**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated that he/she required physical assistance of two staff members for bed mobility, bathing and hygiene care ( which included incontinence care), the Facility failed to ensure nursing staff implemented and followed interventions identified in his/her Plan of Care while meeting his/her care needs. On 09/05/23, Certified Nurse Aide (CNA) #1 provided Resident #1 morning care, which included incontinence and hygiene care to Resident #1 without another staff member present to assist her. During care, after CNA #1 rolled Resident #1 onto his/her left side, CNA #1 stepped away from the bed and went to the doorway to call for the nurse, leaving Resident #1 unassisted, and he/she fell off the bed on to the floor, striking the right side of his/her head. Resident #1 was transferred to the Hospital Emergency Department for evaluation and diagnosed with contusions (region of injured tissue or skin in which blood capillaries have ruptured) to his/her forehead and face, as well as a subconjunctival hemorrhage (a broken blood vessel on the white part of the eye) with an abrasion (area damaged by scraping) to the right side of his/her forehead. Findings include: Review of the Facility's Policy, titled Fall Reduction, dated as revised 6/22/22, indicated the following: -Facility would implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based on the individual resident's needs; - Residents will be identified as low, moderate, or high risk for falling based on the Fall Assessment tool; -Residents at risk, in addition to the Universal Safety Standards, will be reviewed for resident specific interventions as deemed appropriate; -The nurse will document the fall risk prevention measures that have been instituted in the Resident Care Plan and on the CNA Care Card. Resident #1 was admitted to the Facility in November 2019, diagnoses include cerebral infarction (stroke), generalized muscle weakness, abnormalities of gait and mobility, and pulmonary embolism without acute cor pulmonal (disease of the circulatory system). Resident #1's Annual Minimum Data Set (MDS) assessment, dated 8/11/23, indicated he/she was cognitively impaired, required two-person physical assist for all his/her care needs, including bed mobility, bathing, incontinent care, transfers, and was non-ambulatory. Resident #1's Care Plan titled Activities of Daily Living (ADL), reviewed and renewed with his/her August 2023 MDS, indicated to provide two-person physical assistance for bed mobility (repositioning and turning in bed), bathing, incontinence care, and hygiene related to impaired functional mobility. Resident #1's Certified Nurse Aide (CNA) Care Card, dated 5/31/23, indicated he/she was totally dependent and required the assistance of two staff members for bed mobility, bathing and toilet use, which included incontinence and hygiene care. Review of the Facility's Internal Investigation Report, dated 9/05/23, indicated that on 9/05/23 around 8:30 A.M., the CNA (later identified as CNA#1) walked away from Resident #1's bed to obtain supplies and he/she rolled out of bed onto floor. The Report indicated, staff noted swelling and discoloration to Resident #1's right forehead and facial area. The Report indicated that Resident #1 was sent to the Hospital Emergency Department (ED) for evaluation, the ED obtained a CT scan and X-rays with negative results, and Resident #1 returned to the facility with a diagnosis of contusion to his/her forehead. Further review of the Report indicated that Resident #1 was left alone by CNA #1 and that he/she was a two person assist. Review of a Nurse Progress Note, dated 9/05/23 at 9:15 A.M., indicated that Resident #1 had a fall out of bed around 8:30 A.M., and was transferred to the Hospital Emergency Department. Review of a Hospital Emergency Department Discharge summary, dated [DATE], indicated that Resident #1 sustained contusions to his/her forehead and face, an abrasion to his/her forehead and subconjunctival hemorrhage (a broken blood vessel on the white part of the eye) and CT scans of head, orbits and neck as well as x-rays of shoulders, knee and chest did not show any acute problems. Review of a Nurse Progress Note, dated 9/05/23 at 1:43 P.M., indicated that Resident #1 returned to the Facility with a diagnosis of a contusion to his/her forehead, his/her right eye was swollen and bruised and the CT scan and X-ray results were negative. Review of a Nurse Progress Note, dated 9/05/23 at 6:26 P.M., indicated that Resident #1's right orbit (cavity at socket/hole of skull in which eye is situated) area had ecchymosis (bruising) with remarkable edema (swelling) and right forehead had a large intact blister with a bandage dressing covering forehead. During an observation on 10/12/23 at 8:55 A.M., the surveyor observed Resident #1 (who was in his/her room) lying in bed and noted to have ecchymosis with a raised lump on the side of his/her right forehead. The surveyor was unable interview Resident #1 about his/her injuries, due to his/her cognitive impairment. During an interview on 10/12/23 at 9:00 A.M., Nurse #1 said that