/22, indicated a now unstageable necrotic pressure ulcer was located on the left heel. The visit note further indicated the wound size was 4.0 cm length x 3.0 cm width with no depth measured. Small amounts of serous exudate present. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 7/18/22, indicated an unstageable necrotic pressure ulcer was located on the left heel. The visit note further indicated the wound size was 3.0 cm length x 2.5 cm width with no depth measured. Small amounts of serous exudate present. The wound was not improved. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 8/1/22 indicated an unstageable necrotic pressure ulcer was located on the left heel. The visit note further indicated the wound size was 4.5 cm length x 2.5 cm width with no depth measured. Small amounts of serous exudate present. The wound was not improved. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 8/15/22, indicated an unstageable necrotic pressure ulcer was located on the left heel. The visit note further indicated the wound size was 3.4 cm length x 2.4 cm width with no depth measured. Small amounts of serous exudate present. The surveyor observed throughout the entire survey (8/16/22 through 8/24/22), Resident #87 was positioned in bed lying on his/her back with a neck roll behind his/her neck. The left foot had a Prevalon boot that was observed to be twisted on left foot on multiple days. The Resident's air mattress was observed to be set on 325 throughout the survey and his/her current weight is 108.6 lbs (recorded on 8/19/22). 1) Review of the Physician's Orders for Resident #87 indicated the following: -Prevalon boots to bilateral lower extremities for improved off-loading During an interview on 08/16/22 at 12:48 P.M., Resident #87 said he/she has a big sore on the left foot, and he/she has to wear this big boot. The surveyor observed the left foot had a Prevalon boot that was twisted, not properly positioned, with his/her foot up on a pillow. During an interview on 08/17/22 at 03:05 P.M., the surveyor observed Resident #87 wearing a Prevalon boot on their left foot. The Prevalon boot was twisted and not properly positioned on the foot. During an interview on 08/18/22 at 10:40 A.M., Resident #87 said no one has come in to wash him/her up today, he/she said they have been lying in bed all morning. Resident #87 said no one has repositioned him/her this morning. The surveyor observed the left Prevalon boot to be in a poor position on the left foot. During an interview on 08/18/22 at 12:20 P.M., Certified Nursing Assistant (CNA) #9 said she just finished providing morning care for Resident #87 which included washing and changing him/her. On 08/22/22 at 10:45 A.M., Resident #87 was observed lying flat on his/her back. On 08/22/22 at 12:29 P.M., Resident #87 was observed lying flat on his/her back with neck roll behind his/her neck. On 08/22/22 at 05:35 P.M., Resident #87 was observed lying flat on his/her back with the neck pillow behind his/her neck. The Resident was not wearing the Prevalon boot, it was on the chair across the room. The surveyor observed the left heel resting directly on the air mattress and not off-loaded. During an interview on 08/23/22 at 09:35 A.M., Resident #87 said Unit Manager #1 took the boot off yesterday and never put it back on. The surveyor observed the left heel weight bearing directly on the air mattress. The Resident was lying directly on his/her back with the neck roll behind his/her neck. The surveyor asked Resident #87 if he/she could off weight the left heel off the mattress. Resident was observed making multiple attempts, but said he/she was unable with the blankets covering his/her legs. On 08/23/22 at 11:15 A.M., the surveyor observed Resident #87 lying flat on his/her back and the Prevalon boot on the chair. The surveyor observed the Resident's left heel lying directly on the air mattress. During an interview on 08/23/22 at 10:50 P.M., Nurse #3 said the Certified Nursing Assistants are supposed to reposition all residents every two hours and document it in the CNA flow book. 2) Review of the facility's policy titled Low Air Loss Mattress Guidelines, dated 2/3/22, indicated but was not limited to the following: Low air loss mattress uses indicated as follows: -To assist in the prevention of pressure ulcers as part of a holistic program of pressure ulcer management Settings: -The patient weight indication is a close approximation of correct setting if the mattress is too soft or firm simply press up or down arrow to adjust as necessary for patient comfort wait between set points for mattress stabilization. Linens: -Should be used as minimally as possible, fitted sheet is preferable, and breathable under pads. On 08/16/22 at 12:48 P.M., the surveyor observed Resident #87 lying on his/her back in bed. The air mattress had bolster sides and the pressure was set on 325. During an interview on 08/17/22 at 03:05 P.M., Resident #87 said I have this air mattress with these things on the sides and I can't roll at all. Resident #87 was observed lying on his/her back in bed. The air mattress had bolster sides and the pressure was set on 325. On 08/18/22 at 10:40 A.M., the surveyor observed Resident #87 on his/her back in bed. The air mattress had bolster sides and the pressure was set on 325. On 08/22/22 at 10:45 A.M., the surveyor observed Resident #87 lying flat on his/her back and the air mattress was set on 325. During an interview on 08/22/22 at 12:29 P.M., the Resident said the air mattress was okay, he/she didn't like the side panels because it made it difficult to move him/herself in bed. The surveyor observed Resident #87 lying on his/her back and the air mattress setting to be on 325. On 08/22/22 at 05:35 P.M., the surveyor observed Resident #87 lying flat on his/her back with the neck roll behind his/her neck. The air mattress was set at 325. On 08/23/22 at 11:15 A.M., the surveyor observed Resident #87 lying flat on his/her back. The air mattress was set at 325. During an interview on 08/23/22 at 01:30 P.M., the Maintenance Director said the contracted company comes in and sets up the air mattress and sets the setting at 325 for max inflate to fill the bed quickly, the nurses need to set it to the resident's weight. During an interview on 08/23/22 at 1:00 P.M., the Staff Development Coordinator (SDC) said there should be physician orders for the air mattress settings based on the resident's weight. Maintenance sets up the mattress. The nurses monitor the mattress and document on the treatment record the air mattress is on the right setting and working properly every shift. The surveyor informed the SDC Nurse that Resident #87's air mattress has been set on 325 throughout the survey and the Resident's current weight is 108 lbs. Review of Resident #87's Physician's Orders failed to indicate an order for the use of an air mattress and to check the settings every shift. 3) Review of weekly skin checks for Resident #87 indicated that since admission the Resident only had weekly skin checks on the following dates: - 4/29/22, 5/6/22, 5/13/22, 5/20/22, and 5/27/22 There were no weekly skin assessments performed after 5/27/22 to check for impaired skin and monitor current open areas and skin concerns, a total of 12 weeks of missing assessments. During an interview on 08/23/22 at 01:05 P.M., the surveyor informed the Director of Nurses of observations made throughout the survey relative to Resident #87 positioning in bed, the left heel not being off-loaded and the Prevalon boots being worn incorrectly, the incorrect setting on the air mattress and the missing weekly skin assessments for the past 12 weeks. The Director of Nurses said the air mattress is a pressure relieving device and the nursing staff should adjust the settings and should be monitoring the function of the mattress. She said she is aware there has been a problem with assessments being completed.

