Based on interview and document review, the facility failed to notify the physician of an ongoing and significant weight loss for one Resident (#26), out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Weight Loss Policy, dated as reviewed 2/2024, indicated but was not limited to the following: - all confirmed weight loss of 5 pounds (lbs.) or more within one month is reported to the dietician, the weight information is recorded in the chart - staff must also report any continuing trends of monthly weight loss, even if it is below 5 lbs. - the dietician is responsible for determining if weight loss is significant, unplanned (weight loss greater than (>) 5% in one month, 10% in 6 months) - the physician is to be notified by nursing staff of any significant weight loss Resident #26 was admitted to the facility in December 2023 and has diagnoses including: Hypothyroidism and dysphagia (difficulty swallowing). The Brief Interview for Mental Status (BIMS), dated 6/14/24, indicated the Resident was cognitively intact with a score of 15 out of 15. Review of the current Physician's Orders, dated 8/21/24, indicated but were not limited to the following: - Weekly weight to be obtained: notify MD/NP of any significant weight loss/gains over past week and any trends, once a day on Thursdays (12/14/23) During an interview on 8/15/24 at 8:09 A.M., Resident #26 said he/she had lost at least 20 pounds since being admitted to the facility. During an interview on 8/15/24 at 4:13 P.M., Nurse #2 said Resident #26 has had a weight loss but has recently started to gain a little back. She said she does not know the exact amount of weight loss. Review of Resident #26's weight monitoring report from 12/2023 to 8/15/24 indicated but was not limited to the following: 2/29/24- 119.0 lbs. 3/28/24- 112.8 lbs. (significant weight loss in one month (2/29/24) of 5.21%) 4/04/24- 113.9 lbs. 4/25/24- 110.8 lbs. 5/02/24- 106.8 lbs. (significant weight loss in one month (4/4/24) of 6.23%) 5/09/24- 104.6 lbs. Review of the Minimum Data Set (MDS) assessment for Resident #26 indicated the following weights were used on the following MDSs: - 12/14/23 - MDS recorded a weight of 125 lbs. - 03/07/24 - MDS recorded a weight of 115 lbs. - 06/14/24 - MDS recorded a weight of 104 lbs. In the three months from the December 2023 MDS to the March 2024 MDS the Resident had a significant loss of 8.12%. In addition, in the three months between the March 2024 MDS and the June 2024 MDS, the Resident had another significant weight loss of 9.88% (significant weight loss is = > 7.5% in 3 months). Review of the MDS assessment, dated 6/14/24, indicated, but was not limited to the following: SECTION K (Swallowing/Nutritional Status): K0200: Height = 66 inches Weight = 104 lbs. (most recent and measured in the last 30 days) K0300: Weight loss: Loss of 5% or more in the last month or 10% or more in the last 6 months: YES, not on a physician prescribed weight loss regimen The MDS indicated that from the 12/14/23 MDS recorded weight of 125 lbs. to the 6/14/24 MDS recorded weight of 104 lbs. Resident #26 experienced a significant weight loss of 16.8% over 6 months. Review of the progress notes for Resident #26 from 1/2024 to 8/21/24 failed to indicate the physician was made aware of the significant and ongoing weight loss. During an interview on 8/21/24 at 12:57 P.M., Nurse #3 said the Resident had been losing weight and has only started gaining weight in the last few weeks. She said the Resident was admitted at 125.6 lbs. and was currently 111 lbs. She reviewed the progress notes for the Resident from admission to 8/21/24 and said she could not find any evidence that the physician was made aware of the weight loss that had occurred. Review of the Registered Dietitian's (RD) documentation for Resident #26 from 12/2023 to 8/21/24 indicated but was not limited to the following: - 12/21/24: Comprehensive dietary assessment and note: weight = 125.6 lbs.; BMI = 20.1; stable when compared to hospital weights; reported a poor to fair appetite; goal to maximize intake to maintain current weights and heal skin integrity (related to recent surgery) - 3/14/24: Quarterly assessment and note: weight = 115.4 lbs., ideal body weight is 125 - 132 lbs.; intake fair to good; previous goals achieved; weight decline of 3% in 30 days and 8% since December 2023. Add: 240 milliliters (ml) fortified apple juice supplement to all meals to promote weight maintenance - 4/11/24: Note: discontinue fortified juice at breakfast, lunch and dinner due to resident not drinking; continue to monitor weights - 6/6/24: Quarterly assessment and note: weight 104 lbs., this is a weight loss; intake mostly variable; stable weights in 30 days with a significant loss since admission Further review of the RD's documentation failed to indicate that the RD notified the physician of the significant weight loss. During an interview on 8/21/24 at 1:28 P.M., the RD said Resident #26 has an ideal body weight of 125 - 132 lbs. and currently weighs 111 lbs. She said she does not typically notify the physicians of weight loss or significant weight loss and she believes that is done by nursing. She said, on review of the nursing progress notes for Resident #26, she could not find any evidence that the physician was made aware of the significant weight loss for the Resident. During an interview on 8/21/24 at 2:08 P.M., Physician #1 said he did not recall being made aware of Resident #26's progressive and significant weight loss and therefore no further evaluation of the situation had been completed at this time. He said he is unaware of any medical reason for Resident #26 to have an ongoing or significant weight loss and the loss was unplanned. During an interview on 8/21/24 at 2:22 P.M., the Director of Nurses reviewed the medical record of Resident #26 and said she could not find any evidence that the physician was aware of the ongoing and significant weight loss for Resident #26. She said the process is for the physician to be notified of changes to a resident's condition and there is no evidence that had occurred. See F692

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and documentation review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one Resident (#26), out of 18 sampled residents. Specifically, the facility failed to ensure ideal or usual body weight was maintained and interventions implemented and re-evaluated to prevent significant and ongoing weight loss for the Resident which was unplanned and undesired. Findings include: Review of the facility's policy titled Weight Loss Policy, dated as reviewed 2/2024, indicated but was not limited to the following: - all confirmed weight loss of 5 pounds (lbs.) or more within one month is reported to the dietician, the weight information is recorded in the chart - staff must also report any continuing trends of monthly weight loss, even if it is below 5 lbs. - the dietician is responsible for determining if weight loss is significant, unplanned (weight loss greater than (>) 5% in one month, 10% in 6 months) - if the dietician determines weight loss is significant, an interim note is written documenting the weight loss and including suggested approaches for prevention of further loss - the dietician is responsible to ensure the interdisciplinary care plan is updated for weight loss prevention as warranted Review of the facility's policy titled Meal