she was the nurse assigned to care for Resident #1 during the 7:00 A.M. through 3:00 P.M. shift on 9/05/23. Nurse #1 said that on 9/05/23, CNA #1 came out of Resident#1's room to get her to look at a red area that she had noticed while providing ADL care to him/her. Nurse #1 said when she went into Resident#1's room with CNA #1, they found him/her on the floor on the left side of the bed. Nurse #1 said there was no other staff member in Resident #1's room at that time. Nurse #1 said Resident #1 had bruising on the right side of his/her forehead and right lower jaw. Nurse #1 said she completed her assessment of Resident #1 and called 911. Nurse #1 said Resident #1 must have rolled out of bed. Nurse #1 said Resident #1 required two staff members to assist with his/her care needs. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, undated, indicated that on 9/05/23, she provided morning care to Resident #1 in his/her bed, had positioned him/her on his/her left side, noticed a wound that was dirty that had a patch over it, stepped to the doorway of the room ( away from the bed) to get the nurse, stepped back in the room and Resident #1 was on the floor. During a telephone interview on 10/13/23 at 10:50 A.M., CNA #1 said that she worked on 9/05/23 and that Resident #1 was assigned to her. CNA #1 said that she was bathing him/her and saw a red area on his/her bottom when she rolled him/her onto his/her left side and she stepped away from the bed, out into the doorway to call out to the nurse. CNA#1 said when she stepped back into the room, Resident #1 was on the floor by the left side of the bed. CNA #1 said that she reviewed Resident #1's CNA Care Card and was aware that he/she required two staff members to assist when providing ADL care. During a telephone interview on 10/13/23 at 10:43 A.M., CNA #2 said Resident #1 required total assistance from two staff members with care, that she was working on Resident #1's unit on 9/05/23, but CNA #1 did not ask her to assist her that day. During an interview on 10/12/23 at 12:35 P.M., CNA #3 said she was familiar with Resident #1's care, that he/she was totally dependent for care and required two staff members to assist with bathing and bed mobility. During an interview on 10/12/23 at 1:44 P.M., the Unit Manager said that CNA #1 did not follow interventions identified on Resident #1's CNA Care Card for the need for two staff members to assist during care and was by herself providing care to Resident #1. The Unit Manager said it is her expectation that staff follow the plan of care. During an interview on 10/12/23 at 2:01 P.M., the Director of Nurses (DON) said that Resident #1 required the assistance of two staff members with all ADL care. The DON said that CNA #1 provided care to Resident #1 without the assistance of another staff member and walked away from the bedside. The DON said that CNA #1 did not follow Resident #1's plan of care and said that it was her expectation that staff follow the plan of care. During an interview on 10/12/23 at 2:27 P.M., the Administrator said that the staff informed him that CNA #1 had left Resident #1 alone and turned on his/her side with the bed elevated prior to the fall. On 10/12/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A) Resident #1 was immediately assessed by Nursing and was transferred to the Hospital Emergency Department for evaluation. B) On 09/05/23, Resident #1 returned to the Facility. C) 09/06/23, the Unit Manager and the DON provided Educational In-services for nursing department staff on following the plan of care for residents according to their specific care plan, CNA care card and the need to provide the required level of staff assistance. D) 09/06/23, all resident CNA Care Cards were reviewed and audited by the Unit Managers, and updated as needed. E) 10/10/23, a Mandatory staff meeting was held reviewing education on care plans and CNA care cards to ensure the correct care and level of assistance is provided by staff. Expectations of staff, documentation, and resident rounds were also reviewed at this time. F) 10/5/23, Standards of Care & Compliance Check List, with designated staff assignments for facility wide audits, review of audits was conducted by the Administrator. G) Daily Rounds are being conducted by DON and Unit Managers to ensure resident care needs identified on CNA Care Cards are being followed. H) Concierge rounds were implemented on 10/10/23, management staff are assigned 4 rooms each and check in with their assigned residents daily. I) Ongoing audits will be conducted by the DON and/or Designee until substantial compliance is achieved. J) Results of the audits will be presented to the Quality Assurance Performance Improvement (QAPI) committee at the next QAPI meeting on 10/27/23. K) The DON and/or Designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing to be at high risk for falls, and required physical assistance of two staff members for Activities of Daily Living (ADL) care, the Facility failed to ensure he/she was provided with the required level of staff assistance during care to maintain his/her safety, in an effort to