3.) Resident #301 was admitted to the facility in June 2022 with diagnoses that included cellulitis, Chronic Obstructive Pulmonary Disorder (COPD), and difficulty walking. Review of the MDS assessment, dated 7/12/22, indicated the Resident had a BIMS of 13 out of 15 indicating Resident #301 is cognitively intact. Further review of the MDS indicated the Resident is totally dependent for transfers and requires extensive assist with ambulation. During an interview on 8/18/22 at 10:49 A.M., Resident #301 said he/she broke his/her leg after falling in the bathroom. The Resident said he/she tried to get up off the toilet and fell to the floor. Review of the Nurse's Progress Notes indicated the following: -7/23/22 at 7:12 P.M.: the Resident was found on the floor in the bathroom with his/her back against the wall. The note indicated the Resident was assisted to the wheelchair with the assist of two staff. -7/24/22 at 6:00 P.M.: the Resident had no apparent injuries and denied pain. -7/25/22 at 7:35 P.M.: the Resident complained of leg pain and could not participate with therapy. The physician was notified and an order for an x-ray was obtained. Results of the x-ray showed a left tibia fracture. Resident #301 was transferred to the hospital for treatment. Further review of the nurse progress notes indicated Resident #301 returned to the facility on 7/26/22 with a knee immobilizer in place to the left leg. Review of the Nursing Assessments indicated no documented evidence that a fall assessment was completed after the fall. Review of the Falls Care Plan, initiated 6/29/22, indicated Resident #301 was at risk for falls characterized by a history of falls/injury. The goal was Resident #301 would have no falls with injury. The interventions to achieve this goal were as follows but not limited to: - Have commonly used articles within reach (6/29/22) - Reinforce need to call for assistance (6/29/22) - Resident to wear proper and non-slip footwear (6/29/22) Further review of the Falls Care Plan indicated the care plan was revised on 7/26/22, three days after the fall occurred, to include: - Analyze previous Resident falls to determine whether pattern/trend can be addressed - Assist Resident with regular toileting and remind Resident to call for toileting assistance when required - PT/OT to assess and treat as needed Review of the medical record indicated the facility failed to assess and implement appropriate interventions to reduce falls. 4.) Resident #81 was admitted to the facility in May 2020 with diagnoses that included hypertension and dementia. Review of the MDS assessment, dated 7/12/22, indicated the Resident had a BIMS of 6 out of 15 indicating the Resident has severe cognitive impairment. Further review of the MDS indicated the Resident is totally dependent on staff for transfers and does not ambulate. Review of the Nurse's Progress Notes indicated the following: -7/27/22 at 5:07 P.M.: the Resident had a fall in the morning and should continue to be monitored for injuries. Resident had no pain. Review of the Nurse Practitioner's note, dated 8/7/22, indicated that floor mats had been implemented after the fall. Review of the Falls Care Plan, initiated 5/27/20, indicated the Resident was at risk for injury related to fall history. The goal was the Resident would not sustain a fall related to injury by utilizing fall precautions. The interventions to achieve this goal were as follows but not limited to: - Fall assessment quarterly (10/25/21) - Offer Resident to rest after breakfast and lunch (1/3/21) (revised 4/26/21) - Bed in lowest position (5/21/20) (revised 10/6/20) Further review of the Falls Care Plan indicated no documented evidence the care plan was revised or reviewed to reflect the use of floor mats. Review of the nursing assessments indicated no documented evidence that a fall assessment was completed after the fall on 7/27/22. 5.) Resident #63 was admitted to the facility in July 2022 with diagnoses that included stroke, anemia, and coronary artery disease. Review of the MDS assessment, dated 7/12/22, indicated a BIMS of 13 out of 15 indicating the Resident is cognitively intact. Further review of the MDS indicated the Resident was dependent on staff for transfers and required extensive assist with ambulation. Review of the medical record indicated Resident #63 had an unwitnessed fall on 8/14/22 while the CNA stepped out of the bathroom to gather supplies. The Resident was assessed for injury and was observed to have swelling of his/her right hand. The physician was notified and an order for an x-ray was obtained. The results of the x-ray were negative. Review of the nursing assessments indicated no documented evidence that a fall assessment was completed after the fall. Review of the Falls Care Plan, initiated on 7/7/22, indicated the Resident was at risk for falls related to reduced strength and endurance. The goal was the Resident will be free of falls through the next review date. Interventions to achieve this goal is as follows but not limited to: - PT evaluate and treat as ordered (7/7/22) - Follow facility policy (7/7/22) - Ensure the Resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair (7/7/22) Further review of the Falls Care Plan indicated no documented evidence that the care plan was reviewed or revised for the fall on 8/14/22. 6.) Resident #79 was admitted to the facility in April 2022 with diagnoses that include hernia repair, dementia with behavioral disturbances, and anxiety. Review of the MDS assessment, dated 7/12/22, indicted a BIMS of 10 out of 15 indicating the Resident has moderate cognitive impairment. Further review of the MDS indicated the Resident required supervision with transfer and limited assist with walking. Review of the Nurse's Note, dated 7/10/22 at 1:08 P.M., indicated the Resident had a fall in the hallway and sustained a laceration to his/her left temple. The Resident was transferred to the hospital for treatment and returned the same day to the facility with two sutures to the left forehead. Review of the nursing assessment indicated no fall assessment was completed after the Resident's fall. 7.) Resident #65 was admitted to the facility in July 2022 with diagnoses that included pneumonia, hypertension, and diabetes. Review of the MDS assessment, dated 7/14/22, indicated the Resident had a BIMS of 14 out of 15 indicating the Resident was cognitively intact. Further review of the MDS indicated the Resident required assist with transfers and ambulation. Review of the medical record indicated the Resident had the following falls: - 8/1/22- Resident was found on the floor next to the bed - 8/8/22- Resident was found on floor next to the bed - 8/14/22- Resident was found on his/her right side with two skin tears on right elbow and left hand - 8/16/22- Resident found on floor next to bed Review of nursing assessments indicated no documented evidence that fall assessments were completed for any of the four falls. Review of the Falls Care Plan, initiated on 7/8/22 and revised on 8/1/22, indicated the Resident was at risk for falls related to deconditioning, history of falls, and recent falls. The goal was the Resident will be free of minor injury through the review day by utilizing fall precautions. Interventions to achieve this goal is as follows but is not limited to: - Follow facility protocol (7/8/22) - Lock brakes on bed, chair, etc. before transferring (8/1/22) - Appropriate footwear (8/1/22) - Provide/monitor use of adaptive devices (8/1/22) Further review of the falls care plan indicated no documented evidence that the care plan was reviewed or revised after the falls sustained on 8/8/22, 8/14/22, or 8/16/22. Review of the medical record indicated the facility failed to review and revise the care plan timely for appropriate interventions to reduce future falls. B. Resident #70 was admitted to the facility in July 2022 with diagnoses of polyneuropathy (damage nerves featuring weakness, numbness and burning pain) and epilepsy. Review of the Minimum Data Set (MDS) assessment, dated 7/26/22, indicated Resident #70 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. In addition, it indicated tobacco use was unknown. A review of the Centers for Medicare & Medicaid Services (CMS) circular letter, dated November 10, 2011, titled Smoking Safety in Long Term Care Facilities indicated but was not limited to the following: -The facility is obligated to ensure the safety of designated smoking areas which includes protection of residents from weather conditions and non-smoking residents from second hand smoke. -The facility is also required to provide portable fire extinguishers in all facilities (NFPA 101, 2000 ed., 18/19.3.5.6). -The Life Safety Code (NFPA 101, 2000 ed., 19.7.4) requires each smoking area be provided with ashtrays made of noncombustible material and safe design. -Metal containers with self-closing covers into which ashtrays can be emptied must be readily available. Review of the facility's policy titled Smoking by Residents, dated 2/18/2022, indicated but was not limited to the following: -Smoking presents health, fire, and safety hazards and, therefore, Pointe Group Care shall discourage smoking and reinforce non-smoking practices among residents, employees and visitors. -Smoking or the use of electronic smoking devices by residents shall be permitted only in areas designated by the Administrator, and in full compliance with all applicable laws, fire safety codes and internal procedures. -Designated smoking areas shall have adequate ventilation and shall contain a sufficient number of ash trays or other prescribed receptacles which must