Replacement, dated as reviewed 10/2023, indicated but was not limited to the following: - every possible effort will be made to maintain meal satisfaction and intake by residents - as soon as nursing or dietary staff discover the resident has consumed less than 50% of a meal, they will offer additional forms of nourishment - nursing and dietary staff should encourage residents to accept the alternate to the prepared meal - if the resident refuses the alternate selection to the menu, he/she should be offered food items on the additional readily available food list - if a resident refuses all alternate foods available a commercial supplement may be offered and is a last resort of meal replacement Review of the facility's policy titled Selective Menu Policy, dated as reviewed 10/2023, indicated but was not limited to the following: - every possible effort will be made to maintain meal satisfaction and intake by residents - menus are posted on floors for reference - a representative from dietary meets with all new residents within 24 hours for an initial interview to discuss food preferences, likes and dislikes in accordance with the resident's diet restrictions - cycle menus will be individually reviewed with the resident until they are completed - main dining room is open for all meals, menus are posted, residents in the main dining room make their choices Resident #26 was admitted to the facility in December 2023 with diagnoses which included hypothyroidism and dysphagia (difficulty swallowing). Review of the Brief Interview for Mental Status (BIMS), dated 6/14/24, indicated Resident #26 was cognitively intact with a score of 15 out of 15. During an interview on 8/15/24 at 8:09 A.M., Resident #26 said he/she had lost at least 20 pounds since being admitted to the facility. The Resident was observed to have breakfast of scrambled eggs and toast in front of them and consumed about 25% at that time. He/She said the coffee is like an oil slick. He/She said people have talked to him/her about the food and weight loss and he/she thinks the food is overall not bad but prefers other things brought in by their family. The Resident said he/she has always been a picky eater. During an interview on 8/15/24 at 4:13 P.M., Nurse #2 said Resident #26 was not a good eater and will decline meals at times, adding that the Resident's family will bring in food and snacks because the Resident is a picky eater. She said she knows the Resident has had a weight loss but has recently started to gain a little back. She said she does not know the exact amount of weight loss or if there are any interventions in place to prevent the weight loss, but she offers the Resident ice cream in the afternoons and it is usually accepted. She said the Resident doesn't get any type of supplements and is not offered any other meals if he/she doesn't eat well unless they request something else. She said the Resident needs lots of encouragement to eat. She said the Resident will usually accept foods brought in by the family. Review of the current Physician's Orders, dated 8/21/24, indicated but were not limited to the following: - DIET: NAS (No added salt diet) (1/23/24 and 4/12/24) - May omit diet restrictions on special occasions (12/14/23) - Snack offered at bedtime (12/14/23) - Speech therapy evaluation and treatment as indicated (1/9/24) - Weekly weight to be obtained: notify MD/NP of any significant weight loss/gains over past week and any trends, once a day on Thursdays (12/14/23) - Aspiration precautions: Resident is an aspiration risk monitor for signs and symptoms (s/s) such as: cough, congestion, fever, runny nose, etc., monitor lung sounds, oxygen saturation, and temperature every shift (1/8/24) Review of the Certified Nurse Assistant (CNA) care plan [NAME] currently in use by the facility indicated but was not limited to the following: NUTRITION: Diet/Texture: Regular; Ability to eat: Independent During an interview on 8/21/24 at 8:17 A.M., CNA #3 said Resident #26 eats independently after meal set up. She said the Resident's intake fluctuates and sometimes the Resident eats well and sometimes not so good. She said the Resident is weighed weekly and she knows the Resident has a history of weight loss but had a gain this past week and is up to 111 pounds (lbs.). She said she is not aware of any interventions for the staff to provide to help the Resident not lose any more weight, but the Resident has told her he/she prefers sandwiches with tomatoes for lunch and pancakes for breakfast. During an interview on 8/21/24 at 8:31 A.M., the surveyor observed Resident #26 eating breakfast consisting of scrambled eggs and toast with jelly. The meal ticket on the tray indicated the Resident was supposed to have a hard-boiled egg. The Resident said the breakfast was fine but they wished it was pancakes or waffles; they are sick of eggs everyday. The Resident said he/she gained weight this past week because he/she can't resist the treats and ice cream in the afternoons. The Resident said there are foods that they like but the facility has not offered them to him/her and he/she likes to have options with his/her meals and may change his/her mind on the meal daily depending on what might be available. The Resident said he/she was offered milkshakes and juice drinks to purposely get fat but the use of those are against his/her beliefs. Resident #26 said he/she enjoys sandwiches but only gets them when his/her family brings them in because the facility sends him/her whatever they want for meals and he/she doesn't have any options. During an interview on 8/21/24 at 9:22 A.M., the Food Service Director (FSD) said the process for selective menus and meal preferences for the unit Resident #26 resides on is for staff to call for a meal replacement if necessary. She said she learns different resident preferences as time goes on and the nursing staff, residents, and dietitian will also communicate items of preference to her so she can update the meal tray tickets. She said residents should get what their tickets say are their preferences with each meal because the kitchen staff will automatically follow the ticket and make the substitution and she does not keep any other system to track preferences. She said she would provide the surveyor with a copy of Resident #26's meal tickets for the day which would reflect the daily preferences. Review of the 8/21/24 meal tickets for Resident #26 indicated but were not limited to the following: BREAKFAST: Hard-boiled egg, cereal, toast, juice, coffee, milk, jelly, sugar LUNCH: Meatloaf, brown gravy, broccoli, mashed potatoes, bread, peach cobbler, milk, coffee, sugar, tomato slices (Serve sliced tomatoes when ordering a sandwich) DINNER: Glazed ham, mixed vegetables, sweet potato, fruit cocktail, milk, coffee, sugar, tomato slices (Serve sliced tomatoes when ordering a sandwich) During an interview on 8/21/24 at 10:02 A.M., the FSD said Resident #26 only gets tomatoes if he/she orders a sandwich, but he/she gets a hard-boiled egg each morning. When she was informed the Resident had scrambled eggs this A.M., she said scrambled eggs were available this morning but the Resident should have gotten a hard-boiled egg and she does not know how that error occurred. She said the process is for the Resident to get their preferred foods according to their meal tickets. Review of Resident #26's weight monitoring report from 