**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure two Residents (#108 and #100) with pressure ulcers receive care consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. Specifically, 1. For Resident #108 the facility failed to: 1a. Implement recommendations from the consultant wound physician and, 1b. Ensure air mattress settings were set according to the plan of care. 2. For Resident #100 the facility failed to implement recommendations from the consultant wound physician. Findings Include: Review of facility policy titled Consultant Services, dated as April 2015, indicated the following: -Policy: [The facility] will identify and facilitate consultant services to meet the resident's needs, to ensure optimum care for each resident/ patient through consultant services. - Procedure: The charge nurse will then notify the attending physician of findings and he/she can then order the specific treatments as outlined by the consultant. Review of facility policy titled Prevention and Management of Pressure Injuries, undated, indicated the following: -Standard: the facility is dedicated to preventing pressure injuries and to developing a preventive plan of care based on individual needs. Residents receive the care and services they need according to established practice guidelines, so that residents who enter the facility without a pressure injury do not develop one unless the individuals clinical condition demonstrates that they were unavoidable. The necessary treatment and services will be provided to promote healing, prevent infection and prevent new pressure injuries from developing. -Policy: Residents with pressure injuries and those at risk for skin breakdown are identified, assessed, and provided appropriate treatment to encourage heeling and/or maintenance of skin integrity. Care plans are developed based on individual resident's goals and decisions for treatment. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. -Protocol -Assessment: 2. The resident is assessed for pressure injury risk factors. -The Resident's skin is observed daily with care 4. Residents will have a weekly body audit completed by the licensed staff. Review of facility policy titled Pressure Injury/ Non-Pressure Wound Risk Management, undated, indicated the following: -Those residents who score at risk on the Braden or Norton Scale, or those identified to be at risk through comprehensive assessment or who have actual skin impairment are provided with care to address their individual risk factors and goals of treatment. -Procedure: Determine cause of pressure and remove the causative agent if possible. Interventions may include: 2. Provide appropriate pressure redistributing devices to beds and wheelchairs. 3. Heels are extremely vulnerable and must be elevated completely off the bed and /or chair surface. Residents identified at risk will have an order in place to offload heels. 1. Resident #108 was admitted to the facility in May 2024 with diagnoses that include acute metabolic acidosis and protein- calorie malnutrition. Review of Resident #108's most recent Minimum Data Set (MDS) Assessment, dated 6/7/24, indicates a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating the Resident has moderate cognitive impairment. The MDS further indicates that the resident has no pressure ulcer or injuries but is at risk for developing pressure ulcers or injuries. The MDS indicates that Resident #108 has no diabetic foot ulcers or other open lesions on the foot. Further the MDS indicates that Resident #108 requires substantial/ maximal assistance for activities of daily living (ADLs) On 8/26/24 at 9:22 A.M., Resident #108 was observed lying in bed, an air mattress was in use. Resident #108 said he has a sore on his/her right heel that developed at the facility. His/her heels were directly on the mattress. Review of Weekly skin Audit, dated 6/1/24 indicated the following: -Indicate type of audit: Admission/ Readmission -Are there any skin impairments: No Review of Resident #108's Norton Assessment (an assessment tool used to determine risk for development of pressure ulcers), dated 6/1/24 indicated a score of 8, indicating that Resident #108 is at high risk of developing pressure ulcers. Review of the progress notes indicated the following: -A nursing progress note dated 6/30/24 indicated but was not limited to, Pt [patient] has blister on his/her right heel. -A second nursing progress note dated 6/30/24 indicated that the Resident was Noted to have a blister to right heel, area is blanchable. Measures 2.0 centimeters (cm) length, 3.0 cm, zero depth noted, no drainage. An Interim Skin Audit with an effective date of 6/30/24 indicated the following: -Are there pre-existing skin impairments? No. -Are there any new skin impairments? Yes. -If yes, indicate type(s): New suspected pressure ulcer/ deep tissue injury (DTI) indicated as being located on the right heel. A Pressure Injury Evaluation with an effective date of 6/30/24 indicated Resident #108 has an unstageable deep tissue injury (DTI)to the right heel with a date of origin of 6/30/24. Review of Resident #108's active care plan indicated the following: -A care plan dated as initiated on 7/10/24, ten days after the right heel ulcer was noted, which indicated the resident has potential alteration in skin integrity related to decreased/ impaired mobility or function, friction, nutrition, risk assessment, shearing (sic) with interventions including apply heel protectors posey Xlg Rx (extra-large prescribed) (sic) as ordered with skin prep. -A care plan dated as initiated on 8/13/24, forty-four days after the right heel ulcer was noted, which indicated actual alteration in skin integrity related to decreased mobility, DTI unstageable to right heel with interventions that included to follow physician's orders for skin care and treatments. 1a. On 8/26/24 at 9:22 A.M., Resident #108 was observed by the surveyor lying on his/her back in bed, an air mattress was in place, and the Resident's heels were noted to be directly on the mattress. On 8/27/24 at 10:13 A.M., the surveyor observed a nurse and a certified nurse's assistant (CNA) place a pillow under the Resident #108's knees, leaving bilateral heels to fall directly on the mattress. On 8/28/24 at 10:13 A.M., Resident #108 was observed lying in bed with his/her heels directly on the mattress. An off-loading boot was observed in the corner of the room in a chair, not in use. On 8/28/24 at 4:00 P.M., Resident #108 was observed lying in bed, sleeping with bilateral heels directly on the mattress. On 8/29/24 at 6:50 A.M., Resident #108 was observed lying in bed on his/her back with bilateral heels directly on the mattress. Review of Resident #108's medical record indicated that a consultant wound physician assessed the Resident on 7/9/24 for an initial evaluation. The progress note indicated that the resident presented with wounds on his/her left posterior heel, right posterior heel. Both areas were classified as unstageable DTIs. Recommendations for treatment included skin prep to bilateral heels every shift, off-load wound, float heels in bed: 2 pillows under the ankle; pressure off-loading boot. Review of Resident #108's July 2024 Treatment Administration Record (TAR) indicated that skin prep was initiated to bilateral heels once daily on 6/27/24 and failed to indicate that the frequency was increased to every shift as recommended by the consultant wound physician. The July 2024 TAR also indicated that an order to off load heels every shift was initiated on 6/26/24 but failed to indicate that a pressure off-loading boot was initiated as per the consultant wound physician's recommendations. Review of the consultant wound physician's progress note, dated 7/23/24, indicated that the left heel DTI had resolved, and that the right heel continues to be evaluated as an unstageable DTI. The recommendations for treatment of the right heel were skin prep to right heel every shift (3 times daily), off-load wound, float heels in bed; pressure off-loading boot. Review of Resident #108's July 2024 TAR indicated that skin prep was discontinued on 7/23/24 to bilateral heels, and an order was put into place for skin prep to the right heel daily on 7/24/24. Review of the July 2024 TAR failed to indicate that skin prep had been ordered as recommended every shift (3 times daily) or that a pressure- off loading boot was initiated. Review of the consultant wound physician progress note, dated 8/6/24, indicated that the right heel had a full thickness, stage 3 pressure wound. The wound size was documented as 0.5 cm x 0.5 cm with no measurable depth. Treatment recommendations made included Alginate Calcium, apply once daily for 30 days, cover with a gauze island dressing once daily, off-load wound, float heels in bed: pressure off-loading boot. Review of Resident #108's August 2024 TAR failed to indicate that the recommendations for Alginate Calcium and pressure off-loading boot were put into place. The treatment order for the right heel remained as skin prep once daily. Review of the consultant wound physician progress note, dated 8/13/24, indicated a right heel wound size of 1.0 cm x 1.0 cm with no measurable depth. Treatment recommendations made included hydrocolloid sheet (thin). apply three times per week for 30 days, off-load wound, float heels in bed: pressure off-loading boot. Review of Resident #108's August 2024 TAR indicated that until 8/16/24 the treatment to the right heel was skin prep once daily and that the treatment recommendations for hydrocolloid sheet were not put into place until 8/17/24, four days after the recommendation was made. The August 2024 TAR also failed to indicate that an off-loading boot was put into place. Review of the consultant wound physician progress note, dated 8/20/24 indicated a right heel wound size of 1.0 cm x 1.0 cm x 0.1 cm depth. Recommendations to continue the same treatment were made. Review of the consultant wound physician progress note, dated 8/30/24, indicated a right heel full thickness stage 3 pressure wound that measured 1.0 cm x 1.0 cm x 0.1 cm depth. Wound progress was documented as not at goal. Recommendations were made to change treatment to Alginate calcium once daily x 30 days, then wrap with gauze (kerlix). Recommendations remain to float heels in bed, pressure off- loading boot. During an interview on 8/27/24 at 12:47 P.M., Nurse #3 said that when recommendations are made from the consultant wound physician, they should be communicated to the Nurse Practitioner and put into place. During an interview on 8/29/24 at 10:46 A.M., the Director of Nurses (DON) said that a nurse from the facility rounds every week with the consultant wound physician, and that nurse is responsible for communicating and implementing those recommendations. The DON said that consultant wound physician recommendations should be implemented within 24 hours and not implementing recommendations could contribute to worsening of a pressure area. During an interview on 8/29/24 at 3:00 P.M., the consultant wound physician said that the facility should elevate heels with the use of an off-loading boot as recommended. He said there have been several times that he has noticed heels are not being off-loaded appropriately. The consultant wound physician said he would expect that his recommendations be put into place. 