be used for extinguished smoking materials. -Residents shall be required to use lighters kept safely by the facility. -Residents must dispose of all tobacco residues in the proper receptacles. -Residents smoking safety shall be reassessed every quarter and when warranted by change of clinical condition. -Enforcement of this policy shall be the shared responsibility of all staff. Review of most recent smoking evaluation, dated 10/21/21, indicated but was not limited to the following: -Resident is able to communicate that they understand smoking materials are for use in designated smoking areas and must be stored in the facility's designated storage area (smoking box). Answer- yes -Does the resident have a seizure disorder- Answer No -Resident is an independent smoker. No further smoking evaluations were performed on Resident #70 after 10/21/21. Review of Resident #70's current care plan indicated but was not limited to the following: Smoking: -Resident wishes to smoke and assessed for supervision level as independent (revised 4/29/22) -Resident will follow policy and procedures through next review. -Complete smoking assessment initiated 11/4/2021 -Education on safe smoking practices initiated 11/4/2021 -Observe independent smoking periodically initiated 11/4/2021 -Smoking policy reviewed Resident and/or responsible party initiated 11/4/2021 During an interview on 08/16/22 at 03:04 P.M., the surveyor observed Resident #70 wearing a red shirt with two burn holes located in the right lower quarter. Resident #70 said he/she was a smoker and goes out on the patio to smoke every day. On 08/17/22 at 10:12 A.M., the surveyor observed Resident #70 leave his/her room, exit the building to the rear patio and sit on the bench. Resident was observed getting his/her cigarettes and lighter from the four-wheeled walker basket and light a cigarette. The Resident was observed smoking the cigarette until the ashes got so long, they fell off landing on the Resident's shirt. Resident #70 was then observed extinguishing the cigarette by rubbing it on the arm of the wooden bench and then getting up and throwing it in the trash receptacle that was in close proximity to the building. The Resident repeated this process smoking a second cigarette. After smoking the second cigarette, the Resident re-entered the facility and maintained possession of his/her smoking material and went to his/her room. On 08/17/22 at 11:06 A.M., the surveyor observed the rear patio smoking area and noted cigarette butts in bushes, on the ground, in the open ashtray on the trash can, and cigarette butts inside the trash can mixed in with the trash. There were no fire extinguishers or fire blanket located in the smoking area and the doors to re-enter the facility were locked and required a staff member inside to open the door. On 08/18/22 at 10:19 A.M., the surveyor observed Resident #70 exiting the building to the rear patio, retrieving his/her smoking material from the four-wheeled walker basket, lighting and smoking two cigarettes. As the Resident smoked the two cigarettes, the surveyor observed ashes dropping onto the Resident's shirt. The Resident extinguished one cigarette on the side of the wooden bench, the second cigarette he/she extinguished and then rolled it between his/her fingers breaking it apart. Resident #70 threw both cigarettes in the open trash can located in close proximity to the building. On 08/18/22 at 11:45 A.M., Resident #70 was observed on the rear patio smoking sitting on the bench. The Resident was observed getting his/her smoking material from the four-wheeled walker basket, smoking the cigarette until the ashes fell onto his/her shirt. The Resident was observed to smoke two cigarettes, putting the cigarettes out on the side rail of the chair, and then disposing them into the open trash can. The Resident then entered the building, maintaining his/her smoking materials and sat down in the dining room for lunch. During an interview on 08/18/22 at 05:15 P.M., the surveyor informed the Administrator and the Director of Nurses (DON) of their observations of Resident #70 smoking. They were also informed Resident #70 has not had a smoking assessment to determine if he/she is a safe smoker since October 2021. The DON said a smoking assessment should have been done quarterly to assess for safe smoking. The Administrator and the DON both said they would have to review the facility policy to see if residents can keep their smoking material and what safety equipment is required to be in the designated smoking area. During an interview on 08/18/22 at 05:30 P.M., the surveyor and the Administrator viewed the rear patio and there were multiple cigarette butts lying in the ashtray on top of the trash can and inside the trash can mixed in with the trash. There were a few cigarette butts on the ground and in the bushes that abut the patio and no fire extinguisher present. The Administrator said sometimes people empty the cigarette butts from the ashtray into the trash can or they blow on the ground. 8.) Resident #26 was admitted to the facility in May 2022 with the following diagnoses: Alzheimer's disease, hypertension, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #26, dated 5/25/22, indicated a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating the Resident has severe cognitive impairment. Further review of the MDS indicated Resident #26 was independent for bed mobility, transfer out of bed, and ambulation with use of a rolling walker. On 8/18/22 at 12:06 P.M. the surveyor observed Resident #26 ambulating from his/her room to hallway four times. Resident #26 was observed to not be using his/her walker. Review of the Care Plan for Resident #26, dated 5/19/22, indicated the Resident was a fall risk and interventions for fall prevention included the following: - Be sure call light is within reach and encourage the resident to use it for assistance as needed. Resident needs prompt response to all requests for assistance. (6/2/22) - Ensure that Resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. (6/2/22) - Follow facility fall protocol (5/19/22) - PT evaluate and treat as ordered or PRN (5/19/22) Resident #26's Care Plans further indicated the Resident required assist with Activities of Daily Living, using a rolling walker and requires distance supervision with ambulation (5/19/22). Review of the Nursing Progress Notes indicated Resident #26 had four falls from May 2022 through August 2022 as follows: - 5/28/22 at 1:30 A.M.: Resident #26 had a witnessed fall while ambulating in the hallway and tripped over a chair. There was no indication in the medical record that Resident #26 was utilizing his/her rolling walker at the time of the fall. Review of the medical record failed to include a falls packet, referral/screen to rehab services, CNA statements, falls assessments, or interventions implemented to reduce the risk of falls. - 5/29/22 at 3:23 P.M.: Resident #26 had a witnessed fall. The Resident stumbled and fell backwards on to his/her bottom. There was no indication in the medical record that Resident #26 was utilizing his/her rolling walker at the time of the fall. Review of documentation failed to include a falls packet, referral/screen to rehab services, CNA statements, or falls assessments. Review of the medical record indicated the Falls Care Plan was revised on 6/2/22 to include: -Be sure call light is within reach and encourage the resident to use it for assistance as needed. -Resident needs prompt response to all requests for assistance. -Ensure that Resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. - 7/17/2022 at 12:48 P.M.: Resident #26 had an unwitnessed fall. The Resident was found lying on floor in front of nurses' station, leaning towards his/her left side. There was no indication in the medical record that Resident #26 was utilizing his/her rolling walker at the time of the fall. Review of the medical record failed to include a falls packet, referral/screen to rehab services, CNA statements, falls assessments, or interventions implemented to reduce the risk of falls. - 8/15/22 at 5:45 P.M.: Resident #26 had an unwitnessed fall. The Resident was found lying on his/her back on the floor at nurses' station, behind the closed gate with his/her feet up resting against counter and his/her head against the wall. (The gate is affixed to the nurses' station and acts as a barrier to deter wandering residents from entering the nurses' station). There was no indication in the medical record that Resident #26 was utilizing his/her rolling walker at the time of the fall. Review of the medical record failed to include a falls packet, referral/screen to rehab services, CNA statements, falls assessments, or interventions implemented to reduce the risk of falls. During an interview on 8/18/22 at 2:20 P.M., the Director of Nursing said, I do not have completed investigations for Resident #26's falls. The investigations were not completed because management and I have been working on med carts. During an interview on 8/23/22 at 09:30 A.M., the Rehab Manager said, no rehab screens were conducted for the four falls Resident #26 had on 5/28/22, 5/29/22, 7/17/22 and 8/15/22. 