12/2023 to 8/15/24 indicated but was not limited to the following: 2/29/24- 119.0 lbs. 3/28/24- 112.8 lbs. (significant weight loss in one month (2/29/24) of 5.21%) 4/04/24- 113.9 lbs. 4/25/24- 110.8 lbs. 5/02/24- 106.8 lbs. (significant weight loss in one month (4/4/24) of 6.23%) 5/09/24- 104.6 lbs. Review of the Minimum Data Set (MDS) assessments for Resident #26 indicated the following weights were used: - 12/14/23 - MDS recorded weight of 125 lbs. - 3/7/24 - MDS recorded weight of 115 lbs. - 6/14/24 - MDS recorded weight of 104 lbs. In the three months from the December 2023 to the March 2024 MDS assessments the Resident experienced a significant loss of 8.12%. In addition, in the three months between the March 2024 MDS and the June 2024 MDS the Resident had another significant weight loss of 9.88% (significant weight loss is = > 7.5% in 3 months). Review of the MDS assessment, dated 6/14/24, indicated but was not limited to the following: SECTION K (Swallowing/Nutritional Status): K0100: Signs and symptoms of swallowing disorders: None K0200: Height = 66 inches Weight = 104 lbs. (most recent and measured in the last 30 days) K0300: Weight loss: Loss of 5% or more in the last month or 10% or more in the last 6 months: YES, not on a physician prescribed weight loss regimen K0520: Nutritional approaches: Therapeutic diet while a resident The MDS indicated that from the 12/14/23 MDS recorded weight of 125 lbs. to the 6/14/24 MDS recorded weight of 104 lbs. Resident #26 experienced a significant weight loss of 16.8% over 6 months. Review of the Speech Language Pathology (SLP) evaluation and treatment notes for Resident #26 in May 2024 indicated but were not limited to the following: - 5/16/24 Evaluation: Reason for referral: This patient was noted to have a significant weight loss as follows: 4/4/24 - 113.9 lbs., 4/25/24 - 110.8 lbs., 5/2/24 - 106.8 lbs., 5/9/24 - 104.6 lbs. [sic] Patient goals: He/She would like to get foods he/she likes so they'd have an appetite to eat them Clinical bedside assessment: Regular solids with mild clinical s/s of dysphagia characterized by poor attention to task Recommendations: distant supervision for intake - 5/16/24 Treatment note: has particular interest in eating certain foods and aversion to others; realizes he/she is losing weight and would like to improve intake if they get the foods they like - 5/24/24 Treatment note: no complaints of dysphagia; patient stated: I ate all that I wanted, don't make me eat anything else - 5/28/24 Treatment note: patient states he/she eats the food they like and denies any difficulties with trouble chewing or swallowing - 5/28/24 Discharge Summary: Previous goal met (5/16/24): patient appetite was sufficient to maintain his/her weight and remain stable but currently has a significant weight loss; current goal met: patient demonstrated safe intake of regular solids and thin liquids consuming at least 50-75% per meal over three consecutive meals without dysphagia. Review of the Meal and Snack intake report for Resident #26 from 3/1/24 through 8/20/24 indicated but was not limited to the following: MARCH 2024: Out of 93 meal opportunities: 20 meals were not documented and out of 31 bedtime snack opportunities 9 snacks were undocumented Of the meals received, the Resident consumed an average of 26-50% of breakfast; 26-50% of lunch; 51-75% of dinner and 51-75 % of bedtime snacks. APRIL: 2024 Out of 90 meal opportunities: 14 meals were not documented with 2 additional meals refused; and 9 out of 30 bedtime snack opportunities undocumented with an additional 10 refused Of the meals received, the Resident consumed an average of 51-75% of breakfast; 26-50% of lunch; 25-50% of dinner and 25-50% of bedtime snacks. MAY 2024: Out of 93 meal opportunities: 22 meals were not documented with 4 additional meals refused; and 14 and out of 31 bedtime snack opportunities were undocumented with an additional 12 snacks refused Of the meals received, the Resident consumed an average of 26-50% of breakfast; 26-50% of lunch; 1-25% of dinner and 1-25% of bedtime snacks. JUNE 2024: Out of 90 meal opportunities: 21 meals were not documented with an additional 2 meals refused; and 6 out of 30 bedtime snack opportunities were undocumented with an additional 9 snacks refused Of the meals received, the Resident consumed an average of 26-50% of breakfast; 26-50% of lunch; 26-50% of dinner and 1-25% of bedtime snacks. JULY 2024: Out of 93 meal opportunities: 13 meals were not documented with an additional 2 meals refused; and 7 out of 31 bedtime snack opportunities were undocumented with an additional 11 snacks refused Of the meals received, the Resident consumed an average of 26-50% of breakfast; 26-50% of lunch; 26-50% of dinner and 26-50% of bedtime snacks. AUGUST 2024: Out of 60 meal opportunities: 4 meals were not documented with an additional one meal refused; and 1 out of 20 bedtime snack opportunities were undocumented Of the meals received, the Resident consumed an average of 26-50% of breakfast; 26-50% of lunch; 26-50% of dinner and 1-25% of bedtime snacks. Review of the Registered Dietitian's (RD) documentation for Resident #26 from December 2023 to 8/21/24 indicated but was not limited to the following: - 12/21/23: Comprehensive dietary assessment and note: House diet with HS (hour of sleep) snacks; weight = 125.6 lbs.; BMI = 20.1; stable when compared to hospital weights; reported a poor to fair appetite; goal to maximize intake to maintain current weights and heal skin integrity (related to recent surgery) - 3/14/24: Quarterly assessment and note: NAS diet with HS snacks; weight = 115.4 lbs., ideal body weight is 125 - 132 lbs.; intake fair to good; previous goals achieved; weight decline of 3% in 30 days and 8% since December 2023. Add: 240 milliliters (ml) fortified apple juice supplement to all meals to promote weight maintenance - 4/11/24: Note: discontinue fortified juice at breakfast, lunch and dinner due to Resident not drinking; continue to monitor weights - 5/23/24: Note: please add a plate of sliced tomatoes to lunch and dinner meals per resident preference; resident states he/she will eat any sandwich with tomato on it; likes hard boiled (HB) eggs only - no other kind of eggs; notice provided to kitchen - 6/6/24: Quarterly assessment and note: NAS diet with HS snacks and aspiration precautions; weight 104 lbs., this is a weight loss; intake mostly variable; stable weights in 30 days with a significant loss since admission, self-reported picky eater; Resident declines supplements and will accept sandwiches with tomato slice, provide encouragement at meals During an interview with observation on 8/21/24 at 12:12 P.M., the surveyor observed Resident #26 having lunch in his/her room. The meal on the plate consisted of meatloaf with gravy, broccoli, a piece of bread, and a scoop of mashed potatoes. No sandwich or tomato were observed on the tray or in the Resident's room. He/She was not eating the meatloaf but was consuming the bread and mashed potatoes. The Resident said he/she did not like the meatloaf and would love to get sandwiches at lunchtime with tomato but has not gotten them in a few weeks. Resident #26 said he/she does not have the capability of picking their meals and has not been given a large selective menu to complete in ages. The Resident said he/she would not call and bother the nursing staff for a replacement meal since