1b. On 8/26/24 at 9:22 A.M., Resident #108 was observed lying in bed on his/her back on an air mattress that was set at 250. On 8/28/24 at 10:13 A.M., and 2:07 P.M., Resident #108 was observed lying in bed on his/her back on an air mattress that was set at 250. On 8/29/24 at 6:50 A.M., Resident #108 was observed sleeping in bed on his/her back on an air mattress that was set at 250. On 8/29/24 at 10:27 A.M., a nurse was in Resident #108's room completing a wound dressing change. The nurse exited the room and the Resident remained in bed, lying on an air mattress that was set on 250. Review of physician's orders failed to indicate an order for an air mattress. Review of Resident #108's active care plan dated as initiated on 8/13/24 indicated that the Resident has a DTI unstageable to right heel with interventions that included specialty air mattress setting 140 (sic). Review of Resident #108's current weight indicated that on 8/1/24 he/she weighed 141.6 pounds. During an interview on 8/29/24 at 10:46 A.M., the Director of Nurses (DON) said there should be a physician's order for the air mattress, and that it should be set at or around the resident's weight. She said the air mattress should be set at around 140. If the mattress is set too high, it could be a safety issue, and would be ineffective as a pressure relieving mattress. During an interview on 8/29/24 at 3:00 P.M., the consultant wound physician said it is inappropriate to over inflate an air mattress, and it becomes more like a regular mattress. Overinflating the mattress has the potential to cause worsening of the wound.2. Resident #100 was admitted to the facility in August 2023 with diagnoses including heart failure and muscle weakness. Review of Resident #100's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, which indicated he/she had intact cognition. The MDS also indicated Resident #100 required maximal assistance from staff for bed mobility tasks. Review of the Wound Evaluation & Summary Management note dated 8/20/24, indicated Resident #100 has a pressure wound to his/her left posterior heel for over 210 days and the wound is not at goal. On 8/26/24 at 9:55 A.M., Resident #100 was observed lying in bed with both heels lying directly on the mattress. During this observation, Resident #100 said he/she has a wound on his/her left heel. On 8/27/24 at 7:10 A.M., Resident #100 was observed lying in bed with both heels lying directly on the mattress. On 8/28/24 at 8:26 A.M., Resident #100 was observed lying in bed with both heels lying directly on the mattress. Review of Resident #100's physician orders indicated the following order: -Offload heels every shift as tolerated, initiated 7/28/24. Review of the Wound physician notes dated 7/23/24, 7/30/24, 8/6/24, 8/13/24 and 8/20/24 -Pressure off-loading boot, Prevalon (a pressure relieving positioning boot), float heels in bed, off-load wound. Review of Resident #100's skin integrity care plan, last revised 7/24/24, indicated the following interventions: -Follow MD (physician) orders for skin care and treatments, -Provide positioning intervention as indicated on impaired functional mobility care plan. During an interview on 8/27/24 at 10:55 A.M., Resident #100 said he/she used to have a boot for his/her left heel but has not had one in months. On 8/28/24 at 8:41 A.M., Resident #100 was observed lying in bed with both heels directly on the mattress and not offloaded from pressure. During an interview on 8/27/24 at 11:01 A.M., Certified Nursing Assistant #1 said Resident #100 has protective socks but does not need to elevate his/her heels while in bed. During an interview on 8/27/24 at 11:09 A.M., Nurse #2 said Resident #100 has a wound on his/her left heel and should be offloaded from pressure at all times when lying in bed. Nurse #2 said the Resident does not have a prevalon boot. During an interview on 8/28/4 at 8:54 A.M., Nurse #7 said Resident #100 has had a wound on his/her left heel for several months and is treated by the wound doctor every week. Nurse #7 said Resident #100 should be offloading his/her heels while in bed and his/her heels should never be directly on the bed. Nurse #7 said Resident #100 does not have a prevalon boot. During an interview on 8/28/24 at 9:56 A.M., the Director of Nursing said nursing is responsible for making sure all recommendations from the wound doctor are transcribed over and followed. The Director of Nursing said all wound recommendations are expected to be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide behavioral health services by a) ensuring recommendations from the Psychiatric Nurse Practitioner were implemented and b) psychotropic medications were provided as ordered for one Resident (#80) out of a total sample of 30 residents. Findings include: Review of the facility policy titled, Psychotropic Medication Management, dated April 2015, indicated the following: -Administer medications as directed by the physician and manufacturer. -Monitor target behaviors daily for antipsychotics, antidepressants and anxiolytics using behavior monitoring tool. -Review the care plan with IDT (interdisciplinary team) when a resident is admitted on psychoactive medications, quarterly, annually and as needed for changes in resident status and revise as necessary. -Review should include verification that adequate indications for use of the psychotropic medication exist, the medications are note being used for extended duration, and residents are free from duplicate therapy and being monitored for adverse consequences, per current professional standards of practice and in accordance with Federal and State guidelines. Review of the policy titled, Consultant Services, sated April 2015, indicated the following: -A note should be recorded on the consultation form by any health care consultant who sees the resident/patient at the request of the MD of family. The consultant should document findings and recommendations on this form. -The charge nurse will then notify the attending physician of findings and he/she can then order the specific treatments as outlined by the consultant. Resident #80 was admitted to the facility in June 2024 with diagnoses including Alzheimer's Disease, major depression, unspecified dementia with other behavioral disturbance. Review of Resident #80's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had severe cognitive impairment with a score of 0 out of a possible 15 on the Brief Interview for Mental Status. The MDS also indicated Resident #80 required partial assistance with all functional daily tasks. Throughout the survey, Resident #80 was observed pacing throughout the C Unit and was unable to be redirected by staff. During the survey period, Resident #80 sustained two falls and was involved in a resident-to-resident altercation. Review of the Documentation Survey Report for the months of June, July and August, indicated Resident #80 displayed behaviors daily, however, did not specify the type of behaviors. Review of the admitting Nurse Practitioner note written on 6/5/24 indicated the following: -Resident #80 was admitted to the facility with a preexisting prescription for Risperidone (an antipsychotic medication) and Trazadone (a mood stabilizer) and the plan was to continue both medications. -Resident #80 was cooperative with exam upon admission. At time of admission, the following orders were initiated for Resident #80: -Psych consult as indicated. -Risperidone 0.25 mg (milligrams) oral tablet, every 24 hours PRN (as needed). -Risperidone 0.25 mg BID (twice a day). -Trazadone 50 mg at bedtime. a. Review of Resident #80's nursing notes, six weeks after admission indicated the following: -6/23/24: Patient had episodes of increased agitation with physical aggression towards staff. Banging on the table and throwing stuff off the nurse's station counter, redirected multiple times and Risperidone utilized as needed with no effect. -6/28/24: Patient is having increased behaviors, agitation, intrusive yelling and aggression. -6/30/24: Resident walked through halls all day and had to be redirected. -7/3/24: resident continue with increased agitation and aggressive behavior towards staff and other residents. Resident not redirectable, PRN risperidone administered in the AM with no effects. -7/3/24: Patient continued to exhibit increased behaviors, with physical aggression towards staff and attempting to hit other residents. New order to increased risperidone. 7/4/24: patient has not slept in days. Increased confusion, restlessness, agitation and aggression towards staff and residents. Patient refusing to take medications. The nurse received doctor ordered to send resident out to ER, nurse complied. 7/4/24: patient returned from (hospital) with recommendations to increase Risperdal to 1 mg (milligram) at HS (night) and .5 mg in am and .5 mg as needed for agitation. 7/6/24: Resident alert, (he/she) has been up all night and refused to take medication. (He/she Was very aggressive and agitated, going from room to room uncovering residents who are sleeping this shift. (He/she) Was very difficult to redirect. Roommate was very upset and not happy because (he/she) kept going to her, screaming, yelling at her and calling her names. 7/6/24: Resident #80 had hit his/her roommate and was being sent out to the hospital for a psychiatric evaluation. 7/8/24: a psych consult was requested for Resident #80. Review of Resident #80's medical record indicated he/she was first evaluated by the behavioral health team on 7/11/24, six weeks after the Resident's admission, over two weeks after his/her first behaviors presented and over a week after the Resident had been aggressive towards staff and residents. Review of the behavioral health note indicated the following: - Problem: 86 YO (year old) new to this clinician, here for LTC (long term care) as family was no longer able to care for (him/her) at home. (He/she) has a psych hx (history) of dementia with ETOH (alcohol) abuse, MDD (major depressive disorder), agitation, aggression, and psychosis. Seen per staff request for initial assessment and due to significant mood and behavioral disturbance. Staff report resident has been highly irritable, agitated, restless, delusional and aggressive at times since admission and has had to be sent out on multiple occasions. (He/she) Has had multiple evaluations by the crisis team in the ER and they have been upward titrating (his/ her) Risperdal with some benefit. Staff report (he/she) is now being less aggressive but remains highly restless and intrusive and can be difficult to redirect at times. -Plan/recommendations: Remeron (a mood stabilizer), recommend trialing resident on Remeron 7.5 MG (milligrams) PO (by mouth) daily at bedtime to help with mood and appetite. Review of the nursing note from 7/11/24 indicated Resident #80 was seen by the Psychiatric Nurse Practitioner, however, failed to indicate the recommendation for the initiation of Remeron was relayed to the Physician. Review of the Medication Administration Record for July and August 2024 failed to indicate Remeron was initiated. Review of the Physician note dated 7/26/24, failed to indicate the physician was aware of this recommendation. Review of the nursing notes from July and August 2024 indicated the following: -7/15/24: Continues to have increased anxiety and aggression. (He/she) was wandering the hallway at about 7PM, (he/she) slapped a staff's hand who was sitting there documenting. -7/20/24: Resident #80 refused all day time