9.) Resident #37 was admitted to the facility in December 2020 with diagnoses that included: cirrhosis/hepatic encephalopathy, bilateral lower extremity edema, and vascular wounds. Review of the Minimum Data Set (MDS) assessment, dated 6/7/22, indicated Resident #37 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating he/she was cognitively intact. During an interview on 8/16/22 at 3:10 P.M., Resident #37 said he/she recently had a fall in his/her room. The Resident said he/she was having a dream and attempted to walk from the bed and fell to the floor. The Resident said since that time he/she has had some lower back pain, which is chronic, but has been worse of the past few days. Review of the medical record for Resident #37 indicated he/she had an unwitnessed fall on 8/12/22 at 2:30 P.M. The Resident was found sitting on his/her buttocks on the floor in his/her bedroom. Resident #37 said he/she was having a dream and attempted to walk. Review the Care Plans for Resident #37 indicated that he/she was a high risk for falls related to altered gait and balance, deconditioning, and a history of falls. The Falls Care Plan was last revised 3/15/22 and failed to reflect any new or updated interventions to prevent future falls following the fall on 8/12/22. Review of the medical record failed to indicate a fall assessment was completed following the fall, a fall investigation was completed, a rehab screen was initiated, or that the care plan was updated to reflect updated interventions to prevent further falls for the Resident per the facility policy. During an interview on 8/18/22 at 3:14 P.M., the Director of Nurses said all assessments and incident reports should be completed following all falls. She said interventions should be put in place to prevent further falls. She said she could not locate an incident report, fall assessment, or updated interventions for Resident #37. 10.) Resident #71 was admitted in April 2022 with diagnoses that included Alzheimer's disease and fracture of the left femur. Review of the MDS assessment, dated 4/9/22, indicated the Resident had a BIMS score of 4 out of 15, indicating severe cognitive impairment. Review of the medical record indicated Resident #71 had three falls: -on 5/2/22 with no injury, -on 7/30/22 resulting in complaints of pain, a right elbow and right hand bruise, and swelling requiring the cutting of a ring on the right hand, fourth finger, and -on 8/16/22 with no injury. Review of the Progress Notes for Resident #71 indicated the following: - 5/2/22: Resident found sitting on the floor, on top of cushion, in front of wheelchair. Legs out in front of him/her. Unable to state what happened. Denies pain. No injuries noted. Assisted to bed. Dysum pad with strap applied to wheelchair. - 7/30/22: The roommate notified the CNA who in turn notified the nurse, upon entering the room it was noted that the patient was on the floor between the two beds lying on his/her right side. The patient said he/she hit their head when asked by the nurse. The patient denied being in pain. - 8/16/22: Resident called out for help. Discovered lying on his/her side, next to the bed, upright wheelchair next to her. Assessed for injury and then assisted to bed. Denied pain. Further review of the medical record indicated following the fall on 7/30/22, the right ring finger (fourth finger) was very red and swollen requiring the fire department to be notified to assist with cutting a ring off the finger resulting in a new order for a dressing to be applied daily to the fourth finger until healed. There was no description or assessment of the right fourth finger injury located within the medical record. Review of the Care Plans indicated that Resident #71 was at risk for falls due to deconditioning and had a fall on 8/16/22. The care plan indicated it was revised on 8/22/22, however failed to identify any new interventions following the falls on 5/2/22, 7/30/22 or 8/16/22. The interventions were as follows: - Anticipate and meet the resident's needs (4/3/22) - Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance (4/3/22) - Follow facility fall protocol (4/3/22) - PT to evaluate and treat as ordered and PRN (as needed) (4/3/22) Further review of the medical record failed to indicate interventions were implemented for Resident #71 following the three falls, a rehabilitation screen was written and reviewed, and post fall assessments were completed per facility policy. During an interview on 8/18/22 at 3:14 P.M., the Director of Nurses said all assessments should be completed following all falls. She said interventions should be put in place to prevent further falls. Based on observations, interviews, record review, and policy review, the facility failed to ensure 11 Residents (#56, #82, #301, #81, #63, #79, #65, #26, #37, #71, #70), out of a total sample of 27 residents, were provided adequate supervision and assistance devices to prevent accidents. Specifically, the facility failed to: A. Follow their Falls Management and Prevention Policy of investigating falls and initiating fall prevention interventions for: 1.) Resident #56, resulting in nine falls, two falls resulting in major injury (hip fractures) 2.) Resident #82, resulting in 24 falls with one fall resulting in a cut/bruise between the resident's eyes, one fall resulting in a cut on the upper lip, and a third fall resulting in a skin tear. 3.) Resident #301, resulting in one fall with major injury (fractured femur) 4.) Resident #81, resulting in one fall with no injury 5.) Resident #63, resulting in one fall with no injury 6.) Resident #79, resulting in one fall with a laceration to temple resulting in two sutures 7.) Resident #65, resulting in four falls and was sent to emergency room for a head strike (bump to head) and two 2 skin tears 8.) Resident #26, resulting in four falls with no injury 9.) Resident #37, resulting in one fall with no injury 10.) Resident #71, resulting in three falls, one fall resulting in complaints of pain, bruising and swelling of the right elbow and hand requiring a ring removal to the right fourth finger. B. For Resident #70, follow their smoking policy and Centers for Medicare & Medicaid Services (CMS) guidance for a safe smoking area. Findings include: A. Review of the facility's policy titled Fall Management Program, revised 1/28/2022, indicated the following: The Fall Response steps are a comprehensive approach that forms the backbone of the Falls Management Program (FMP). It includes the following eight steps: 1. Evaluate and monitor resident for 72 hours after the fall. 2. Investigate fall circumstances. 3. Record circumstances, resident outcomes, along with resident and staff response. 4. Notify primary care provider. 5. Implement immediate intervention within first 24 hours. 6. Complete falls assessment. 7. Develop plan of care. 8. Educate and monitor staff compliance. Review of the Falls Packet indicated the following must be completed for every fall including: 1. Point Click Care incident report 2. Care plan update with new immediate interventions implemented following falls 3. Write new interventions on ADL (activity of daily living) status sheet in CNA (Certified Nursing Assistant) ADL documentation binder 4. Obtain CNA statements 5. Complete rehab screen for every fall 1. Resident #56 was admitted to the facility in September 2021 with diagnoses that included Alzheimer's disease and hypertension. Review of the medical record indicated that Resident #56 would wander the halls independently. Review of the medical record indicated Resident #56 had nine falls in six months, two resulting in major injury. Review of the Resident's falls failed to include a fall investigation, completed falls assessment after each fall, CNA/nursing statements, request for rehab screen, and immediate interventions to prevent further falls. -2/2/22 at 7:30 A.M., Resident #56 had an unwitnessed fall and was found sitting on his/her bottom beside another resident and an empty bed. The nurse documented that the Resident was assessed and assisted back to standing position. Review of documentation indicated no documented evidence of an investigation, falls assessment, rehab screen, or interview statements from CNA/nursing, and immediate interventions to prevent further falls -2/17/22 at 8:30 A.M., Resident #56 had an unwitnessed fall in the hallway. The