no one cares enough to provide him/her with a menu. Resident #26 said he/she would complete a weekly menu if that was still an option but it was not. The Resident said if the meal was something he/she liked, he/she would eat it. He/She said the facility did try to give him/her supplement drinks a few months ago but he/she would not drink them; he/she preferred real food. During an interview on 8/21/24 at 12:31 P.M., the FSD said Resident #26 doesn't do a selective menu and gets whatever the kitchen has as the meal for the day and can have someone call down if he/she wants something different. She said she could not recall the last time the Resident had completed a selective menu, but said they follow the meal ticket for preferences. During an interview on 8/21/24 at 12:57 P.M., Nurse #3 said she was unsure if Resident #26 had a significant weight loss or any weight loss and would need to review the record. She said the Resident had been losing weight and has only started gaining weight in the last few weeks. She said the Resident was admitted at 125.6 lbs. and currently weighed 111 lbs. She reviewed the assessments, progress notes, orders and care plans for the Resident and said she does not see any interventions currently in place to reflect what the staff should be doing to prevent further weight loss for the Resident. She said she did see that the Resident had attempted to take supplements for a short time in March but did not like them. She said, There are so many types of real foods we could use, I don't know why that's not an option shown in here. She said the facility had the ability to attempt fortified foods and even additional snacks like ice cream in the afternoon to help with weight loss prevention but she did not see any documentation in the record that these things were attempted and said the care plan does not reflect any interventions at all except for providing the Resident with a meal. She said as far as the Resident preferences she noticed the Resident had scrambled eggs this morning and was surprised since the ticket said hard-boiled egg, but the Resident told her, They just send what they want anyway and declined a replacement meal or food item. She said they would only offer any resident a supplement or replacement meal if they ate less than 50% if they had orders to do so, and this Resident did not. She said if the Resident requested an alternate meal the staff would accommodate that, but that had not happened at either meal today. She said she could not find anything on the care plan that would indicate the Resident had weight loss or required any interventions to prevent weight loss so she wasn't aware the concern existed until it was brought to her attention by the surveyor. Review of the care plan currently in place for Resident #26 indicated the following: PROBLEM: Nutritional status, Nutritionally related medical diagnoses: hypertension (HTN), hypothyroidism, hyperlipidemia, and Vitamin D deficiency; requires a therapeutic diet at this time related to HTN. Supplementation in place and accepted by Resident to promote weight maintenance. (6/25/24) GOAL: Maintain current status; prevent exacerbation of medical diagnosis (6/25/24) APPROACHES: House diet (6/25/24) The care plan failed to indicate the Resident experienced any weight loss or provided any interventions to prevent further weight loss for the Resident. During an interview on 8/21/24 at 1:28 P.M., the RD said Resident #26 is a self-admitted picky eater and resistant to any creamy supplements so she recommended the juice supplement, but the Resident did not consume it and it was discontinued. She said she did send a preference update to the kitchen in May alerting them to the Resident's preference to eat sandwiches with sliced tomato. She said once the information is sent to the kitchen they place it on the tray ticket. She said this Resident has an ideal body weight of 125 - 132 lbs. and is currently 111 lbs., but that is an increase from previous and at one point the Resident got as low as 103 lbs. so she is happy with the weight coming back up. She said the Resident remains below ideal body weight at this time because they are very particular about what they will eat. She said the FSD is the person that would provide a selective menu to residents, but only to those who are willing to complete them and want to select their own foods and she doesn't know if the Resident does those menus but thinks it would likely benefit Resident #26 to have this option so they can receive foods they are more interested in. She said she was aware of the significant weight loss for the Resident but when reviewing the care plan said she realizes the care plan is not specific to the Resident losing weight, and does not have any interventions on it that may help prevent further weight loss and only indicates a current diet order for the Resident. She said the Resident has had a continual weight loss since admission until just recently and she would need to reevaluate the Resident and the documentation since it appears to be lacking. During an interview on 8/21/24 at 2:08 P.M., Physician #1 said he is not aware of any medical reason for Resident #26 to have an ongoing or significant weight loss and it was unplanned. He said he doesn't recall being made aware of the situation and therefore no further evaluation of the situation had been completed and the issue has not been documented by him in the medical record. During an interview on 8/21/24 at 2:22 P.M., the Director of Nurses reviewed the medical record of Resident #26 and said there were no interventions she could find documented anywhere, except for the juice supplement in March that was discontinued, to prevent further weight loss for the Resident. She said it did not appear by viewing the current and history of the nutritional care plan that any interventions were ever attempted to prevent weight loss and the care plan does not indicate the Resident had experienced any weight loss and inaccurately reflected the Resident's use and acceptance of supplements. She said she could not find any documentation that a medical work up had occurred in an attempt to rule out any cause of the progressive weight loss, nor could she find any evidence the physician was aware of the situation. She said the expectation is that the Resident be evaluated and provided with interventions in an attempt to prevent undesirable ongoing weight loss, especially when a significant weight loss occurs, but also prior to reaching that level. She said the Resident should have been receiving his/her preferences at mealtimes and receiving alternate meals as needed. She said it appears the process for managing weight loss and providing interventions to prevent further weight loss were not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #2), whose Plan of Care indicated he/she required physical assistance of one staff member with toileting which included assistance with hygiene care needs, utilized bed/chair alarms for safety and was assessed by nursing at high risk for falls, the Facility failed to ensure nursing staff consistently implemented and followed interventions from his/her Plan of Care while meeting his/her care needs. On 08/30/23, Certified Nurse Aide (CNA) #1 brought Resident #2 into the bathroom, transferred and positioned him/her onto the toilet (which was not alarmed), CNA #1 then exited