medications. -8/2/24: Resident was observed pulling on another resident's hair by staff .Social worker made aware and working on section 12 (involuntary transportation to hospital for evaluation of mental health). Resident #80 returned to the facility the same day, on 8/2/24. Resident #80 was seen by the Psychiatric Nurse Practitioner again on 8/16/24, 2 weeks after the Resident was sectioned 12'd to the hospital for being a danger to self or others. Review of the Psychiatric Nurse Practitioner indicated the following: -Chief complaint: Pt (patient) pacing around unit, agitation, aggression, and refusing medications. Target symptoms: aggression. agitation, anxiety and paranoia. -Clinical assessment: Patient pacing in (his/her) room and unit, patient with agitation, and at times moving fast, restless, having racing thoughts, and refusing medications. Aggressive, poor concentration, poor judgement, aggressive behaviors. No s/sx (signs or symptoms) of SI (Suicide Ideation). Recommending to start Ativan (an anti-anxiety medication) 0.5mg as follows: give 1 tab by mouth twice a day prn for anxiety/agitation. -Plan/recommendation: Notify of any changes or concerns. Continue to monitor. Recommendation to start new medication(s). Recommending start Ativan as follows: 0.5mg as follows: give 1 tab by mouth twice a day prn for anxiety/agitation. Recommending to start Depakote (mood stabilizer) 125 mg twice a day r/t (due to) psychotic disorder with delusions due to known physiological condition. Review of the nursing note on 8/16/24 failed to indicate these recommendations were reported to the physician. Review of the Medication Administration Record for August 2024, failed to indicate Ativan or Depakote were ever initiated. Review of the Physician note dated 8/20/24 failed to indicate the physician was made aware of these recommendations. The surveyor attempted to call the physician and his office said he was unavailable for the week. Review of Resident #80's psychotropic medication care plan, last revised 7/2/24, indicated the following intervention: -investigate/monitor need for psychological/psychiatric support provide services as ordered by the physician. During an interview on 8/29/24 at 9:37 A.M., Nurse Practitioner #1 said all recommendations from behavioral health are sent to her by nursing for her to approve. Nurse Practitioner #1 said she was not aware of the Remeron recommendation in July and approved the recommendation for Ativan and Depakote in August but was never aware the medications had not been given. During an interview on 8/29/24 at 9:45 A.M., Nurse #6 said Resident #80 displays a lot of behaviors. Nurse #6 said behavioral health services are at the facility weekly, however, Resident #80 has only been seen twice since admission. Nurse #6 said she feels Resident #80 would have benefitted from being seen more often. Nurse #6 said recommendations from behavioral health are given to nurse who then sends them over to the physician. Nurse #6 said Resident #80's family was never contacted to sign the consent for use of Remeron which is why the Resident was never started on that medication. Nurse #6 said she was also aware of the recommendation to start Ativan and Depakote, however, never followed up to see if the doctor approved and should start them. During an interview on 8/29/24 at 9:55 A.M., Social Worker #1 and the Director of Social Services both said Resident #80 exhibits behaviors often and his/her behavior is pretty significant. Both said behavioral health is in the building weekly but Resident #80 was only seen once a month because of billing and should have been seen more frequently. During an interview on 8/29/24 at 10:59 A.M., Corporate Nurse #1 said she would expect Resident #80 to have been seen by behavioral services after every resident-to-resident incident and when the Resident presented with increased behaviors. During an interview on 8/29/24 at 10:23 A.M., the Director of Nursing (DON) said behavioral services are in the building at least once a week and residents are seen on an as needed basis. The DON said behavioral health services should evaluate/treat a resident who is experiencing increased behaviors and who are involved in resident-to-resident incidents with each increase of behavior or incident. The DON said Resident #80 should have been seen more regularly by the behavioral health team. The DON said if the Psychiatric Nurse Practitioner makes recommendations, the nurses are expected to notify the physician so they can be implemented if he agrees. The DON was unaware of the recommendations made and that they were never followed through. During an interview on 8/29/24 at 2:14 P.M., the Psychiatric Nurse Practitioner said all recommendations are given to nursing and it is expected that the nursing staff report these recommendations to the physician and follow through with them. The Psychiatric Nurse said she was unaware that the three recommendations made were never followed up with and that Resident #80 should have been seen more frequently due to his/her behaviors/presentation. b. Review of the Medication Administration Report for June, indicated Resident #80 was prescribed the following psychotropic medications: -Trazadone oral tablet, 50mg. Give one tablet at bedtime related to major depressive disorder, initiated on 6/5/24 -Risperidone oral tablet 0.5mg. Give 1 tablet by mouth two times a day related to major depressive disorder, initiated on 6/5/24. --Risperidone oral tablet .25mg. Give one tablet by mouth every 24 hours as needed for anxiety, initiated on 6/5/24 Review of the Medication Administration Report for July, indicated Resident #80 was prescribed the following psychotropic medications: -Risperidone oral tablet 0.5 mg. Give 1 tablet two times a day related to major depressive disorder, initiated on 6/5/24 and discontinued on 7/4/24. -Risperidone oral tablet. Give .5mg by mouth three times a day related to Alzheimer's Disease, initiated, and discontinued on 7/4/24. -Risperidone oral tablet 0.5 mg by mouth one time a day related to Alzheimer's Disease, initiated on 7/5/24 and discontinued on 7/8/24. -Risperidone oral tablet 1 mg. Give 1 tablet by mouth in the evening related to unspecified dementia, initiated on 7/5/24 and discontinued on 7/16/24. -Risperidone oral tablet 0.5 mg. Give 1 tablet by mouth at bedtime for increased behavior, initiated 7/15/24 and discontinued 7/24/24. -Risperidone oral tablet 1 mg. Give 1 mg by mouth one time a day for increased behavior, initiated 7/16/24 and discontinued 7/24/24. -Risperidone oral tablet 0.5 mg. Give 1 tablet at bedtime for increased behavior, initiated on 7/24/24 -Risperidone oral tablet 1 mg. Give 1mg by mouth one time a day for increased behavior, initiated 7/25/24. -Risperidone oral tablet 0.25mg. Give one tablet by mouth every 24 hours as needed for anxiety, initiated on 6/5/24 and discontinued on 7/5/24. -Risperidone oral tablet 0.5mg. Give one tablet by mouth every 8 hours as needed for behaviors related to unspecified dementia, initiated 7/5/24. -Risperidone oral tablet. Give 0.5mg by mouth every 8 hours as needed for increased agitation related to major depressive disorder, initiated 7/3/24 and discontinued 7/9/24. -Trazadone 50 mg. Give 1 tablet by mouth at bedtime related to major depressive disorder, initiated 6/5/24 and discontinued on 7/4/24. -Trazadone 50 mg. Give 1 tablet by mouth at bedtime related to major depressive disorder, initiated on 7/25/24. -Trazadone 50 mg. Give 1 tablet by mouth in the afternoon related to major depressive disorder, initiated on 7/23/24. Review of the Psychiatric Nurse Practitioner and Physician notes failed to indicate a recommendation to stop Resident #80's Trazadone on 7/4/24, and he/she was without the mood stabilizer for 20 days. Throughout this time period, there were several nursing notes indicating Resident #80 had increased anxiety and agitation and had several occasions of refusing his/her medications. In addition, there was no indication for a recommendation to start the second dose of Trazadone on 7/25/24 when the medication was reintroduced on 7/23/24. Further review indicated that Resident #80's went 6 days (from 7/9/24 to 7/14/24) with only a one-time dose of the antipsychotic Risperidone, with no indication of that dose reduction being recommended by the Physician or nurse Practitioner. On 7/15/24, after 6 days without the second dose of antipsychotic medication, Resident #80 was physically aggressive towards a staff member. Review of the Medication Administration Report for August, indicated Resident #80 was prescribed the following psychotropic medications: -Risperidone oral tablet 0.5 mg. Give one tablet by mouth at bedtime for increased behavior, initiated on 7/24/24 and discontinued on 8/6/24. -Risperidone oral tablet 1 mg. Give 1 mg by mouth one time a day for increased behavior, initiated on 7/25/24 and discontinued on 8/6/24. -Trazadone 50 mg. Give 1 tablet by mouth at bedtime related to major depressive disorder, initiated 7/25/24 and discontinued 8/20/24. -Trazadone 50 mg. Give 1 tablet by mouth in the afternoon related to major depressive disorder, initiated 7/23/24 and discontinued 8/20/24. -Trazadone 50 mg. Give 1 tablet by mouth three times a day for increased agitation related to dementia, initiated on 8/20/24. -Trazadone 50 mg. Give 1 tablet by mouth every 8 hours as needed for increased agitation, initiated on 8/20/24 and discontinued on 8/21/24. -Trazadone 50 mg. Give 1 tablet by mouth every 8 hours as needed for increased agitation for 14 days, initiated on 8/21/24. Review of the Psychiatric Nurse Practitioner and Physician notes failed to indicate a recommendation to stop Resident #80's Risperidone on 8/6/24 and he/she has been without the antipsychotic medication since, a total of 23 days. Review of the physician note dated 8/20/24 indicated the following: -The patient does have a history of dementia with behavioral disturbance. The patient is currntly on Risperdal 1 mg p.o.q.a.m. (by mouth every morning) and .5mg p.o.h.s.p.r.n. (by mouth every day as needed), although this was scheduled through 8/6/24. It is unclear if this has been continued. Review of Resident #80's psychotropic medication care plan, last revised 7/2/24, indicated the following intervention: -Administer medication as prescribed by the physician. Review of Resident #80's behavioral care plan, last revised 7/19/24, indicated the following intervention: -Administer medications as ordered and monitor for effectiveness. Document resident's medication effects and notify MD/NP if behavior escalates. The surveyor attempted to call the physician and his office said he was unavailable for the week. During an interview on 8/29/24 at 9:37 A.M., Nurse Practitioner #1 said she was unaware Resident #80's Trazadone and Risperidone had been stopped and did not know why that would have happened. Nurse Practitioner said all medication changes should be approved by the physician. During a follow-up interview on 8/29/24 at 1:07 P.M., Nurse Practitioner #1 said the side effects of stopping an antipsychotic abruptly without tapering would be increased behaviors which Resident #80 has been exhibiting. Nurse Practitioner said the abrupt stopping without authorization from the medical team can be harmful to the Resident. During an interview on 8/29/24 at 9:45 A.M., Nurse #6 said she was aware there was a period Resident #80 was not on any psychotropic