Resident was observed lying in the hallway and noted to have facial grimacing. The physician was contacted and ordered was obtained to have the Resident sent to the hospital for evaluation. The Resident returned to the facility in March 2022 with a diagnosis of a right hip repair. Review of the documentation indicated there was no documented evidence of an investigation of the fall, a falls assessment, interview statements from CNA/nursing staff, and immediate interventions to prevent further falls -3/1/22 at 9:00 P.M., Resident #56 was lowered to the floor by the CNA after the Resident's roommate attempted to assist Resident #56. There was no documented evidence of an investigation of the fall, a falls assessment, or interview statements from CNA/nursing staff. Review of the medical record indicated a new care plan was developed, dated 3/3/22, for an actual fall with surgical intervention (ORIF right femoral shaft), poor balance, unsteady gait. -The interventions included: -1:1 attention and supervision when possible -fat mat on both sides of the bed -low bed -PT consult for strength and mobility -3/3/22 at 3:45 P.M., Resident #56 had an unwitnessed fall and was found kneeling next to his/her bed in a praying position. Resident was assisted to a Broda chair (positioning chair) with 1:1 CNA in attendance. There was no documented evidence of an investigation of the fall, falls assessment, interview statements from CNA/nursing staff or changes to the care plan to prevent further falls. -3/5/22 at 9:20 P.M., Resident #56 was rocking in the Broda chair when it fell backwards, the CNA caught it and lowered it to the floor and the Resident fell out. The CNA remained with the resident. There was no documented evidence of an investigation of the fall, falls assessment, interview statements from CNA/nursing staff, or changes to the care plan to prevent further falls. Review of the Minimum Data Set (MDS) for Resident #56, dated 3/7/22, indicated that the Resident required extensive assistance, with one person assist, for bed mobility, transfers, walking in the room or corridor, dressing, toileting, and personal hygiene. The MDS did not reflect the Resident's history of falls. -4/2/22 at 9:09 A.M., Resident #56 had an unwitnessed fall, and the CNA found the Resident on the floor between the two beds while holding on to the bed rail. The Resident was transferred to a wheelchair. There was no documented evidence of an investigation of the fall, completed falls assessment, and interview statements from CNA/nursing staff. A new care plan was developed, dated 4/4/22, that identified the application of an external device for prevention of injury to self, characterized by high risk for injury/falls, impaired mobility, physical aggression related to anxiety and cognitive impairment. The intervention was a lap buddy while in the wheelchair. -4/16/22 at 12:54 A.M., Resident #56 had an unwitnessed fall and was found on the floor mat next to the bed. The resident's head was against the wall. There was no documented evidence of an investigation of the fall, falls assessment, interview statements from CNA/nursing staff, or changes to the care plan to prevent further falls. On 6/16/22 the lap buddy was removed and replaced with an alarming seat belt to wheelchair, remove and adjust to stand and reposition every two hours and as needed. -7/27/22 at 6:45 A.M., Resident #56 had an unwitnessed fall and was found on blue mats on the floor in a prone position. The Resident was assisted back to bed. There was no documented evidence of an investigation of the fall, falls assessment, interview statements from nursing staff, or changes to the care plan to prevent further falls. -7/29/22 at 6:34 A.M., Resident #56 had an unwitnessed fall and was found sitting upright on the floor. The Resident was inspected for wounds, and none were found. There was no documented evidence of an investigation of the fall, falls assessment, interview statements from CNA/nursing staff, or changes to the ca[TRUNCATED]

4. Resident #79 was admitted to the facility in April 2022 with diagnoses that included dementia with behavioral disturbance and anxiety. Review of the medical record indicated the following weights were obtained for Resident #79: -4/13/22- 105 lbs. (pounds) - 4/19/22- 102.8 lbs. - 4/20/22- 102.8 lbs. - 5/2/22- 103.2 lbs. - 5/18/22- 102 lbs. - 6/15/22- 101.6 lbs. - 7/8/22- 103.2 lbs. - 7/20/22- 97.6 lbs. (flagged in electronic medical record as a -5% change in weight) - 7/27/22- 95.4 lbs. (flagged in electronic medical record as -7.6% change in weight) - 8/19/22-96.8 lbs. - 8/24/22- 97.2 lbs. Review of the Dietitian's Recommendations, dated 7/18/22, indicated the Resident be started on the nutritional supplement Ensure Plus daily at 2:00 P.M. for additional protein. The Dietitian recommendation indicated a slight/gradual decrease in weight was observed since admission. The goal was to prevent further loss and to maintain stable weights. The recommendation was approved by the physician and documented as filed by the nurse. Review of the Dietitian's Note, dated 7/17/22, indicated Resident #79 had a 7.6% weight loss. The note indicated to continue the nutritional supplement Ensure Plus daily at 2:00 P.M. that was recommended on 7/18/22. Further review of the documentation in the medical record by the dietitian, dated 7/21/22, indicated the Resident triggered for significant weight loss and required close monitoring. Review of the Physician's Orders, dated August 2022, indicated the order for the nutritional supplement Ensure Plus was not initiated until 7/28/22, a total of 10 days after the initial recommendation was made and approved by the physician. Review of the Medication Administration Record (MAR), dated August 2022, did not provide documented evidence of the percentage amount of intake the Resident took for the nutritional supplement Ensure Plus. On 8/9/22, the Dietitian recommended Resident #79 be weighed weekly due to a downward trend triggering significant weight loss at this time. The Resident per the dietitian note required close monitoring. Review of the meal percentage sheets (sheets that indicate how much the Resident eats at mealtime) indicated no documented evidence for meal intake for the following: - May 2022- 25/31 days with no documented evidence of meal intake - June 2022- 15/30 days with no documented evidence of meal intake - July 2022- 6/31 days with no documented evidence of meal intake Review of the Physician's Orders, dated August 2022, indicated the order to weigh the Resident weekly was not initiated until 8/18/22, a total of nine days after the recommendations were made. 5.) Resident #49 was admitted to the facility in September 2019 with diagnoses that included osteoporosis, Alzheimer's disease, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 6/21/22, indicated a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating the Resident had moderately impaired cognition, required supervision and set up with eating, and was 63 inches tall. The resident's weight section was left blank. Review of Resident #49's weights indicated the following: 1/26/22- 111 pounds 2/2/22- 110 pounds 2/28/22- 106.8 pounds 4/13/22- 105 pounds 4/20/22- 104.8 pounds 5/18/22- 105.4 pounds Review of the Medical Nutrition Therapy assessment dated , 6/27/22, completed by Dietitian #1 indicated Resident #49's weights had been trending down without significant loss. The Dietitian used the most recent weight of 105.4 pounds to conduct the assessment. The Dietitian indicated Resident #49 was receiving Mighty Shakes twice per day. The Dietitian made recommendations to increase the Mighty Shakes to three times per day and left the recommendation form in the MD binder. Record review indicated the Dietitian's recommendations had been signed by the Nurse Practitioner and then signed by Nurse #5 on 6/30/22. Review of the current August 2022 Physician's Orders indicated Mighty Shakes were only scheduled twice per day. The order to increase Mighty Shakes to three times per day had not been implemented. During an interview on 08/23/22 at 12:47 P.M., Nurse #1 said that every provider has their own binder for facility staff to leave requests and/or recommendations. When a provider comes to the facility, they check the binder and approve or deny any requests or recommendations. Then, a facility nurse will transcribe orders as indicated and file the recommendations in the resident record. During an interview on 8/23/22 at 1:00 P.M., Nurse # 5 said I signed that recommendation after the Nurse Practitioner approved it, I should have transcribed it into his/her orders. Nurse #1 indicated that she would follow up with the Dietitian. During an interview on 08/23/22 at 12:15 P.M., the Dietitian said she