the bathroom and Resident #2's room, leaving him/her unattended and unassisted by a staff member. A short time later Resident #2 was heard calling out for help, and was found lying on his/her back on the floor near the recliner in his/her room complaining of left hip pain. after he/she had transferred him/herself off of the toilet and ambulated unassisted by staff. Upon assessment, Resident #2's left leg was noted to be externally rotated, he/she was transferred to the Hospital Emergency Department for evaluation, where he/she was diagnosed with a left hip and left elbow fracture from the fall. Findings include: Review of the Facility's Policy, titled Comprehensive Care Plan, dated July 2023, indicated the Facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident right set forth, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident #2 was admitted to the Facility in February 2021, diagnoses included wedge compression fracture of the first thoracic vertebrae, fracture of second thoracic vertebrae, osteoporosis, vascular dementia, muscle weakness and difficulty in walking. Review of a Physicians Order, dated 9/26/22, indicated nursing to assist Resident #2 with all aspects of toileting. Review of Resident #2's Activity of Daily Living (ADL) Care Plan, dated 06/07/23, indicated he/she required staff assistance with all aspects of toileting, interventions included staff assistance with transfers on and off the toilet, and assistance with hygiene care. Review of Resident #2's Physician's Order, dated 6/17/23, indicated nursing to use a chair and bed alarms for his/her safety. Review of Resident #2's Care Plan related to Risk for Falls, dated 06/20/23, indicated interventions included the use of alarms (bed and chair) for safety. Review of the Quarterly Minimal Data Set Assessment (MDS), dated [DATE], indicated Resident #2 was moderately cognitively impaired, required limited physical assistance from staff with transfers, extensive physical assistance of one staff member with toileting and hygiene care needs. The MDS indicated Resident #2 was unsteady when he/she moved from a sitting to a standing position, unsteady with ambulation, unsteady with turns, and unsteady when moving on/off the toilet and was only able to stabilize him/herself with human (staff) assistance. Review of Resident #2's CNA Care Plan, (used as a reference guide by CNA's), undated, indicated Resident #2 was at risk for falls, required physical assistance with transfers and toileting, and utilized bed and chair alarms. Review of CNA #1's Written Witness Statement, dated 8/30/23, indicated that at approximately 9:20 A.M., she heard an alarm go off, went into Resident #2's room and helped him/her into the bathroom and then left the room. During an interview on 09/06/23 at 1:00 P.M., Certified Nurse Aide (CNA) #1 said that on 08/30/23 at 9:35 A.M., she heard Resident #2's chair alarm sound. CNA #1 said that Resident #2 requested to go to the bathroom, so she walked Resident #2 to the bathroom, assisted him/her onto the toilet and then left his/her room to assist another resident. CNA #1 said that she left Resident #2 unassisted on the toilet and left him/her alone in the bathroom. CNA #1 said that Resident #2 required staff assistance with toileting and transfers and used a chair alarm for safety. CNA #1 said she should not have left Resident #2 alone on the toilet in the bathroom and said she did not follow his/her plan of care. CNA #1 said that she did not review Resident #2's Care Plan, but said she knew what level of care he/she required and said she had taken care of Resident #2 many times. Review of a Nurse Progress Note, dated 08/30/23, indicated Nurse #2 heard Resident #2 yelling out for help. The Note indicated that Resident #2 was found lying on the floor (in his/her room) next to his/her recliner complaining of left hip pain with his/her left lower extremity externally rotated. The Note indicated that Resident #2 was transferred to the hospital for evaluation. During an interview on 9/11/23 at 10:19 A.M., Nurse #2 said that on 8/30/23 at 9:35 A.M., she was standing at the medication cart when she heard Resident #2 call out for help. Nurse #2 said that when she entered Resident #2's room, she found him/her lying on his/her back near his/her recliner in his/her room complaining of left hip pain. Nurse #2 said that Resident #2 had transferred him/herself off the toilet and exited the bathroom unassisted by staff. Nurse #2 said that upon assessment, Resident #2's left lower extremity was externally rotated. Nurse #2 said that she called 911 and Resident #2 was transferred to the hospital for evaluation of his/her injuries. Nurse #2 said that Resident #2 was at high risk for falls, utilized bed and chair alarms for safety, required assistance of one staff member with toileting and should not have been left alone and unattended on the toilet. Nurse #2 said Resident #2 is confused at baseline, has a history of getting up and transferring him/herself without calling for staff assistance, and that was why he/she needed safety alarms. Nurse #2 said that CNA #1 did not follow Resident #2's plan of care. Review of the Hospital Discharge summary, dated [DATE], indicated Resident #2 had sustained a fall at the Facility on 8/30/23 and presented at the hospital with a left hip deformity and left elbow pain. The Discharge Summary indicated Resident #2's x-rays confirmed a left distracted (force applied to the forearm or hand with the arm extended can allow the radial head to slip out of the collar) intra-articular ulnar volcano process fracture with joint effusion (the pointy segment of bone that is part of the ulna, one of the three bones that come together to form the elbow joint) and a comminuted impacted and angulated left intertrochanteric hip fracture. The Discharge Summary indicated that Resident #2 underwent an open reduction internal fixation (ORIF) surgery of his/her left hip and conservative management of the left elbow fracture. During interview on 09/06/23 at 3:15 P.M., the Director of Nurses (DON) said that Resident #2 is at high risk for falls, has a physician's order for nursing staff to assist with all aspects of toileting. The DON said that Resident #2 requires physical assistance of one staff member with toileting and transfers, is confused, gets up by him/herself and that was why he/she required alarms. The DON said residents requiring alarms for safety should not be left alone in the bathroom. The DON said that CNA #1 should not have left Resident #2 alone on the toilet in the bathroom and said that CNA #1 did not follow Resident #2's plan of care. The DON said that as a result of being left alone on the toilet in his/her bathroom, Resident #2 fell and sustained a left elbow and left hip fracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was assessed by nursing at high risk for falls, whose Plan of Care indicated that he/she required physical assistance with toileting care needs, including transfers on and off the toilet, the Facility failed to ensure he/she was provided with the required level of staff assistance to maintain his/her safety, in an effort to prevent incidents/accidents resulting in an injury. On 08/30/23, Certified Nurse Aide (CNA) #1 brought Resident #2 into the bathroom, assisted with transferring and positioning him/her on the toilet (which was not equipped with an alarm) and then left