medication and was unsure of the reason. During an interview on 8/29/24 at 10:23 A.M., the Director of Nursing (DON) said she was unaware of both the Trazadone and Risperidone being discontinued and could not explain how or why this occurred. The DON said there are possible side effects of stopping psychotropic medications without a taper, which would include instability, shakes, increased agitation and confusion, and general symptoms of withdrawal. During an interview on 8/29/24 at 10:59 A.M., Corporate Nurse #1 said she would expect Resident #80 to have been seen by behavioral services after every resident-to-resident incident and when the Resident presented with increased behaviors. Corporate Nurse #1 said she would expect the interdisciplinary team to discuss every incident, including a medication review and the stopping of Resident #80's Risperidone and Trazadone should have been caught by the team. Corporate Nurse #1 said stopping antipsychotic medications abruptly would create increased symptoms. Corporate Nurse #1 said the facility had recently completed education on psychotropic medications and she believes a nurse put an end date on all psychotropic medications without speaking with the doctor. Corporate Nurse #1 said the facility went through all the medication orders to ensure this end date was deleted, however the end date of Resident #80's Risperidone must have been missed. During an interview on 8/29/24 at 2:14 P.M., the Psychiatric Nurse Practitioner said she was unaware that Resident #80's medication had been stopped and said this could have caused harm to the Resident causing increased behaviors, instability and a fast increasing of symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review , policy review and interview the facility failed to ensure two Residents (#71 and #73) were provided effective interventions and supervision to prevent falls, out of a total sample of 36 residents. Specifically, the facility failed to 1) ensure for Resident #71 that effective interventions were in place to prevent further falls after sustaining multiple falls which then resulted in Resident #71 sustaining a hip fracture, and 2) ensure for Resident #73 was provided effective supervision and interventions to prevent a fall. Findings include: Review of the facility policy titled Falls Management last revised August 2018 indicated that a fall risk evaluation will be conducted after each fall and the interdisciplinary team will develop, initiate, and implement an appropriate individualized care plan based on the fall risk evaluation score. Review of the facility policy titled Comprehensive Care Plans dated last revised November 2017 indicated the care plan is revised as needed. 1. Resident #71 was admitted to the facility in February 2019 with diagnoses including dementia with behavioral disturbance, weakness and history of transient ischemic attacks (mini strokes). Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #71 was an extensive assist of two staff members for transfers in and out of chairs and bed. Further review indicated that Resident #71 scored four out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Review of the medical record indicated that Resident #71 fell out of bed on 1/5/23. Further review failed to indicate that the plan of care was reviewed or revised. Review of the facility document titled Nur- Fall Risk Assessment -V2 dated 1/6/23, indicated that Resident #71 scored a 13 (above a score of 10 is considered high risk) indicating a high risk for falls. Review of the medical record indicated that Resident #71 fell in her/his room on 3/16/23. Further review failed to indicate that the plan of care was reviewed or revised. Review of the facility document titled Nur- Fall Risk Assessment -V2 dated 3/16/23, indicated that Resident #71 scored a 16 indicating a high risk for falls. Review of the medical record indicated that Resident #71 in her/his room on 4/6/23. Further review failed to indicate that the plan of care was reviewed or revised. Review of the facility document titled Nur- Fall Risk Assessment -V2 dated 4/6/23, indicated that Resident #71 scored a 20 indicating a high risk for falls. Further review of the three documents ( Nur- Fall Risk Assessment -V2 dated 1/6/23, 3/16/23 and 4/6/23)indicated an increasing rate of risk for falls with each fall. Review of the medical record indicated that Resident #71 fell in the lounge on 5/2/23. Further review indicated that Resident #71 sustained a fracture of the left femoral neck ( a type of hip fracture) requiring hospitalization and surgical intervention. Review of Resident #71's care plan with the focus on falls, dated as initiated 4/27/22, indicated that the interventions in place to prevent falls included the following: a) Invite, encourage, remind, escort to activity programs consistent with the Resident's interests to enhance physical strengthening needs. b) Provide, monitor use of adaptive devices: walker, wheelchair c) Referral for screen an treatment as needed: PT (physical therapy), OT (occupational therapy) and mental health. d) Remind Resident #71 and reinforce safety awareness: a) when rising from a lying position, sit on side of bed for a few minutes before transferring/standing. b) Educate/remind Resident to request assistance prior to ambulation. c) appropriate footwear. Further review failed to indicate that the care plan was reviewed or updated until 5/23/23, after Resident #71 sustained a hip fracture from falling out of a chair. Review of the Nurse's note dated 5/2/23, indicated that Resident #71 was in the lounge room when a certified Nurse's aide found the Resident on the floor and yelled for the nurse to help. Further review indicated that Resident #71 stated that she/he was attempting to get the walker but her/his feet got all tangled up. Review of the facility document titled #268 Fall, dated 5/2/23, indicated that Resident #71 was wearing improper footwear at the time of the fall. During an interview on 8/9/23, at 2:16 P.M., the SDC (Staff Development Coordinator) said that he was not able to locate any documentation in the medical record that indicated the care plan was reviewed or updated after the falls that occurred on 1/5/23, 3/16/23 and 4/6/23, for if effectiveness of the current interventions were adequate to prevent further falls. The SDC then said that the care plan should have been reviewed and updated to determine if the current interventions were adequate to prevent further falls. 2. For Resident #73 the facility failed to implement effective interventions including adequate supervision to prevent Resident #73 from falling. The most recent fall on 8/7/23 resulted in a hematoma and abrasion on his/her forehead. Resident #73 was transferred to the hospital emergency department for further evaluation and returned to the facility. Resident #73 was admitted to the facility in May 2019 with diagnoses including heart disease, unspecified dementia, and repeated falls. Review of Resident #73's Minimum Data Set assessment with an assessment reference date of 5/31/23 indicated Resident #73 scored an eight out of 15 on the Brief Interview for Mental Status, indicating moderately intact cognition, and required extensive assistance from staff for transfers and toileting. Review of Resident #73's medical record indicated Fall Risk Assessments dated 3/24/23, 5/24/23 and 6/19/23 indicated Resident #73 was assessed as a high risk for falls. On 8/9/23 at 9:17 A.M., Resident #73 was in his/her room, sitting in a wheelchair. The right side of Resident #73's forehead was reddened and bruised. Resident #73 said he/she fell skipping down the stairs to see his/her sister. A CNA was in the room assisting the resident in the other bed. On 8/9/23 at 9:23 A.M., the CNA left the room. Resident #73 remained in the room without staff present, a chair alarm box was attached to his/her wheelchair. At 9:27 A.M., the chair alarm sounded when Resident #73 leaned forward in his/her chair, it turned off when he/she leaned back after approximately one minute. No staff were observed to respond during the time the alarm sounded. Review of Resident #73's incident reports indicated the following: -On 2/15/23 at 14:48 (2:48 P.M.) Resident #73 sustained a fall on 2/15/23 in his/her room. Resident #73 was trying to transfer from the toilet to his/her wheelchair. The staff statements indicated it was an unwitnessed fall. No injury. -On 2/24/23 Resident #73 was on the floor in his/her room at about 5:15 P.M. during mealtime. Resident stated he/she was trying to pick up ice from the floor and fell from his/her wheelchair. Resident was assessed for a bump on his/her upper forehead. The fall was unwitnessed. -On 3/24/23 Resident #73 fell in his/her bathroom at 12:05 P.M., the incident description indicated the Resident said he/she (had) gone into the bathroom by him/herself and tripped and hit his/her head three times. He/she is complaining of having pain in the forehead. The incident report indicated the Resident did not call for assistance when ambulating from his/her wheelchair. The fall was unwitnessed. -On 6/19/23 at 11:11 A.M., Resident was found sitting on his/her bathroom floor. Resident said he/she propelled him/herself and put him/herself on the toilet then tried to use the bar to pull him/herself up and fell to the floor on his/her buttocks. The fall was unwitnessed. -On 8/7/23 at 17:52 (5:52 P.M.) Patient (Resident #73) had an unwitnessed fall in his/her room from his/her wheelchair. He/she stated that he/she was trying to go downstairs to see his/her friend. Upon assessment, the patient was observed to sustain a hematoma on his/her forehead, and he/she complained of pain on his/her left side. MD (medical doctor) notified and advised to send patient to the ED (emergency department) for evaluation. Patient has a history of falls due to poor safety awareness. A nursing progress note dated 8/7/23 indicated a call was made to the hospital, spoke to the nurse who confirmed that the patient did not sustain any fracture and will be returning to the facility. Review of the incident reports indicated all five of Resident #73's falls reviewed were unwitnessed, three were while Resident #73 was in the bathroom alone, and two falls were when Resident #73 was alone in his/her room. On 8/9/23 at 10:09 A.M., Review of Resident #73 care plan dated as revised 7/17/23 indicated the following: At risk for fall related injury related to disease process/condition (dementia, diabetes, PVD (peripheral vascular disease) CVD (coronary artery disease) .) fall history 6/19/23, fall in last month, fall in the last 2-6 months, medication usage antidepressant, use of assistive devices walker/wheelchair. Interventions included: *Call bell in reach. Give reminders to use the call bell, dated 10/24/22. *Encourage Resident to go to day room after A.M. care, 6/19/23. *Fall mats on either side of bed when resident in bed, 11/17/22. *Invite encourage, remind, escort to activity programs consistent with resident's interests to enhance physical strengthening needs 5/11/22 *Keep bed in the lowest position 11/17/22. *Padded side rails 6/14/23 * Provide/monitor use of adaptive devices: walker/wheelchair 4/27/22 *Referral for screen and treatment as needed: PT (physical therapy) *Report falls to physician and responsible party 4/27/22. *Use fall risk screen to identify risk factors 4/27/23. At the time of the care plan review, the care plan did not indicate the use of a chair alarm and indicated canceled as potential preventative measure in place is/are bed alarm, floor mat alarm, other alarm, canceled date 4/27/22. Review of the physician's orders indicated an order dated 8/9/23, two days after the 8/7/23 fall, for a chair alarm, check placement and function every shift. Review of the Resident Care Card (a reference card which breaks down a resident's daily needs), dated 3/2020 indicated the following under additional information, staff to be with the pt (patient) at all times during toileting, dated 9/16. 