is aware that Resident #49's weight is trending down, but it has not been significant. She left a recommendation to increase nutritional supplements in the MD book. The Dietitian said she does not follow up on her recommendations to ensure that they have been approved and implemented. Further review of Resident #49's weights indicated that he/she continued to have weight loss as follows: 6/29/22- 102.8 pounds 7/27/22- 103 pounds 8/3/22- 101.8 pounds 6. Resident #87 was admitted in April 2022 with diagnoses including cellulitis (skin infection) of the right lower limb, Pressure ulcer right heel stage 3 (full thickness deep skin wound), localized edema, history of malignant neoplasm of esophagus (throat), severe protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 7/28/22 indicated Resident #87 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Review of the clinical record, dated 6/22/22, indicated new orders for weight every week for four weeks initiated 6/22/22, and a second order written 7/27/22 for continued weekly weight due to nutritional risk/poor intake. Review of Resident #87's weight history indicated the following: 4/19/22 148.8 pounds (lbs.) (Hospital record) 5/5/22 133.0 lbs. 5/19/22 127.4 lbs. 5/31/22 123.6 lbs. 5/31/22 123.6 lbs. 6/10/22 126.8 lbs. 6/21/22 125.6 lbs. 7/28/22 114.0 lbs. (9.2% weight loss past 30 days since 6/21/22 loss of 11.6 lbs.) 8/17/22 108.6 lbs. 8/19/22 108.6 lbs. (14.6% weight loss past two months since 6/21/22 loss of 17 lbs.) Review of Resident #87's current care plan indicated but was not limited to the following: Nutrition: -Resident presents with actual or potential nutrition risk related to past medical history severe protein, hypertension, iron deficiency anemia, difficulty walking and lack of coordination (reduce mobility), stage three pressure ulcer of the right heel, history of esophageal cancer, hypokalemia, GERD, low body mass index indicating underweight status and multiple wounds with compromised skin integrity -Presenting with questionable weight trends exhibiting significant losses in the past quarter, continues with losses despite interventions in place. -Presents with increased protein and calorie needs to protect and promote wound healing date initiated 6/27/22 Goal: 1. Will continue to tolerate diet 2. Will consume 50% or more of offered foods, beverages, and supplements with adequate hydration with focus on protein rich foods and snacks 3. Improve skin integrity and wound healing 4. Will maintain labs/body mass as able 5. Will maintain stable weight trends, prevent losses as able with true gains acceptable should they occur Plan: 1. Provide diet as ordered house diet with regular textures thin liquid consistencies for max choice/intakes 2. Provide vitamins as ordered 3. Honor food preferences as able to promote acceptance/good intakes: yogurt with all meals 4. Provide supplements as ordered: Pro-stat 30 mL (milliliters) twice a day, Magic cup twice a day, Ensure Clear Liquid once a day 5. Monitor skin /labs /BMI /weight/ intake as ordered 6. Provide medications as ordered 7. Continue to promote/encourage selection of protein-rich food /snacks. Review of the Nutrition Intake Record binder (record of resident meal intake for breakfast, lunch, and dinner) from April through August 2022 indicated no meal intake was recorded for Resident #87 for 57 days and only partially filled out for seven days. Reviewed the Nursing Flow Sheets for June, July, and August 2022 which also recorded meal intake for breakfast, lunch, and dinner indicated there was no meal intake for 47 days and only partial meal intakes for eight days. In addition, the days that overlapped recording meal intake with the Nutrition Intake Record binder, the recording did not consistently match for percent meal consumed. Review of the Medical Nutrition Therapy Assessment, dated 4/28/22, indicated but was not limited to: -Height 69.0 inches, weight 148.8 lbs. (Hospital record) -Diet to include 2 grams no salt added with regular texture and thin liquid -Denies chewing and swallowing at his time -Resident reports good appetite 75-100%, enjoys meals -Most recent weight 148.8 lbs. (Hospital) used for this assessment. Recommend to provide. -Continue to encourage adequate hydration and protein rich meals/snacks -Magic cup twice a day with lunch and dinner for additional protein and calories Review of the Medical Nutrition Therapy Assessment, dated 6/23/22, indicated but was not limited to: -Average food beverage intake is averaging more than 50% in the last 7 days. -Height 69.0 inches, weight 125.6 lbs. recorded 6/21/22 -Diet to include house regular texture and thin liquids, approbate for max choice/intake. -Denies chewing and swallowing at his time -Documented intake of 75% at this time -Resident reports improved oral intake, previously poor however close monitoring required due to history of false reporting. -Mirtazapine (Remeron), appetite stimulant. -Pro-stat twice daily for wound healing. Yogurt provided with all meals; kitchen updated. -Most recent weight 6/21/22 was 125.6 lbs. and continues to trigger for significant weight loss 15.6%, 23.2 lbs. since 4/19/22 148.8 lbs. (hospital weight) -Continued diet, vitamins and supplements as ordered. Recommend to also provide Magic cup twice daily for increased protein and kcal, encourage adequate hydration and protein-rich meals/snacks. Review of Medical Nutrition Therapy Assessment, dated 7/26/22, indicated but was not limited to: -Average food beverage intake is averaging more than 50% in the last 7 days. -Weight loss of 9.2% for 1 month and weight loss of 23.4 % for 6 months. -Resident presenting with questionable weight trends triggering for significant losses however unable to determine accuracy of the trends. -House regular texture and thin liquids, appropriate for max choice/intake. -Staff interview presenting with poor oral intake, however Resident continues to report good oral intake- previously variable between poor/good, however close monitoring required to related to history of false reporting. -Mirtazapine, appetite stimulant -Potential decline in appetite recently related to active urinary tract infection, oral intake encouraged and resident states he/she will try their best. -Continues multiple supplements for wounds/support of stable weight trends -Pro-stat 30 mL twice daily, Ensure Clear Liquid once daily and Magic cup twice daily. Yogurt also with all meals for included protein and calories -Most recent weight 7/28/22 was 114 lbs. and at this time continues to trigger for significant losses from hospital weight and now in the past one month -Nursing recent downward trend related to unit change and in different scales used -Dietitian awaits further weights. -Resident did accurately present with some losses initially upon admission however unable to determine verify extent of triggered losses. -Continue to encourage oral intake and hydration will monitor. Review of history of nutritional supplements Resident has received: -Magic Cup two times a day for additional kcals and protein for improved skin/wound healing initiated 04/29/22 -Ensure Plus one time a day for diet initiated 06/04/22 and changed to Ensure Clear Liquid Ensure Clear Liquid 07/27/22 -Promod (liquid protein fruit punch) 30 ML one time a day initiated 06/02/22, discontinued 06/15/22 -Remeron Tablet (Mirtazapine) Give 7.5 mg by mouth at bedtime for appetite stimulant initiated 06/03/22, increased Remeron Tablet to 15 MG 07/17/22 -Pro-Stat Liquid (liquid protein drink) Give 30 ml by mouth two times a day initiated 6/21/22 During an interview with Resident #87 and Family Member #2 on 8/23/22 at 12:30 P.M., Resident #87 said, The food is not that good; like today he/she was having trouble cutting the ham and chewing it. The Resident said he/she often has a hard time eating the meat because it is tough. The Resident continued to say he/she has been asking to make meal selections, and they finally gave him/her a menu to fill out. Family Member #2 added the Resident needs help filling out the menu or it won't get done. The Resident said sometimes he/she gets a yogurt to eat, but not always and said if the Magic Cup is not open, he/she can't get it open because of the arthritis in their hands. A Certified Nursing Assistant came in to take the tray away and the Magic Cup which remained unopened. Family Member #2 stopped the tray from being removed and took off the cover and the Resident started eating it. Resident #87 said if he/she had their choice of a meal it would be a turkey dinner with all the fixings, fresh fish, or pizza. Resident #87 said the food is not that good here. During an interview on 8/24/22 at 2:00 P.M., the Dietitian said she is aware Resident #87 continues to show significant weight loss