prevent an accident resulting in an injury. On 09/05/23 at approximately 8:30 A.M., Certified Nurse Aide (CNA) #1 provided Resident #1 with morning care, which included assisting Resident #1 with bed mobility, as well as incontinence and hygiene care, and proceeded to do so without another staff member present to assist her. CNA #1 stepped away from the bed and out into the doorway, leaving Resident #1 in bed, which was in the raised position, on left his/her side, and unattended by a staff member. Resident #1 fell off the bed on to the floor, striking the right side of his/her head, was transferred to the Hospital Emergency Department for evaluation and diagnosed with a contusion (region of injured tissue or skin in which blood capillaries have been ruptured) to the right side his/her forehead and face, as well as a subconjunctival hemorrhage (a broken blood vessel on the white part of the eye) with an abrasion (area damaged by scraping) to the right side of his/her forehead. Findings include: Review of the Facility's Policy, titled Fall Reduction, dated as revised 6/22/22, indicated the following: -Facility would implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based on the individual resident's needs; - Residents will be identified as low, moderate, or high risk for falling based on the Fall Assessment tool; -Residents at risk, in addition to the Universal Safety Standards, will be reviewed for resident specific interventions as deemed appropriate; -The nurse will document the fall risk prevention measures that have been instituted in the Resident Care Plan and on the CNA Care Card. Review of the Facility's Internal Investigation Report, dated 9/05/23, indicated that on 9/05/23 around 8:30 A.M., the CNA( later identified as CNA #1) walked away from Resident #1's bed to obtain supplies and he/she rolled out of bed onto floor. The Report indicated, staff noted swelling and discoloration to Resident #1's right forehead and facial area. The Report indicated that Resident #1 was sent to the Hospital Emergency Department (ED) for evaluation, the ED obtained a CT scan and X-rays with negative results, and Resident #1 returned to the facility with a diagnosis of contusion to forehead. Further review of the Report indicated that Resident #1 was left alone by CNA #1 and that he/she was a two person assist. Resident #1 was admitted in November 2019, diagnoses include cerebral infarction (stroke), generalized muscle weakness, abnormalities of gait and mobility, and pulmonary embolism without acute cor pulmonal (disease of the circulatory system). Resident #1's Certified Nurse Aide (CNA) Care Card, dated 5/31/23, indicated he/she was totally dependent and required the assistance of two staff members for bed mobility, bathing and toilet use, which included incontinence and hygiene care. Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively impaired, required two-person physical assist for all care needs, including bed mobility, bathing, incontinent care, transfers and he/she was non-ambulatory. Resident #1's Care Plan titled Activities of Daily Living (ADL), reviewed, and renewed with his/her August 2023 MDS, indicated to provide two-person physical assistance for bed mobility (repositioning and turning in bed), bathing, incontinence care and hygiene related to impaired functional mobility. Resident #1's Falls Care Plan, reviewed, and renewed with his/her August 2023 MDS, indicated he/she was at risk for falls, interventions included to follow facility policy related to fall reduction. Review of a Nurse Progress Note, dated 9/05/23 at 9:15 A.M., indicated that Resident #1 had a fall out of bed around 8:30 A.M., and was transferred to the Hospital Emergency Department. Review of a Nurse Progress Note, dated 9/05/23 at 1:43 P.M., indicated that Resident #1 returned to the Facility with a diagnosis of contusion to his/her forehead, his/her right eye was swollen and bruised and the CT scan and X-ray results were negative. Review of a Hospital Emergency Department Discharge summary, dated [DATE], indicated that Resident #1 sustained contusions to his/her forehead and face, abrasion to forehead and subconjunctival hemorrhage (a broken blood vessel on the white part of the eye) and CT scans of head, orbits and neck as well as x-rays of shoulders, knee and chest did not show any acute problems. During an observation on 10/12/23 at 8:55 A.M., the surveyor observed Resident #1 (who was in his/her room) lying in bed and noted to have ecchymosis (bruising) with a raised lump on right forehead. The surveyor was unable to interview Resident #1 about his/her injuries due to his/her cognitive impairment. Review of a Nurse Progress Note, dated 9/05/23 at 6:26 P.M., indicated that Resident #1's right orbit (cavity at socket/hole of skull in which eye is situated) area had ecchymosis (bruising) with remarkable edema (swelling) and right forehead had a large intact blister with a bandage dressing covering forehead. During an interview on 10/12/23 at 9:00 A.M., Nurse #1 said that she was the nurse who was assigned to care for Resident #1 during the 7:00 A.M. through 3:00 P.M. shift on 9/05/23. Nurse #1 said that on 9/05/23, CNA #1 came out of Resident #1's room to get her to look at a red area that she noticed while providing ADL care to him/her. Nurse #1 said when she went into Resident#1's room with CNA #1, they found him/her on the floor on the left side of the bed. Nurse #1 said there was no other staff member in Resident #1's room at that time. Nurse #1 said Resident #1 had bruising on the right side of his/her forehead and right lower jaw. Nurse #1 said she completed her assessment of Resident #1 and called 911. Nurse #1 said Resident #1 must have rolled out of bed. Nurse #1 said Resident #1 required two staff members to assist with his/her care needs. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, undated, indicated that on 9/05/23, she provided morning care to Resident #1 in his/her bed, had positioned him/her on his/her left side, noticed a wound that was dirty that had a patch over it, stepped to the doorway of the room to get the nurse, stepped back in the room and Resident #1 was on the floor. During a telephone interview on 10/13/23 at 10:50 A.M., CNA #1 said that she worked on 9/05/23 and that Resident #1 was assigned to her. CNA #1 said that she was bathing him/her and saw a red area on his/her bottom when she rolled him/her onto his/her left side and stepped away to the doorway to call out to the nurse. CNA#1 said when she stepped back into the room, Resident #1 was on the floor by the left side of the bed. CNA #1 said that she reviewed Resident #1's CNA Care Card and was aware that he/she required two staff members to assist when providing care. During a telephone interview on 10/13/23 at 10:43 A.M., CNA #2 said Resident #1 required total assistance from two staff members with care, that she worked on Resident #1's unit on 9/05/23, but that CNA #1 did not ask her to assist her that day. During an interview on 10/12/23 at 12:35 P.M., CNA #3 said she was familiar with Resident #1's care, that he/she was totally dependent for care and required two staff to assist with bathing and bed mobility. During an interview on 10/12/23 at 1:44 P.M., the Unit Manager said that CNA #1 did not follow interventions identified on Resident #1's CNA Care Card for the need for two staff members to assist during care and was by herself providing care to Resident #1. The Unit Manager said it is her expectation that staff provide the appropriate level of assistance when caring for residents. During an interview on 10/12/23 at 2:01 P.M., the Director of Nurses (DON) said that Resident #1 required the assistance of two staff members with all ADL care. The DON said that CNA #1 provided care to Resident #1 without the assistance of another staff member and walked away from the bedside. The DON said that CNA #1 did not follow Resident #1's plan of care and said that it was her expectation that staff provide the necessary level of staff assistance during care. During an interview on 10/12/23 at 2:27 P.M., the Administrator said that the staff informed him that CNA #1 had left Resident #1 alone and turned on his/her side, prior to the fall. On 10/12/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A) Resident #1 was immediately assessed by Nursing and was transferred to the Hospital Emergency Department for evaluation. B) On 09/05/23, Resident #1 returned to the Facility. C) 09/06/23, the Unit Manager and the DON provided Educational In-services for nursing department staff on following the plan of care for residents according to their specific care plans, CNA care cards and the need to provide the required level of staff assistance. D) 09/06/23, all resident CNA Care Cards were reviewed and audited by the Unit Managers, and updated as needed. E) 10/10/23, a Mandatory staff meeting was held reviewing the education on care plans and care cards to ensure the correct care is provided by staff. Expectations of staff, documentation, and resident rounds were also reviewed at this time. F) 10/5/23, Standards of Care & Compliance Check List, with designated staff assignments for facility wide audits, audit reviews were conducted by the Administrator. G) Daily Rounds are being conducted by DON and Unit Managers to ensure resident care needs identified on there Care Cards were being followed. H) Concierge rounds were implemented on 10/10/23, management staff are assigned 4 rooms each and check in with their assigned residents daily. I) Ongoing audits will be conducted by the DON and/or Designee until substantial compliance is achieved. J) Results of the audits will be presented to the Quality Assurance Performance Improvement (QAPI) committee at the next QAPI meeting on 10/27/23. K) The DON and/or Designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who upon admission to the Facility in August 2022, had no areas of skin breakdown, the Facility failed to ensure he/she was provided with care and services that met professional standards of practice in an effort to prevent the development of a pressure injury, when several months after his/her admission Resident #1 developed a pressure injury to his/her coccyx which continued to worsen and progressed