15-minute checks dated 10/17. Toilet after meals and before sleep. Staff being with Resident #73 during toileting did not occur in three falls. The care plan and Resident Care card had conflicting information regarding Resident #73 implemented safety interventions to prevent falls. During an interview on 8/9/23 at 12:47 P.M., CNA #4 said Resident #73 is a high risk for falling and you must keep your eye on him/her because he/she will sneak away and go back to his/her room. CNA #4 said Resident #73 believes his/her roommate is a sibling and that is why he/she wants to go back to his/her room. CNA #4 said he always tries to know where Resident #73 is. During an interview on 8/9/23 at 4:18 P.M., CNA #5 said she was working with Resident #73 the evening of his/her last fall (8/7/23) CNA #5 said Resident #73 is at risk for falls, needs frequent checks and they (staff) try to keep him/her out of his/her room. CNA #5 said Resident #73 would not have dinner in the dining room and was left in his/her room during the dinner meal. CNA #5 said staff were passing trays and helping other residents when Resident #73 fell in his/her room. During an interview on 8/10/23 at 11:03 A.M. Unit Manager #1 said Resident #73 is not on 15-minute safety checks and said she just reinstated the chair alarm after this last fall. Unit Manager #1 said Resident #73 is mostly continent and that is why he/she tries to go into the bathroom him/herself. Unit Manager #1 reviewed the fall care plan and said interventions were related to bed safety and could be updated to address Resident #73's safety when in his/her room for using the bathroom or when in his/her room alone. Aside from encouraging Resident #73 to go to the day room after morning care the care plan failed to have effective person-centered interventions to prevent the risk of falling for Resident #73, who is a known high risk for falls, who has known falls during bathroom use, or when in the room without supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to 1. protect residents from ongoing verbal abuse after 1 Resident (#76) alleged abuse to staff and 2.) failed to protect 1 Resident (#88) who does not have the ability to consent to physical touch with another resident out of a total of 32 sampled Residents. Findings include: Review of the facility policy titled Abuse prohibition policy revised September 2020 indicated the following: *Every [NAME] facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation. *The procedure includes screening of personnel for a history of abuse. *Identifying events, occurrences, patterns, and trends of potential abuse for residents. *Performing internal facility investigations of alleged violations and identification of staff members responsible for investigating incidents and the reporting of same to proper authorities. *Protecting residents from harm during an investigation of alleged abuse. *It will be the facility's responsibility to identify, correct and intervene in situations where abuse, mistreatment, neglect, exploitation and/or misappropriation of resident property occur. 1. Resident #76 was admitted to the facility in September, 2021 with diagnoses including post traumatic stress disorder (PTSD), End stage renal disease (ESRD), and Diabetes Mellitus. Review of Resident #76's Minimum Data Set (MDS) assessment completed 8/10/22 indicated that Resident #76 had a Brief Interview for Mental Status (BIMS) score of 15 out of possible 15, indicating intact cognition. During review of the facility's incident report titled Abuse by Staff-Verbal dated 8/23/22, a witness statement written by the Assistant director of nurses(ADON) indicated that she came in to work on the morning of 8/23/22 and read a note from the 24-hour report regarding an alleged incident of abuse the night before during the 3:00 P.M.-11:00 P.M. shift regarding certified nurse's assistant (CNA #2) toward Resident #76. The witness statement indicated Resident #76 alleged that CNA #2 had been treating him/her poorly. It had been happening since CNA #2 was assigned to his/her unit. Resident #76 said that CNA #2's demeanor toward him/her makes him/her feel like a burden. CNA #2 told Resident #76 she/he used the call light too often. CNA #2 also became angry at the sound of Resident #76's chair alarm and when Resident #76 requested to be changed after a bowel movement, CNA #2 made it clear she did not want to change him/ her. During an interview with the ADON on 9/30/22 at 9:54 A.M., she said the incident happened during the 3:00P.M. -11:00 P.M. shift, Resident #76 reported the incident at the end of the shift to Nurse #6, Nurse #6 wrote the incident progress note at midnight. Nurse #6 failed to alert administration of Resident #76's allegation of abuse, therefore, CNA #2 returned to work on 8/23/22 and began working on the 7:00 A.M. -3:00P.M. shift putting Resident #76 and other Residents at risk for continued abuse. During an interview with the Director of Nurses (DON) at 3:15 P.M., on 9/30/22, she said CNA #2 who was already in the building and providing care to the Residents was walked out of the building at 9:15 A.M., on 8/23/22.The investigation concluded it was in the best interest of the facility terminate CNA #2 based on neglect and verbal abuse. During an interview with both the ADON and the DON on 9/26/22 at 8:57 A.M., they both stated that the above incident was abusive towards Resident #76 and substantiated that CNA #2 was abusive towards Resident #76. 2. For Resident #88, the facility failed to prevent physical contact between him/her and Resident #39. Resident #88 is unable to consent to physical intimacy and expressed relief when he/she was separated from Resident #39. Review of the Facility's Abuse Prohibition Policy dated 2020 indicated: *Sexual Abuse includes but is not limited to: sexual harassment, sexual coercion, or sexual assault. Sexual abuse is non consensual sexual contact of any type with a resident. Resident #88 was admitted to the facility in August 2022 with diagnoses including developmental disorder and anxiety disorder. Review of his/her most recent Minimum Data Set Assessment indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating he/she is severely cognitively impaired and he/she requires assistance with transfers, dressing and toileting. Review of Resident #88's clinical record included a letter from Resident #88's family physician dated 8/20/21, regarding his/her cognitive status: The patient suffers from mental retardation. His/Her cognitive ability is lacking and he/she requires constant supervision which to date has been provided by his/her sister. Resident #88 is illiterate and lacks insight and any learning capacity due to cognitive dysfunction. The clinical record also indicated that Resident #88 became Resident #39's roommate in August 2022. Resident #39 was admitted to the facility in July 2021 with diagnoses including unspecified psychosis, brain injury and psychotic disorder. Review of his/her most recent Minimum Data Set Assessment indicated he/she scored a 15 out of 15 on the Brief interview for Mental Status Exam (BIMS) indicating he/she is cognitively intact and he/she requires assistance with toileting and dressing. Review of Resident #39's clinical record indicated he/she has an activated health care proxy, (meaning he/she cannot make medical decisions for himself/herself due to his/her traumatic brain injury) Review of Resident #39's clinical record indicated a nurse progress Note dated 9/2/22, that staff had observed Resident #39 holding hands with his/her roommate (Resident #88) during an activity. Later that afternoon staff opened the door to their room and observed Resident #88 sitting on Resident #39's lap fully clothed but jumped up nervous. The note indicated that staff then placed the residents on 15 minute checks. Review of Resident #88's nursing progress note dated 9/2/22, indicated that Resident #88's sister was notified of the incident and she was upset and concerned about Resident #88's safety. She said that Resident #88 was never involved in that lifestyle. The clinical record failed to indicate an evaluation of Resident #88's ability or willingness to participate in touching or being with Resident #39, or methods for staff to monitor the interactions between Resident #88 or Resident #39 other than 15 minute checks. Review of Resident #88's nursing progress note dated 9/4/22, indicated Resident #88 said he/she was scared because Resident #39 was being loud and throwing things. Resident #88's sister reported that in the night, Resident #39 had removed Resident #88's blanket off the bed and an immediate room change then took place, (2 days after the 15 minute checks had been initiated and after Resident #88 had been observed on Resident #39's lap). Review of Resident #88's social service progress note dated 9/6/22, indicated that Resident #88 met with the Social Worker and told her about what happened and was scared, but is now happy in his/her new room. Review of Resident #39's Psychiatric Nurse Practitioner Note dated 9/13/22, indicated: Resident and his/her roommate (Resident #88), who has a developmental disorder became very close and he/she thinks they were in a relationship. Per the nursing staff he/she was inappropriate at times with touching him/her, lying in his/her bed and holding hands with him/her throughout the day. [Resident #39] asked him/her to sit on his/her lap to stop his/her legs from shaking which was very inappropriate. Resident #39 was told that they had to break up and the roommate had to change rooms as the family was very upset and they demanded an immediate room change for safety. During an interview with Resident #39 on 9/26/22, at 11:05 A.M., when asked how long he/she and Resident #88 were together he/she responded 3 weeks. When asked if they were physically romantic, Resident #39 said that they held hands and kissed. Resident #39 said that staff at the facility were not supportive of their relationship and that they had to break up when Resident #88's family found out. Resident #39 said that Resident #88 acts afraid when he/she sees him/her now and that it is upsetting for Resident #39. During an interview with Unit Manager #1 on 9/22/22, at 8:46 A.M., she said that Resident #88 could not cognitively consent to being in a physical or romantic relationship. During an interview with Nurse #3 on 9/22/22, at 8:32 A,M. he said that Resident #88 could not consent to being physical or in a relationship with another resident. During an interview with the Psychiatric Social Worker on 9/22/22, at 11:39 A.M., she said that during her visit with Resident #39 on 9/7/22, he/she had disclosed that Resident #39 and Resident #88 had been kissing previous to 9/2/22, and that Resident #39 had said that they were attracted to each other. The Psychiatric Social Worker said