despite dietary supplement in place, including Magic cup twice daily, Pro-stat liquid protein twice daily, Ensure Clear liquid once daily and yogurt provided at every meal. The Dietitian said she was also aware the Resident was not being weighed weekly as ordered by the physician and she has repeatedly asked for the weights but is not getting them. In addition, she said the meal percentages are not being consistently filled out and she relies on asking the staff or the Resident for information on how much food is consumed at mealtime. She said it's a problem with Resident #87, because he/she tends to overstate how much food he/she is consuming. The surveyor and the Dietitian reviewed Resident #87's meal ticket and it did not indicate the Resident should be getting a yogurt with the lunch meal. The surveyor informed the Dietitian the Resident reports he/she is not getting a yogurt with meals consistently and the Resident reports the food is not good and the meats are difficult for him/her to eat and just now getting to pick the foods he/she wants to eat. The surveyor also informed the Dietitian of the Resident having difficulty opening the Magic Cup due to arthritis in the hands. The Dietitian could not speak to any additional interventions put into place after Resident #87 continued to have significant weight into July and August and did not think adding any more supplements would help. She said she was not aware the Resident was not receiving the yogurt consistently, or how much of the supplement the Resident is actual consuming or how much of the meal the Resident is eating. The Dietitian could not speak to if the Resident was receiving snacks in between meals. During an interview on 8/22/22 at 2:00 P.M. with a subsequent interview on 8/24/22 at 11:30 A.M., the Dietitian said she was having difficulty with all residents getting weighed including obtaining admission weight, weekly weights and having the resident be reweighed, if requested. The Dietitian said she has had to use the hospital weight to complete her nutritional assessment, if there were no admission weights available. Based on observation, interviews, record review, and policy review, the facility failed to ensure staff identified, addressed, and monitored significant weight changes for six Residents (#56, #71, #78, #79, #49, and #87) with unplanned, insidious (gradual), and/or significant weight changes, out of a total sample of 27 residents. In addition, the facility failed to weigh residents upon admission and not use hospital weights to conduct nutrition assessments, weigh residents according to physician's orders, re-check residents' weights timely when indicated, monitor food intake consistently, and implement nutritional interventions to prevent further insidious and significant weight loss. Specifically, the facility failed to: 1. Resident #56, reweigh the resident to ensure accurate weights, and failed to provide nutrition interventions when there was a significant weight loss; 2. Resident #71, weigh the resident upon admission and not use the hospital weight to conduct an initial assessment, weigh the resident weekly per physician's orders, and provide nutrition interventions when the resident had a significant weight loss; 3. Resident #78, weigh the resident upon admission and not use the hospital weight to conduct the initial assessment, weigh the resident weekly per physician's orders, and provide nutrition interventions to prevent further weight loss; 4. Resident #79, weigh resident weekly per recommendation of the dietitian, and provide nutrition interventions to prevent further weight loss when the resident experienced significant weight loss; 5. Resident #49, implement nutrition recommendations to prevent further weight loss and; 6. Resident #87, weigh the resident upon admission and not use the hospital weight to conduct an initial assessment, weigh the resident weekly per physician's orders, and provide nutrition interventions when the resident had a significant weight loss. Findings include: Review of the facility's policy titled Weight Policy, reviewed on 2/15/22, indicated the following: POLICY: Weight can be a useful indicator of nutritional status, when evaluated within the context of the individual's personal history and overall condition. When weighing a resident, adjustment for amputation or prostheses may be indicated. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. PROCEDURE: -Each resident shall be weighed on admission or readmission (to establish a baseline weight), weekly for the first four (4) weeks after admission and a least monthly thereafter to help identify and document trends such as insidious weight loss. -Monthly weights should be obtained by the 10th day of the month, or a date set by the Director of Nursing service. -The last weight in the hospital may differ markedly from the initial weight upon admission to the facility and is not to be used in lieu of actually weighing the resident. -Weights may be ordered more frequently if there is a significant change in condition, food intake has declined and persists (more than one week), or there is other evidence of alternated nutritional status or fluid and electrolyte imbalance. -The type of scale used for the initial weight should be noted (wheelchair or bed scale), it also should be noted if the resident is wearing or not wearing orthotics or prostheses. -Any significant change in weight compared to the previous weight should be rechecked and visually verified for accuracy by the nurse on duty before being documented in the medical record. -The dietitian, physician and responsible party should be notified of the significant weight change. 1. Resident #56 was admitted to the facility in September 2021 with diagnoses that included Alzheimer's disease and had a history of a hip fracture in February 2022 and August 2022. Review of the Minimum Data Set (MDS) assessment for Resident #56, dated 3/7/22, indicated the Resident required limited assistance, with one person physical assist for eating, and the Resident was 65 inches tall and weighed 134 pounds. The surveyor made the following observations of Resident #56. - On 8/18/22 at 11:59 A.M., the Resident was observed being fed by staff and ate 100% of the meal. -On 8/22/22 at 12:25 P.M., the CNA brought the Resident into his/her room and fed the Resident. Review of the Physician's Orders, dated 9/15/22, indicated the Resident had an order for a house diet with magic cup at dinner, and the addition of Ensure Plus 237 milliliters (ml) as a morning snack. Further review of the physician's orders, dated 12/11/21, indicated that the Resident had a new order for monthly weights. Review of the Resident's weights indicated the following: *1/3/22-125.2 pounds *2/2/22 132.4 pounds *3/3/22 134.0 pounds *3/9/22 128 pounds *4/13/22 and 4/20/22 130 pounds *5/2022 no weight documented *6/6/22 126 pounds *6/15/22 125 pounds *7/4/22 131 pounds *7/20/22 122.2 pounds (crossed out) *7/28/22 128 pounds *8/19/22 121.6 pounds *8/22/22 125.8 pounds Review of the Resident's Nutrition Assessment, dated 6/29/22, indicated the Resident was 65 inches tall and weighed 125 pounds (indicating minor weight change of 2.2% in 6 months). The Dietitian documented the Resident had a history of unintended weight loss but was stable. The Dietitian documented no further interventions were indicated at the time. Review of a Nutrition Progress Note, dated 7/27/22, indicated the Resident weighed 122.2 pounds, reflecting a 6.7% significant weight loss. The Dietitian requested that the Resident be reweighed. Review of the Nutrition Progress Note, dated 8/9/22, indicated the Dietitian documented that the 122.2 pounds was determined to be inaccurate and was crossed out on the Resident's weight log. Review of the medical record indicated the Resident was hospitalized for repair of left hip fracture and was readmitted to the facility in August 2022. The Dietitian completed the assessment with a weight of 128 pounds which was obtained on 7/28/22. The Dietitian documented that she was waiting for a readmission weight. Review of the Resident's weight log, dated 8/19/22, indicated the Resident's readmission weight was 121.6 pounds, and reflected a significant weight loss of 6.4 pounds (5%) within 30 days. Further review of the weight log indicated the Resident was weighed on 8/22/22 and weighed 125.8 pounds. There was a delay in obtaining the readmission weight by 7 days and the Dietitian failed to reassess the Resident's nutritional needs based on the most current weight of 121.6 pounds and provide a change in the Resident's plan to prevent further weight loss. During an interview on 8/22/22 at 2:00 P.M., the Dietitian said she was not aware of the Resident's weights that were obtained on 8/19/22 and 8/22/22. The Dietitian said she did not know if the Resident was wearing the leg brace when the staff weighed him/her. The Dietitian said she was having difficulties obtaining weights including admission, readmission, and reweighs. During a subsequent interview on 8/23/22 at 10:00 A.M., the Dietitian said the Resident was weighed while wearing the left leg brace, but it was not documented on the weight log per facility policy. The dietitian said she was not sure of the Resident's true weight, or if the Resident had a weight change greater than first identified. 