the bathroom and Resident #2's room leaving him/her unattended by a staff member. A short time later, Resident #2 was heard calling out for help, and was found lying on his/her back on the floor in his/her room near the recliner complaining of left hip pain. Upon assessment, Resident #2's left leg was noted to be externally rotated. Resident #2 was transferred to the Hospital and x-rays revealed he/she had a left hip and left elbow fracture from the fall. Findings include: Review of the Facility's Policy, titled Fall Prevention Program, dated October 2022, indicated the following: -each resident will be assessed for risk factors and predisposition for falling using the facility Fall Risk Assessment Form; -residents having a history of falls or who score high on the Fall Risk Assessment will have an active problem included in their interdisciplinary plan of care; -residents who experience a fall will have a Fall Risk Assessment completed and immediate interventions will be implemented; -all falls will have an initial review by the Fall Risk Committee and recommendations will be added to the resident care plan; -the nurse manager will review the staff education form with all staff on their units; -new interventions are added to the resident's care plan; -interdisciplinary care plans will be established, revised and/or reviewed each time a resident falls; -appropriate interventions to maintain a resident's safety will be included. Resident #2 was admitted to the Facility in February 2021, diagnoses included wedge compression fracture of the first thoracic vertebrae, fracture of second thoracic vertebrae, osteoporosis, vascular dementia, muscle weakness and difficulty in walking. Review of Resident #2's Physicians Order, dated 9/26/22, indicated nursing to assist with all aspects of toileting. Review of Resident #2's Activity of Daily Living (ADL) Care Plan, dated 06/07/23, indicated he/she required physical assistance of one staff member with all aspects of toileting, interventions included staff to assist with transfers on and off the toilet and staff to assist with hygiene care. Review of Resident #2's Physician's Order, dated 6/17/23, indicated to use chair and bed alarms for safety. Review of Resident #2's Risk for Falls Care Plan, dated 06/20/23, indicated interventions included the use of bed and chair alarms for safety. Review of Resident #2's Fall Risk Assessment, dated 8/03/23, indicated that he/she was at high risk for falls. Review of the Quarterly Minimal Data Set Assessment (MDS), dated [DATE], indicated Resident #2 was moderately cognitively impaired, required limited physical assistance from staff with transfers, and extensive physical assistance of one staff member with toileting and hygiene care needs. The MDS indicated Resident #2 was unsteady when he/she moved from a sitting to a standing position, unsteady with ambulation, unsteady with turns, and unsteady when moving on/off the toilet and was only able to stabilize him/herself with human (staff) assistance. Review of Resident #2's CNA Care Plan, (used as a reference guide by CNA's), undated, indicated Resident #2 was at risk for falls, interventions included staff to provide physical assistance for transfers and with toileting, and that he/she utilized bed and chair alarms. Review of CNA #1's Written Witness Statement, dated 8/30/23, indicated that at approximately 9:20 A.M., she heard an alarm go off and went into Resident #2's room and helped him/her into the bathroom and then left the room. During an interview on 09/06/23 at 1:00 P.M., Certified Nurse Aide (CNA) #1 said that on 08/30/23 at 9:35 A.M., she heard Resident #2's chair alarm sound. CNA #1 said that Resident #2 requested to go to the bathroom, said she walked Resident #2 to the bathroom, assisted him/her onto the toilet and then left his/her room to assist another resident. CNA #1 said that she left Resident #2 unassisted on the toilet and left him/her alone in the bathroom. CNA #1 said that Resident #2 required staff assistance with toileting and transfers and used a chair alarm for safety. CNA #1 said she should not have left Resident #2 alone on the toilet in the bathroom. CNA #1 said that she did not review Resident #2's Care Plan, but said she knew what level of care he/she required and said she had taken care of Resident #2 many times. Review of a Nurse Progress Note, dated 08/30/23, indicated Nurse #2 heard Resident #2 yelling out for help. The Note indicated that Resident #2 was found lying on the floor (in his/her room) next to his/her recliner complaining of left hip pain with his/her left lower extremity externally rotated. The Note indicated that Resident #2 was transferred to the hospital for evaluation. During an interview on 9/11/23 at 10:19 A.M., Nurse #2 said that on 8/30/23 at 9:35 A.M., she was standing at the medication cart when she heard Resident #2 call out for help. Nurse #2 said that when she entered Resident #2's room, she found him/her lying on his/her back near his/her recliner in his/her room complaining of left hip pain. Nurse #2 said that Resident #2 had transferred him/herself off the toilet, exited the bathroom, and was found lying on his/her back on the floor near his/her recliner in his/her room complaining of left hip pain. Nurse #2 said that upon assessment, Resident #2's left lower extremity was externally rotated. Nurse #2 said that she called 911 and Resident #2 was transferred to the hospital for evaluation of his/her injuries. Nurse #2 said Resident #2 is confused at baseline, at high risk for falls, has a history of getting up and transferring him/herself without calling for staff assistance, and that he/she required bed and chair alarms for safety. Nurse #2 said Resident #2 required assistance of one staff member with toileting and should not have been left alone and unattended on the toilet. Review of a Resident Incident Report, dated 8/30/23 at 9:35 A.M., indicated that Resident #2 was found lying on the floor next to his/her recliner with his/her left lower extremity noted to be externally rotated, pain noted with movement and a skin tear was also noted to Resident #2's left elbow. The Report indicated that Resident #2 was transferred to the hospital. Review of the Hospital Discharge summary, dated [DATE], indicated Resident #2 had sustained a fall at the Facility on 8/30/23 and presented at the hospital with a left hip deformity and left elbow pain. The Discharge Summary indicated Resident #2's x-rays confirmed a left distracted (force applied to the forearm or hand with the arm extended can allow the radial head to slip out of the collar) intra-articular ulnar olecranon process fracture with joint effusion (the pointy segment of bone that is part of the ulna, one of the three bones that come together to form the elbow joint) and a comminuted impacted and angulated left intertrochanteric hip fracture. The Discharge Summary indicated that Resident #2 underwent an open reduction internal fixation (ORIF) surgery of his/her left hip and conservative management of the left elbow fracture. During interview on 09/06/23 at 3:15 P.M., the Director of Nurses (DON) said that Resident #2 is at high risk for falls, has a physician's order for nursing staff to assist with all aspects of toileting and that his/her plan of care indicates that he/she utilizes a bed and chair alarm for safety. The DON said that Resident #2 requires