that she did not share this information with staff at the facility. During interview an on 9/22/22, at 12:32 P.M., and 9/23/22 at 1:03 P.M. the Director of Nursing (DON) said that she thought Resident #88 was moved out of the room on 9/2/22, and not placed on 15 minute checks. The DON acknowledged that physical incidents could still have occurred with both residents sharing the room while on 15 minute checks. The DON said that the ideal intervention for safety would have been an immediate room change off of the unit. During a follow up interview with the Social Worker and the Director of Nursing on 9/26/22, at 11:26 A.M. the Social Worker said that after they were informed of Resident #39's disclosure of kissing Resident #88 on 9/22/22, but they did not consider it to be assault even though Resident #88 is not able to consent, because they did not feel Resident #39 was malicious, and Resident #88 seemed to be a willing participant. The facility failed to prevent physical contact between Resident #88 and Resident #39. Using the reasonable person concept, a person who is unable to understand or consent to physical contact or romantic involvement with another, would suffer emotional distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #39, the facility administered insulin without an order. Review of the Code of Massachusetts Regulations Section 9.03- Standards of Conduct for Nurses, current through 8/5/22, indicated a nurse licensed by the Board shall not administer any prescription drug or non-prescription drug to any person in the course of nursing practice except as directed by an authorized prescriber. Review of facility policy titled 'Medication Administration by Route or Dosage', revised March 2017, indicated the following: Procedure: Verify medication order on Medication Administration Record (MAR). Check against physician order. Resident #39 was admitted to the facility in July 2021 with diagnoses including diabetes mellitus and major depressive disorder. Review of Resident #39's Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #39 was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), required assistance with care activities and received insulin (an injectable medicine used to treat blood sugar). On 9/21/22, at 9:42 A.M., Resident #39 was observed sitting in his/her room. The Resident said he/she had a concern with his/her insulin administration this morning. Resident #39 said no one had ordered his/her insulin and he/she did not get the correct dose this morning. Resident #39 said this morning after breakfast he/she was given 45 units of insulin instead of the 72 units he/she is supposed to receive. Resident #39 said the nurse told him/her that maybe he/she would get the rest of the dose this afternoon. Review of Resident #39's medical record indicated the following: -A physician's order dated 6/16/22, for Humalog 50/50 (a combination insulin made up of intermediate-acting insulin and a fast acting insulin) MIX vial: generic: Insulin Lispro Protamine. Inject 72 units subcutaneously every morning. Rotate sites. -September 2022 Medication Administration Record (MAR) which indicated the Resident had received 72 units of insulin on 9/21/22 During an interview on 9/21/22, at 10:02 A.M., Nurse #1 said that she only gave the Resident 45 units of insulin as that was all she had on hand. Nurse #1 said there were no other vials of the insulin in the medication fridge. Nurse #1 said she had not notified the physician or Nurse Practitioner of the incorrect dose of insulin being administered and had not gotten an order to administer 45 units only prior to administration. During an interview on 9/21/22, at 10:14 A.M., the Assistant Director of Nursing said the nurse should not have administered a partial dose of the insulin. The Assistant Director of Nursing said that the nurse should have notified the provider that there wasn't enough for a full dose and then gotten a new order. The Assistant Director of Nursing said the nurse can't just administer what is left. During an interview on 9/21/22, at 2:44 P.M., the Director of Nursing said she was aware of the incorrect dose of insulin being given to Resident #39. She said the nurse should have obtained an order prior to administration and said it was serious. Based on observation, interview and record review, the facility 1). failed to assess a relationship between 2 Residents (#39 and #88), 2). failed to obtain a physician's order and assess for the use of oxygen for 1 Resident (#42) and 3). administered insulin without a physician's order for 1 Resident (#39) out of a total sample of 32 residents. Findings include: 1. For Resident #88, the facility failed to assess the relationship between him/her and his/her roommate (Resident #39). Resident #88 does not have the capacity to consent to a romantic relationship or physical intimacy. Resident #88 expressed relief when he/she was separated from Resident #39. American Nursing Associations Scope and Standards of Nursing Practice, 2010, pg 32,: Standard 1. Assessment: The Registered Nurse (RN) collects comprehensive data pertinent to the consumer's health and/or the situation. Competencies: Collects comprehensive data including but not limited to physical functional, psychosocial, cognitive and ongoing process while honoring the uniqueness of the person. Resident #88 was admitted to the facility in August 2022 with diagnoses including developmental disorder and anxiety disorder. Review of his/her most recent Minimum Data Set Assessment indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating he/she is severely cognitively impaired and he/she requires assistance with transfers, dressing and toileting. Review of Resident #88's clinical record included a letter from Resident #88's family physician dated 8/20/21, regarding his/her cognitive status: The patient suffers from mental retardation. His/Her cognitive ability is lacking and he/she requires constant supervision which to date has been provided by his/her sister. Resident #88 is illiterate and lacks insight and any learning capacity due to cognitive dysfunction. The clinical record also indicated that Resident #88 became Resident #39's roommate in August 2022. Resident #39 was admitted to the facility in July 2021 with diagnoses including unspecified psychosis, brain injury and psychotic disorder. Review of his/her most recent Minimum Data Set Assessment indicated he/she scored a 15 out of 15 on the Brief interview for Mental Status Exam (BIMS) indicating he/she is cognitively intact and he/she requires assistance with toileting and dressing. Review of Resident #39's clinical record indicated he/she has an activated health care proxy, (meaning he/she cannot make medical decisions for himself/herself due to his/her traumatic brain injury). Review of Resident #39's clinical record indicated a nurse progress note dated 9/2/22, that staff had observed Resident #39 holding hands with his/her roommate (Resident #88) during an activity. Later that afternoon staff opened the door to their room and observed Resident #88 sitting on Resident #39's lap fully clothed but jumped up nervous. The note indicated that staff then placed the residents on 15 minute checks. On 9/23/22, the surveyor was informed that the facility does not have a policy regarding resident interpersonal relationships or ability to consent to physical or romantic relationships. The clinical record failed to indicate assessments for either Resident #88 or Resident #39 identifying a possible relationship, Resident #88's ability or willingness to participate in touching or being with Resident #39, or methods for staff to monitor the interactions between Resident #88 and Resident #39. During an interview with Resident #39 on 9/26/22, at 11:05 A.M., when asked how long he/she and Resident #88 were together he/she responded 3 weeks. When asked if they were physically romantic, Resident #39 said that they held hands and kissed. Resident #39 said that staff at the facility were not supportive of their relationship and that they had to break up when Resident #88's family found out. Resident #39 said that Resident #88 acts afraid when he/she sees him/her now and that it is upsetting for Resident #39. Review of Resident #39's Psychiatric Nurse Practitioner Note dated 9/13/22, indicated: Resident and his/her roommate (Resident #88), who has a developmental disorder became very close and he/she thinks they were in a relationship. Per the nursing staff he/she was inappropriate at times with touching him/her, lying in his/her bed and holding hands with him/her throughout the day. [Resident #39] asked him/her to sit on his/her lap to stop his/her legs from shaking which was very inappropriate. Resident #39 was told that they had to break up and the roommate had to change rooms as the family was very upset and they demanded an immediate room change for safety. The Psychiatric Nurse Practitioner note indicated that staff had knowledge of Resident #39's involvement with Resident #88 including touching, lying in bed with him/her and holding hands. During an interview with the Psychiatric Nurse Practitioner on 9/23/22, at 10:55 A.M., she said that she had been informed of Resident #39's inappropriate behavior by nursing staff. During an interview with Activities Assistant #1 on 9/22/22, at 8:41 A.M. she said that it was common to see Resident #88 and Resident #39 together. She said that she had seen them holding hands on 9/2/22, and alerted the Activities Director. She also said that in the weeks before that, she had seen them sitting on a bed together and had heard staff talking about how close the two of them were getting. During an interview with Unit Manager #1 on 9/22/22, at 8:46 A.M., she said that she had been alerted by Activities on 9/2/22, that Resident #39 and Resident #88 had held hands during a movie. She said previous to 9/2/22, that she was not aware that Resident #39 or Resident #88 had been involved with one another, but that they were often seen seated together during activities or meals. Unit Manager #1 said that Resident #88 could not cognitively consent to being in a physical or romantic relationship. During an interview with Nurse #3 on 9/22/22, at 8:32 A.M. he said that staff were not really aware of the relationship between Resident #39 and Resident #88 because they always kept the door shut. Nurse #3 said that Resident #88 could not consent to being physical or in a relationship with another resident. During an interview with the Social Worker on 9/22/22, at 9:02 A.M. she said that if two residents in the facility were to begin a romantic relationship, the expectation would be for them to be assessed for the ability to consent to engage in the relationship. The Social Worker said that Resident #39 had been known to act in a caregiver role to his/her roommates. She said that Resident #39 had been seen holding hands with Resident #88, bringing him/her to activities, and sitting together for meals. She said previous to 9/2/22, she had not believed these behaviors to be indicative of romantic or physical in nature between Resident #39 and Resident #88. During an interview with the Psychiatric Social Worker on 9/22/22, at 11:39 A.M., she said that during her visit with Resident #39 on 9/7/22, he/she had disclosed that Resident #39 and Resident #88 had been kissing previous to 9/2/22, and that Resident #39 had said that they were attracted to each