2. Resident #71 was admitted in April 2022 with diagnoses that included Alzheimer's disease, protein calorie malnutrition, and fracture of the left femur. Review of the MDS assessment, dated 4/9/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. The MDS also indicated the Resident was independent for eating and weighed 126 pounds. Review of the Physician's Orders, indicated the following: - 4/2/22, prescribed a house diet. - 4/6/22, a new order for the Resident to receive a one time a day snacks per patient request. - 5/3/22, a new order for weekly weights. Review of the Resident's weights indicated the following: admission weight 126.0 pounds (obtained from Hospital discharge summary) 4/26/22- 134.8 pounds 6/15/22- 126.2 pounds 6/30/22- 119.4 pounds (5% weight loss in 30 days and 10% weight loss since 4/26/22) 7/6/22- 119.4 pounds 7/19/22- 119.4 pounds 7/20/22- 119.4 pounds 8/3/22- 118.2 pounds 8/19/22- 119.8 pounds The facility failed to weigh the Resident weekly per the physician's order. Review of the Nutrition Assessment, dated 4/8/22 (completed on 4/11/22), indicated the Resident was able to feed him/herself, but required encouragement and cues for self-feeding. The Dietitian documented the Resident was 65 inches tall, weighed 126 pounds (hospital acquired weight), and required 1716-2020 calories, 56-69 grams protein to meet their nutritional needs. The Dietitian further documented the Resident's family had requested Ensure Plus and was waiting for staff to obtain an admission weight on the Resident. The Dietitian documented the goal was to prevent weight loss, and recommended a change in supplements to Ensure Plus, once a day, and may benefit from appetite stimulant. Review of the Physician's Order, dated 4/12/22, indicated the supplement and the appetite stimulant were ordered. Review of the Dietitian's Progress Note, dated 5/2/22, indicated the Resident required increased calorie and protein due to compromised skin integrity and poor appetite/intake. The Dietitian reviewed the Resident's weights indicating an increase in weight with the most recent weight of 134 pounds on 4/26/22. The plan was to increase Ensure Plus to two times a day and continue weekly weights for assessment of weight trends. Review of the Physician's Orders, dated 5/2/22, indicated Ensure plus two times a day and weekly weights were ordered. Review of the Nutrition Progress notes, dated 6/30/22, indicated the Resident's most recent weight was 119.4 pounds, representing an 11.4% significant weight loss. The Dietitian documented that she had requested the Resident be reweighed. Review of the Nutrition Progress Note, dated 7/12/22, indicated that a reweigh was obtained with similar results, however she questioned the accuracy related to the staff's weighing methods. The plan was to continue with current plan of care and follow at risk. Review of the Quarterly Nutrition Assessment, dated 7/5/22 (completed on 7/12/22), indicated the Resident weighed 119 pounds, representing an 11.4% weight loss since 4/26/22. The Dietitian documented that she questioned the weight change with the Resident's improved intake, however questioned accuracy with weighing method and unable to ascertain previous weighing methods. The documented plan was to continue with current plan of care. Review of the Dietitian's Progress Note, dated 8/19/22, indicated the Resident continues to trigger for significant weight loss, however observed stable times two months. The Dietitian documented to continue with current plan of care. Review of Resident #71's meal percentage intake indicated the following: May 2022- 26 of 31 days were left blank June 2022- 14 of 30 days were left blank July 2022 - August 2022 completed and reflected the Resident ate fair to good (50-100%) The Dietitian failed to address the Resident's continue significant weight loss and provide interventions to prevent further weight change. 3. Resident #78 was admitted in September 2021 with diagnoses including type 2 diabetes, cerebral infarct, and dementia with behavioral disturbances. The resident had hospitalizations for gastrointestinal bleed in March 2022 and July 2022, and aspiration pneumonia in March 2022. On 8/18/22 at 7:55 A.M., the Resident was observed sitting in bed, with the head of the bed elevated. The Resident was alone and not supervised or assisted for meals as per the plan of care. On 8/18/22 at 11:45 A.M., Resident #78 was observed eating while the CNA was setting up the resident's lunch tray. The tray consisted of double portion entree, mashed potato, puree vegetable and ground meat with gravy. Resident attempted to feed self with a few bites. CNA assisted resident with the rest of the meal. Resident consumed 100% of meal. Review of the Nutrition Care Plan, dated 9/19/21, with revisions on 4/4/22, indicated the Resident was at actual/potential nutrition risk with a history of aspiration pneumonia, hemiplegia affecting left side, diabetes and oropharyngeal phase dysphagia requiring altered mechanical textures, GI bleed, psychotic disorder with delusions, long term use of insulin, ?obese with variable weight trends indicating significant loss. Increased needs related to skin integrity with wounds. -Interventions include: -Continue to encourage and promote selection of high protein foods to improve/protect skin integrity -Continue to update preferences for increased acceptability meals -HCC (house consistent carbohydrate), moist ground texture with extra moist, thin liquids, large portions -Monitored labs as ordered -Monitor PO intake -Monitor skin assessment -Monitor weight per facility policy -Provide medication as ordered Review of the MDS assessment, dated 3/19/22, indicated the Resident had a loss of liquids/solids when eating, difficulty holding food in mouth, cough/choking during meals or when swallowing. The MDS also indicated the Resident was 73 inches tall and weighed 244 pounds. Review of the clinical record, dated 3/23/22, indicated that there was a new order for the Resident to be weighed weekly. Review of the weight history indicated the following: -3/14/22-(readmission weight) 243.6 pounds -3/24/22-238 pounds -4/26/22-236.4 pounds -6/30/22-225 pounds -7/24/22-223 pounds -7/28/22-218 pounds -8/3/22-214 pounds The facility failed to weigh the Resident weekly per the physician's order. Review of the MDS assessment, dated 6/14/22, indicated the Resident had a loss of liquids/solids when eating, difficulty holding food in mouth, cough/choking during meals or when swallowing. The MDS also indicated the Resident was 73 inches tall, but the weight section was left blank. Review of the Nutrition Assessment, dated 6/16/22 (completed on 6/23/22), indicated the Resident was 75 inches tall and weighed 236.4 pounds (last known weight 4/26/22). The Dietitian recalculated the Resident's calorie and protein needs as follows: 2325-2790 calories and 140-186 grams protein. The Dietitian documented the Resident had a downward weight trend on the past quarter, triggered for significant change (-13.1%) since 10/18/21. The Dietitian documented some weight loss likely accurate but question the extent of the weight loss and documented awaiting weight for assessment of weight trends. The Dietitian indicated that as of 6/20/22 the Resident had a stage three (3) pressure ulcer to the right heel, with improved venous ulcer of left lower leg. The Dietitian recommended to increase Glucerna (sugar free supplement) to three times a day to support stable weight and wound healing. Review of the Physician's Order indicated the order for Glucerna, three times a day, was initiated on 6/22/22. Review of the Nutrition Care Plan, dated 6/23/22, indicated an addition of nursing staff/CNA to assist with feeding and monitoring aspiration-requires extensive assistance. Review of the Nutrition Progress Note, dated 7/22/22, indicated the Resident had been discharged from the facility with anticipated return (hospitalization 7/18-7/22/22). The Dietitian documented that the most recent weight (6/30/22) 225# was a trigger for significant weight loss (-10.7% since 1/5/22). The Dietitian documented that the Resident received Glucerna, three times a day, and large portions with usually good acce