physical assistance of one staff member with toileting and transfers, is confused, gets up by him/herself and that was why he/she required alarms. The DON said residents requiring alarms for safety should not be left alone in the bathroom and said CNA #1 should not have left Resident #2 alone on the toilet in the bathroom. The DON said that as a result of being left alone on the toilet in his/her bathroom, Resident #2 fell and sustained a left elbow and left hip fracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and interviews, the facility failed to ensure its staff provided each resident an environment free of accident hazards and adequate supervision and assistance devices to prevent potential accidents or injuries. Specifically, the facility failed: 1. For one Resident (#48), out of a total sample of 19 residents, to ensure effective interventions were implemented to prevent three falls, including one with injury, requiring transfer to an acute care hospital; and 2. To ensure the Treatment Room door was closed and locked, exposing wandering residents to an environment with medication and medical supply hazards, on one of three units. Findings include: 1. Review of the facility's policy titled Fall Prevention Program, last reviewed 10/2022, included but was not limited to: -Residents who experience a fall will have an incident report and resident incident investigation follow up. -Immediate interventions will be implemented. -The nurse manager or shift supervisor will trigger a rehab request. -All falls will have an initial review by the Fall Risk Committee to identify and eliminate any environmental factors and add further recommendations. -The physical therapist will make recommendations for interventions to the Fall Risk Committee. -A Fall Prevention/Incident Interventions/Staff Education form will list the intervention(s) to be added, changed, or deleted in the resident's care plan. -The nurse manager or designee will review the Fall Prevention/Incident Interventions/Staff Education form with all staff on the unit. -Interdisciplinary care plans will be established, revised, and/or reviewed each time a resident falls. -Residents with potential fall risk problems will be re-evaluated at their quarterly care planning meeting. Resident #48 was admitted to the facility in October 2018 with diagnoses including dementia, arthritis, cerebral infarction (stroke), and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 4/18/23, indicated Resident #48 had severe cognitive impairment and was rarely/never understood, required assistance of staff for bed mobility, transfers, toileting, hygiene, and dressing, utilized a wheelchair and had a history of two or more falls. Review of the medical record indicated Resident #48 had five falls from January 2023 to July 2023. Review of the Resident Incident Reports indicated: -1/24/23 at 3:10 A.M., Resident had un unwitnessed fall out of bed and was found sitting on the floor against the bed. The Resident could not tell staff what he/she was trying to do. Bed alarm was sounding. No injury was noted. The follow-up assessment and recommendations section of the Incident Report was signed by Unit Manager #2 and failed to indicate any intervention was implemented or staff education was provided. The Fall Committee Review indicated Rehab was to screen the Resident. Fall Committee Review and Weekly Review sections were signed by the Assistant Director of Nurses (ADON). The Fall Prevention/Incident Interventions/Staff Education form was requested and not provided. The Rehab screen was requested and not provided. Further review of the medical record failed to indicate Rehab had screened the Resident. Review of the interdisciplinary care plan for falls indicated purposeful rounding per policy and Rehab screen were added to the electronic care plan. -3/28/23 at 11:55 P.M., Resident had a witnessed fall out of bed. Bed was in low position and bed alarm was sounding, staff was with roommate and observed Resident roll out of bed, landing on his/her right side. The Resident could not tell staff what he/she was trying to do. No injury was noted. The follow-up assessment and recommendations section of the incident report was signed by Unit Manager #2 and failed to indicate any intervention was implemented or staff education was provided. Fall Committee Review indicated Rehab was to screen the Resident and a defined perimeter mattress (mattress with raised sides to enhance fall prevention by cradling resident in the bed) was to be added to the Resident's plan of care. Fall Committee Review and Weekly Review sections were signed by the ADON. The Fall Prevention/Incident Interventions/Staff Education form was requested and not provided. Rehab screen indicated an evaluation was not needed because reasonable expectation for improvement was not elicited. Review of the interdisciplinary care plan for falls indicated defined perimeter mattress and rehab screen were added to the electronic care plan. Review of the medical record indicated no order was written for a defined perimeter mattress. -4/27/23 at 12:40 A.M., Resident had an unwitnessed fall out of bed and was found kneeling by his/her bed. Bed was in low position and bed alarm was sounding when staff entered the room. The Resident could not tell staff what he/she was trying to do. No injury was noted. The follow-up assessment and recommendations section were left blank and not signed by a Unit Manager or Supervisor. It failed to indicate any intervention was implemented or staff education was provided. The Fall Committee Review indicated Rehab to screen the Resident and a defined perimeter mattress was to be added to the Resident's plan of care (was supposed to be done after 3/28/23 fall). Fall Committee Review and Weekly Review sections were signed by the ADON. The Fall Prevention/Incident Interventions/Staff Education form was requested and not provided. Rehab screen indicated the Resident was currently on caseload. Review of the interdisciplinary care plan for falls indicated to continue the defined perimeter mattress and Rehab screen was added to the electronic care plan. Review of the medical record indicated no order was written for a defined perimeter mattress. -6/1/23 at 1:30 A.M., Resident had an unwitnessed fall out of bed and was found lying on the floor by his/her bed. Bed was in low position and bed alarm was sounding when staff entered the room. The Resident could not tell staff what he/she was trying to do. No injury was noted. The follow-up assessment and recommendations section were signed by Unit Manager #2 and failed to indicate any intervention was implemented or staff education was provided. The Fall Committee Review indicated Rehab to screen the Resident. Med Review for dose reduction of antipsychotic medication. Fall Committee Review and Weekly Review sections were signed by the ADON. The Fall Prevention/Incident Interventions/Staff Education form was requested and not provided. The Rehab screen was requested and not provided. Review of the medical record failed to indicate Rehab had screened the Resident. Further review of the medical record failed to indicate a physician's order had been obtained for the defined perimeter mattress or that the mattress had been put on the Resident's bed at the time of this fall. Review of the interdisciplinary care plan for falls indicated medication review and continue