other. The Psychiatric Social Worker said that she did not share this information with staff at the facility. During interviews on 9/22/22, at 12:32 P.M., and 9/23/22, at 1:03 P.M. the Director of Nursing (DON) said that if Residents wish to engage in relationships, they should be assessed for the capacity to consent. She said that she had been aware of Resident #39 frequently being seen holding hands with Resident #88 but she thought that they were just friends. The DON said that Resident #39 had a history of caring for his/her roommates. The DON said that she thought Resident #88 was moved out of the room on 9/2/22, and not placed on 15 minute checks. The DON acknowledged that physical incidents could still have occurred with both Residents' sharing the room while on 15 minute checks. The DON said that the ideal intervention for safety would have been an immediate room change off of the unit. Review of Resident #88's nursing progress note dated 9/4/22, indicated that Resident #88 said he/she was scared because Resident #39 was being loud and throwing things. Resident #88's sister reported that in the night, Resident #39 had removed Resident #88's blanket off the bed and an immediate room change then took place, (2 days after the 15 minute checks had been initiated and after Resident #88 had been observed on Resident #39's lap) Review of Resident #88's social service progress note dated 9/6/22, indicated that Resident #88 met with the Social Worker and told her about what happened and was scared, but is now happy in his/her new room. The facility failed to assess the relationship between Resident #88's and Resident #39 despite multiple staff observations and reports of behaviors indicative of intimacy like hand holding. Using the reasonable person concept, a person who is unable to understand or consent to physical contact or romantic involvement with another, would suffer emotional distress. 2. For Resident #42, the facility failed to obtain a physician's order and assess for the use of oxygen. Resident #42 was admitted to the facility in June 2022 with diagnoses including adult failure to thrive, heart disease and cancer. Review of Resident #42's Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #42 scored a 13 out of 15 on the Brief Interview for Mental Status exam, which indicated Resident #42 is cognitively intact. On 9/21/22, at 7:53 A.M. and 4:31 P.M., the surveyor observed Resident #42 with oxygen via nasal cannula running at 3 liters (L) per minute. During an interview on 9/21/22, at 7:53 A.M. Resident #42 said that he/she had been using oxygen for quite some time. Review of the Resident's medical record failed to indicate a doctor's order for the use of oxygen. Further review failed to indicate that the use of oxygen was evaluated and monitored for effective use. During an interview on 9/22/22, at 12:53 P.M. Unit Manager (UM) #2 said that all oxygen use requires a doctor's order and should be reflected on the treatment record. UM #2 also said that the evaluation and monitoring of the use of oxygen should include oxygen saturations both on and off of the oxygen at least every shift. During an interview on 9/22/22, at 1:47 P.M., the Director of Nursing (DON) said that all oxygen use requires a doctor's order. The DON also said that she could not find a policy that indicated the need for a doctor's order for oxygen or how to assess the use of oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide necessary treatment to prevent the worsening of pressure ulcers for 1 Resident (#43) out of a total of 32 sampled residents. Findings include: Review of the facility's Prevention and Management of Pressure Injuries policy, dated July 2017 indicated: Wound treatments are done per physician order. Stage 3 and Stage 4 pressure injuries should be covered. Resident #43 was admitted to the facility in April 2022 with diagnoses including dementia, dysphagia and muscle weakness. Review of his/her most recent Minimum Data Set assessment dated [DATE], indicated he/she was severely cognitively impaired and requires assistance with bathing, dressing and toileting. On 9/21/22, at 8:16 A.M., the surveyor observed Resident #43 asleep in bed. One foot was flat on the mattress and the other foot was resting on the floor. Review of Resident #43's care plans indicated: Actual skin alteration in skin integrity, dated 7/31/22; Goal: Resident will show evidence of healing. Interventions: Medicate per orders, complete skin condition check, heels offloaded while in bed, provide positioning intervention as indicated on impaired functional mobility care plan, follow MD orders for skin care and treatments. Review of Resident #43's clinical record indicated he/she developed a deep tissue injury (a kind of pressure injury with localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device) on his/her left heel. Review of Resident #43's physician's orders indicated a treatment addressing the deep tissue injury dated: 7/31/22, Normal Saline Wash (NSW) pat dry, skin prep and leave open to air every (Q) shift until resolved. Offload heels at all times when in bed. Review of the Wound Physician's progress note dated 8/2/22, indicated: Unstageable Deep Tissue Injury (DTI), 2 CM (centimeters) X 2 CM Exudate (drainage): None Surface Area: 4.00 CM Objective: Control Infection Treatment plan: Skin prep Q shift; 3 times per day for 30 days. Review of Resident #43's August Treatment Administration Record indicated his/her wound treatments were not completed on the 7:00 A.M.- 3:00 P.M. shift on 8/2/22, 8/3/22, 8/9/22, 8/17/22, 8/26/22; and also not completed on the 3:00 P.M. -11:00 P.M. shift on 8/3/22, 8/11/22, 8/14/22, 8/23/22, 8/26/22. Review of the Wound Physician's progress note dated 8/23/22, indicated: Stage III Left Heel Ulcer: 4 centimeters (CM) X 4 CM X. 01 CM (which indicated the wound opened) Surface area: 16 CM Slough (dead tissue separating from the ulcer): 50% Granulation tissue (new connective tissue): 50% Exudate: None Periwound (surrounding skin) radius: Odor Treatment Recommendations: Leptospermum honey, apply once daily for 30 days; Metronidazole (an antibiotic) gel, apply once daily for 30 days. Gauze island with BDR (border) apply once daily for 30 days. Objective: Control infection Required surgical Debridement. (A surgical procedure to remove dead tissue from the wound) Review of the nursing progress note dated 8/26/22, indicated: This writer called Nurse Practitioner to report that patient's treatment Metronidazole (flagyl) gel hasn't been delivered due to order faxed had no strength in it, new order given to d/c Metronidazole gel and continue with med honey. The nursing progress note indicated that Resident #43 did not receive an ordered treatment for three days to his/her left heel due to a transcription error on the faxed order. Review of the nursing progress note dated 8/29/22: Resident with left heel wound getting worse. Seen today by nurse practitioner. X-Ray to left heel to evaluate for osteomyelitis, Start Doxycycline 100 mg by mouth BID x 7 days, Augmentin 875/125 mg by mouth BID x 7 days. (Antibiotics to treat infections) Review of the Wound Physician progress note dated 8/30/22, indicated: Stage III Left heel wound: 4 CM X 4 CM X .1 CM Surface area: 16 CM Exudate: Moderate serous (Fluid draining from the wound; there had been none at the previous visit) Slough: 100% (an increase of dead tissue from the previous visit by 50%.) Required Debridement During an interview with the Wound Physician on 9/23/22, at 3:06 P.M., he said that he was not aware that Resident #43 went 3 days without having a treatment as ordered. During an interview with the Director of Nursing and the Assistant Director of Nursing on 9/26/22, at 8:42 A.M., they said that they were not aware about treatments not being completed as ordered for Resident #43.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #60, the facility failed to identify and address a significant weight loss. Resident #60 was admitted to the facility in October 2021 with diagnoses including Dementia and Dysphagia. Review of the most recent Minimum Data Set (MDS) completed in 7/13/22 indicated that Resident #60 could not complete a Brief Interview for Mental Status (BIMS) score because he/she is rarely or never understood indicating severe cognitive impairment. Further review of the medical record indicated Resident #60 has an invoked health care proxy (HCP) with an invocation date 2/17/22. During an observation on 9/21/22 at 8:53 A.M., Resident #60 was observed wandering in and out of rooms. Resident #60 appeared thin and frail. Review of Resident #60's medical record indicated the following weights: *10/22/21-159.2 lbs. (pounds) (Standing) *11/2/21-160.2 Ibs. *11/19/21-128.0 lbs. (Standing) *12/1/21-126.0 Ibs. *12/8/21-125.2 lbs. *1/25/22-123.8 lbs. *2/1/22-123.8 lbs. *2/17/22-124.4 lbs *3/1/22-127.0 lbs. *4/1/22-121.0 lbs. (Standing) *5/1/22-121.8 lbs. *6/2/22-120.2 lbs *7/1/22-122.0 lbs *8/2/22-122.2 lbs *9/1/22-127.6 lbs *9/23/22-129.8 lbs In the 91-day period between 11/2/21 and 2/1/22, Resident #60 had a weight change of 22.72 % lbs indicating a severe weight loss. Review of the nutrition assessment completed on 11/2/21 indicated that Resident #60's Body Mass Index (BMI) indicated he/she was overweight and that the weight loss was desired. However, there was no indication in the medical record that the responsible party (HCP) was notified of the weight changes and if he/she was aware and in agreement that the weight loss between 11/2/21 and 2/1/22 being desired. During an interview with the Dietician on 9/23/22 at 9:38 A.M., she said she was not employed at the facility at the time of Resident #60's weigh loss and was not the Dietitian that completed the evaluation on 11/2/21. The Dietitian said the expectation is for the facility to re-weigh the Resident within 24-48 hours to confirm the weight change, notify the responsible party, confer with the interdisciplinary team (IDT) and come up with interventions. The Dietician also said she considers the 22.72% weight change in that 90-day period (11/2/21-2/1/22) to be significant. During a follow up interview with the Dietician on 9/23/22 at 9:46 A.M., she said to confirm if the weight change was desirable, the responsible party should have been made aware (since the Resident is not able to make his/her own decisions) so that the responsible party could make the decision whether the weight changes were desirable or not. She said it would be hard to determine if the Resident desired the weight loss since no one communicated with the responsible party to determine that. During an interview with the Director of Nurses on 9/26/22 at 8:08 A.M., she said she expects re-weighs to be completed if the weight is in question, notify the responsible party to find out if the weight change is desired or not, if it is not desired, work with the interdisciplinary team (IDT) to come up with interventions. 5. For Resident #102, the facility failed to identify and address a significant weight loss. Resident #102 was admitted to the facility in June 2021 with diagnoses including Alzheimer's disease. Review of the minimum data set (MDS) completed on 8/31/22 indicated that Resident #102 had a brief interview for mental status (BIMS) score of 99 indicating severe impairment. Further review of the medical record indicated that Resident #102 has an invoked health care proxy (HCP) invoked 2/17/22. During an observation on 9/21/22 at 8:38 A.M., Resident #102 was observed in the dining room waiting for breakfast. Review of Resident #102's medical record indicated the following weights: *6/7/21-189 lbs-Standing *9/2/21-186.2 lbs *10/1/21-183.8 lbs *10/12/21-185.0 lbs *11/1/21-182.6 lbs *12/1/21-183.2 lbs *1/25/22-174.4 lbs *2/1/22-175.9 lbs *3/1/22-175.0 lbs *4/1/22-186.8 lbs-Wheelchair *6/29/22-166.2 lbs *7/1/22-160.6 lbs *8/2/22-160.0 lbs *9/1/22-165.2 lbs *9/1/22-164.8 lbs For the 91-day period between 4/1/22 and 7/1/22, Resident #102 had a severe weight loss of 14.03%. Review of the nutritional assessment completed on 6/1/22 indicated that Resident #102 is in the weight class 1 obesity, yet not appropriate for a weight reduction diet due to age and diagnosis, the progress note continued to state that weight loss is anticipated as the diagnosis progresses. Further review of the medical record did not include any documentation from the physician indicating that weight loss is anticipated due to Resident # 102's diagnosis or that Resident #102 was actively declining medically which was causing his/her weight loss. During an interview with the dietician on 9/23/22 at 9:50 A.M., she said she was not employed at the facility at the time of Resident #102's weight loss and did not complete the nutritional assessment dated [DATE]. The Dietitian said a reweigh should have been done to confirm the actual weight on 4/1/22, then notify the responsible party of the weight change, wait for the responsible party to determine if the weight change is desirable or not, if not desirable, work with the interdisciplinary team to put in interventions. The dietician also stated that the weight loss between 4/1/22 and 7/1/22 was a significant weight loss. During an interview with the dietician on 9/23/22 at 9:54 A.M., she said to determine if the weight loss is anticipated due to a diagnosis, there should be documentation from the physician indicating that, and more documentation indicating the responsible party being notified of the physician's expectations. During an interview with the Director of Nurses on 9/26/22 at 8:19 A.M., she said that if a weight appears to be off, a reweigh needs to be done immediately, to confirm the correct weight, if a weight change is noted, the interdisciplinary team (IDT) should be notified so they can come up with interventions, she also said that responsible parties should be notified of weight changes or expected weight changes due to diagnoses. 6. For Resident #46, the facility failed to identify and address a significant weight loss. Resident #46 was admitted to the facility in June 2022 with diagnoses including Dementia. Review of the minimum data set (MDS) completed on 7/7/22 indicated that Resident #46 was not able to complete a brief interview for mental status (BIMS) score because he/she is rarely or never understood. Further review of the medical record indicated that Resident #46's health care proxy (HCP) is invoked. During an observation on 09/21/22 at 8:46 A.M., a staff member was observed feeding Resident #46, the Resident appeared thin and frail. Further review of the medical record indicated the following weights: *7/1/22-110.2 lbs *8/2/22-102.0 lbs *9/2/22-98.7 lbs For the 32-day period between 7/1/22 and 8/2/22, Resident #46 had a severe weight loss of 7.44%. During an interview with the dietician on 9/21/22 at 11:44 A.M., she said that a weight change was missed between 7/1/22 and 8/2/22. The Dietician said a re-weigh should have been done to confirm the weight change, and if confirmed, the responsible party should have been notified of the weight change, work with him/her to come up with ideas on an intervention that would assist the Resident in a weight gain. The Dietician also said the interdisciplinary team (IDT) should be notified to include other interventions. The Dietician stated that the weight loss between 7/1/22 and 8/2/22 was a significant weight loss. During an interview with the Director of nurses on 9/26/22 at 8:12 A.M., she said the Resident #46 should have been re-weighed, when weight change was confirmed, the responsible party should have been notified and the interdisciplinary team (IDT) should have been notified as well. Based on observation, record review and interview, the facility failed to identify and address significant weight loss and failed to implement interventions to prevent weight loss for 6 residents (#7, #28, #105, #60, #102 and #46) out of a total of 32 sampled Residents. Findings include: Suggested parameters for evaluating significance of unplanned and undesired weight loss are: Interval Significant loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% Review of the facility's Weights policy, dated 2015 indicated: *All weight loss/gain of 3 lbs or more on a resident weighing 100 lbs or less and weight loss/gain of 5 pounds or more on a resident weighing 100 lbs or more requires a reweigh for verification. A Reweigh is done on the same scale, with a licensed nurse present. *If a significant weight loss/gain is identified (< 5% in 30 days or > 10% in six months, the IDT, Dietitian, physician and family are notified. *All residents with a significant weight loss are reviewed by the interdisciplinary team and the resident/responsible party and interventions are implemented as appropriate and are monitored weekly. 1. For Resident #28, the facility failed to identify and address a significant weight loss. Resident #28 was admitted to the facility in July 2018 with diagnoses including dementia and dysphagia. Review of his/her most recent Minimum Data Set assessment dated [DATE] indicated he/she is severely cognitively impaired and requires assistance with bathing, dressing and eating. On 9/21/22 at 8:54 A.M., the surveyor observed Resident #28 resting in bed. He/she appeared frail. Review of Resident #28's care plans indicated: Resident #28 at risk for nutritional decline, revised 6/29/22. Interventions: Provide diet as ordered. Provide snacks as desired and in compliance with diet order. Monitor weight as needed. Dietitian to evaluate and make diet change recommendations as needed. Allow the resident adequate time to consume meals. Encourage resident to attend food related activities. Assist with intake as needed. Adaptive equipment as ordered. Provide medical food supplement. Review of Resident #28's weights indicated: 7/1/22: 153.4 lbs (pounds) 8/2/22: 143 lbs a severe loss of 6.78 % of his/her total body weight in 1 month. 9/2/22: 140.4 lbs a severe loss of 8.47% of his/her total body weight in 2 months. Review of the clinical record indicated that Resident #28 had most recently been evaluated by a Dietitian on 6/29/22; previous to the severe weight loss. The clinical record failed to indicate any progress notes or evaluations completed by nursing or the Physician regarding Resident #28's weight loss. During an interview with Unit Manager #3 on 9/22/22 at 10:50 A.M., she said that Certified Nurses Aides (CNAS) obtain weights and give them to the nursing staff who then put them in the computers. Unit Manager #3 said that if there is a 3 lb difference a re-weigh should be done within a couple days to verify and if its a verified change, then the Dietitian and the Physician is notified to assess the Resident. Unit Manager #3 said staff did not tell her that Resident #28 had a weight loss. During an interview with the Nurse Practitioner on 9/22/22 at 11:35 A.M., she said that she was not aware that Resident #28 had lost weight. She said that the expectation is for staff to notify her when a Resident has a significant weight loss. During an interview with the Dietitian on 9/23/22 at 8:24 A.M., she said that she had not been made aware of Resident #28's weight loss. She said she would have asked for a re-weigh to confirm the weight loss and then looked at possible interventions to address Resident #28's weight loss. 2. For Resident #105 the facility failed to identify and address a significant weight loss. Resident #105 was admitted to the facility in January 2022 with diagnosis including dementia and arthritis. Review of Resident #105's most recent Minimum Data Set assessment dated [DATE] indicated he/she is severely cognitively impaired and requires assistance with bathing, dressing and toileting. Review of Resident #105 weights indicated: 12/2/21: 144.8 lbs (pounds) 2/1/22: 143 lbs 3/2/22: 141 lbs 4/1/22 131 lbs; a severe weight loss of 7% of his/her total body weight in 1 month. 5/1/22: 125.6 lbs; 6/2/22: 123.8 lbs; a severe weight loss of 14.5% of his/her total body weight in 6 months. 7/1/22: 124.6 lbs 8/9/22: 131.2 lbs 9/1/22: 126.5 lbs Review of Resident #105's clinical record indicated that Resident #105 had been evaluated by a Dietitian on 5/24/22; 54 days after his/her severe weight loss was first documented on 4/1/22. The evaluation indicated that Resident #105 was hospitalized and should be evaluated upon his/her return. (Resident #105 had sustained the weight loss prior to his/her hospitalization.) Resident #105's clinical record failed to indicate he/she was re-evaluated by a Dietitian upon his/her return from the hospital on 5/25/22 and was not assessed again by a Dietitian until 9/1/22. The evaluation dated 9/1/22 indicated that Resident #105 had sustained a previous weight loss and the evaluation indicated his/her current weight was based on the 8/9/22 weight. During an interview on 9/23/22 at 12:07 P.M., the Dietitian said she was not employed at the facility at the time of Resident #105's weight loss. She said that Resident #105 should have been evaluated upon his/her return from the hospital. 3. For Resident #7, the facility failed to provide fortified foods as recommended by the Dietitian to address a significant weight loss. Resident #7 was admitted to the facility in June 2018 with diagnoses including Alzheimer's disease and unspecified psychosis. Review of his/her most recent Minimum Data Set assessment dated [DATE] indicated he/she is cognitively intact and requires assistance with bathing, dressing and eating. On 9/21/22 at 10:41 A.M., the surveyor observed Resident #7 resting in bed. He/she appeared frail and thin. On 9/22/22 at approximately 10:00 A.M., the surveyor observed staff assisting Resident #7 with eating his/her breakfast. Review of Resident #7's weights indicated: 6/2/22: 125.5 lbs (pounds) 7/6/22: 119 lbs; a significant loss of 5% of his/her total body weight in 1 month. 8/9/22: 109.2 lbs 8/24/22: 114.4 lbs 9/2/22: 117 lbs Review of the clinical record indicated that the Dietitian evaluated Resident #7 and recommended he/she receive fortified foods at all meals as an intervention to address the weight loss. On 9/22/22 at 11:10 A.M. the surveyor and the Food Service Director reviewed Resident #7's meal tickets. The Food Service Director said that although Resident #7 was receiving fortified cereal with breakfast, he/she was not receiving fortified foods with lunch or dinner as recommended by the Dietitian. Review of the Nurse Practitioner Note dated 9/7/22 indicated that Resident #7's current weight is 117 lbs, but his/her weight in June 2022 was 125 lbs. Last September 2021, the patient was 133 lbs. Resident #7 is on a regular textured thin liquid diet and his/her food is fortified. During an interview with the Nurse Practitioner on 9/22/22 at 11:35 A.M., she said she was not aware that Resident #7 was not receiving fortified foods with all his/her meals.