all interventions was added to the electronic care plan. -7/12/23 at 7:30 A.M., Resident had a witnessed fall out of bed. Bed was in low position and bed alarm was sounding. Nurse #2 entered the room and observed the Resident roll off the right side of the bed. The Resident could not tell staff what he/she was trying to do. The Resident had a hematoma and laceration over his/her right eye. Resident was transferred to the Hospital. The follow-up assessment and recommendations section indicated staff education on fall mats but failed to indicate any staff education was provided and was not signed by a Unit Manager or Supervisor. The Fall Committee Review indicated fall mats and defined perimeter mattress added (defined perimeter mattress was to be implemented previously after 3/28/23 fall and again after 4/27/23 fall). It did not indicate a Rehab screen was sent. Fall Committee Review section was not signed, and the Weekly Review section was signed by the Director of Nurses (DON). The Fall Prevention/Incident Interventions/Staff Education form was requested and not provided. The Rehab screen was requested and not provided. Review of the interdisciplinary care plan for falls indicated fall mats and defined perimeter mattress were added to the electronic care plan. Review of the medical record indicated an order was written for a defined perimeter mattress on 7/13/23. Further review of the medical record indicated Resident #48 was transferred on 7/12/23 after a fall. Diagnoses on discharge paperwork include brain concussion, elderly fall and laceration of right eyebrow. The laceration was closed with glue/skin adhesive. On 7/13/23 surveyor observed a defined perimeter mattress on Resident #48's bed. During an interview on 7/18/23 at 2:56 P.M., Nurse #2 said she does not recall what mattress was on the Resident's bed on 7/12/23 when he/she rolled out of bed. Additionally, Nurse #2 said the Resident now has floor mats and a defined perimeter mattress on the bed. During an interview on 7/18/23 at 1:45 P.M., Unit Manager #2 said she did not know when the defined perimeter mattress was put on the bed. During an interview on 7/18/23 at 2:03 P.M., the ADON said the Rehab screen request goes to the Rehab department, but the form doesn't come back to the office. The ADON said every resident that falls will have a Rehab screen done. Additionally, the ADON said she would expect a new intervention to be added to the care plan and implemented with every fall. After the fall on 3/28/23, the defined perimeter mattress should have been put on the bed. The ADON said the usual process is not to double check interventions were implemented. The ADON said she would expect the unit manager to address the interventions written on the incident report review, write the orders if needed and update the care plan. The ADON said she doesn't know why it was not done. In regard to the fall on 4/27/23, the ADON said she did not know why the same intervention was noted for the defined perimeter mattress, because it should have already been in place and it was not. The ADON said a defined perimeter mattress requires a physician's order and it was not put in place until 7/13/23. During an interview on 7/18/23 at 2:37 P.M., Rehab Staff #1 said sometimes the screens get missed. Additionally, Rehab Staff #1 said when the screen is complete it does not go back to nursing, the form stays in the rehab office. Rehab screens were requested for Resident #48's five falls in 2023 and Rehab Staff #1 was unable to provide them for 3 of the 5 falls. Rehab Staff #1 said he did not have all of them and did not know if they were done. During an interview on 7/18/23 at 3:10 P.M., the DON said after every fall the incident report is completed by the nurse and reviewed by the Interdisciplinary Team (IDT) for interventions to be implemented to prevent future falls. Additionally, the DON said the intervention for the defined perimeter mattress should have been implemented in March and was not done until 7/13/23. The DON said the defined perimeter mattress was not on Resident #48's bed at the time of the fall on 7/12/23. The DON said her expectation is that when the incident report is signed by the Unit Manager, Supervisor and/or the ADON, the intervention is put in place, however in this case the order for the mattress was not written until 7/13/23 and that is when the mattress was actually put on the bed. During an interview on 7/18/23 at 3:30 P.M., Unit Manager #1 said Resident #48 did not have a defined perimeter mattress on his/her bed on 7/12/23 when the fall with laceration occurred. Additionally, Unit Manager #1 said the intervention was added to the care plan, physicians order was written, and mattress was put on the bed on 7/13/23 after the Fall Committee Review. Unit Manager #1 said she does not know why it was not done previously. During an interview on 7/19/23 at 8:28 A.M., Nurse #3 said Resident #48 did not have a defined perimeter mattress on his/her bed until after the fall last week. During an interview on 7/19/23 at 12:34 P.M., the ADON said she did not have the Fall Prevention/Incident Interventions/Staff Education Forms for any of these five falls. The ADON provided a blank copy of the form referenced in the facility Falls policy and said, but we do not use it. 2. Review of the facility's policy titled Medication Storage in the Facility, dated February 2019, indicated but was not limited to the following: - Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the suppliers. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. The surveyor made the following observations on the third floor [NAME] Unit where long-term residents, some with cognitive deficits, resided: On 7/13/23 at 2:54 P.M., the surveyor observed the Treatment Room door unlocked and slightly opened and easily accessible to residents residing on the third floor [NAME] Unit. The Treatment Room was located down an L shaped hallway and was not in view of the nurses' station which was located at the opposite end of the L shaped hallway. The surveyor observed the following treatments which were on top of the treatment cart and on the shelving unit in the Treatment Room: - Diclofenac Sodium Topical Gel 1% (nonsteroidal anti-inflammatory) - DermaGinate/Ag Calcium Alginate Wound Dressing with Antibacterial Silver - Idosorb Cadexomer Iodine Gel (antiseptic) - Calcium Alginate Dressing: (highly absorbent, can reduce bacterial infections) - Triamcinolone Acetonide Ointment 0.05%: (corticosteroid) - DermPhor Ointment - Triple Antibiotic Cream - Xeroform Gauze Dressing - Allevyn Gentle Border - Alcohol Prep Pads On 7/13/23 at 2:58 P.M., the surveyor observed a wandering resident ambulate down the hallway past the Treatment Room. At 3:00 P.M., the surveyor observed a resident ambulate with a walker down the hallway past the Treatment Room. During an interview on 7/13/23 at 3:03 P.M., Nurse #7 observed the opened Treatment Room door with the surveyor. Nurse #7 said she was most likely the last nurse into the Treatment Room at approximately 2:30 P.M. and was responsible for not closing the self-locking door. Nurse #7 said the Treatment Room door should never be left opened and unlocked. During an interview on 7/13/23 at 3:37 P.M., the Director of Nurses said there were many residents on the unit and the expectation was the Treatment Room door should never be left opened and unlocked.