to an unstageable area. Findings include: The Facility Policy titled, Pressure Ulcer Prevention, dated 12/22/22, indicated that the Facility will provide the appropriate care and services to residents to assist in the prevention of pressure injuries and to promote optimal healing. Change the resident's position in bed or chair as needed at a minimum of every 2 hours or as tolerated. The Facility Policy titled, Skin Body Audit, dated 5/09/22, indicated that the skin body assessments should identify changes in skin integrity through weekly skin audits (head to toe) on all residents. Nurses will perform skin body audits on a weekly basis. The Nurse assesses the surfaces of the skin that come in contact with the bed and the chair, bony prominence's such as the tailbone, observing for redness, open areas, any significant abnormal finding will be reported to the resident's physician. Resident #1 was admitted to the Facility in 8/2022, diagnoses included acute respiratory failure, pneumonia, asthma, a cerebrovascular accident with dysarthria (difficulty speaking), and dysphagia (difficulty swallowing). Review of Resident #1's Nursing admission Assessment, dated 8/30/22, indicated Resident #1 had no pressure injuries on admission, and no skin issues were noted. Review of Resident #1's Norton Scale (a pressure injury risk assessment scale), dated 8/30/22, indicated he/she was not at high risk for pressure injury, due to being alert, ambulatory, fully mobile, continent and in fair physical condition. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], indicated that Resident #1, was cognitively intact, was an extensive assist of two staff persons for bed mobility, limited assist with one staff person for transfers and ambulation, was continent of bowel and bladder, had no unhealed pressure injuries, or other wounds or skin problems and was at risk for development of pressure injuries. Review of Resident #1's Care Plan related to Skin Integrity, dated 9/07/22, indicated, interventions included to keep skin clean and dry, apply a lotion to dry areas, and perform weekly skin checks. Review of the MDS, Care Area Assessment, dated 9/12/22, indicated pressure injury triggered as an area of concern for Resident #1 and to address the pressure injury risk with a care plan. Review of Resident's Weekly Skin Checks for November 2022, indicated that there was no documentation to support that the weekly skin checks were performed by nursing on: - 11/10/22 and 11/17/22. Review of Resident #1's Nursing Progress Note, dated 11/20/22, indicated he/she had a new pressure injury on the coccyx measuring 1.2 centimeters (cm) in length by 0.5 cm in width and 0.2 cm in depth., the wound bed was pink with a small amount of slough (dead tissue). Review of Resident #1's Physician Order, dated 11/20/22, indicated treatment to the new pressure injury on the coccyx; wash with normal saline, apply a border foam dressing, change daily and as needed. Review of Resident #1's Skin Integrity Care Plan, updated on 11/21/22, indicated the staff were to provide the wound treatment as ordered. Review of Resident #1's Physician Order, dated 12/20/22, indicated treatment to the pressure injury on the coccyx (tail bone), wash with normal saline, apply a border foam dressing, change daily and as needed. Review of Resident #1's Nursing Progress Note, dated 12/03/22, indicated he/she had a small pressure injury on his/her coccyx, which was covered with triad cream (a zinc oxide base wound treatment). Review of Resident's Weekly Skin Checks, for December 2022, indicated that there was no documentation to support that the weekly skin checks were performed by nursing on: - 12/01/22 and 12/29/22 Review of Resident #1's Treatment Administration Record (TAR), for December 2022, indicated there was no documentation to support that nursing completed his/her coccyx dressing changes on 12/7/22, 12/11/22, 12/12/22, 12/16/22, 12/21/22, 12/25/22, and 12/28/22. Review of Resident #1's Nursing Progress Note, dated 1/01/23, indicated his/her pressure injury on the coccyx was worsening. The Note indicated the wound was irregular in shape and measured 1.5 cm in length by 1.8 cm in width by 0.2 cm in depth. The Note indicated the wound bed was red in color with light yellow slough (dead tissue), with a small amount of serosanguineous drainage (secreted by an open wound in response to tissue damage). Review of Resident'#1's Weekly Skin Checks, for January 2023, indicated that there was no documentation to support that the weekly skin checks were performed by nursing on: - 1/12/23 and 1/26/23 Review of Resident #1's Wound Physician Notes, dated 1/05/23, indicated he/she had a coccyx pressure injury, staged as unstageable (full thickness tissue loss) due to necrosis (death of most or all cells in tissue), the open wound measured 1 cm in length by 1.5 cm in width, and 0.2 cm in depth with the wound bed containing 100% epithelial (an indicator of healing tissue). The Note indicated around this wound was Deep Tissue Injury measuring 8 cm in length by 6 cm in width (DTI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shearing (friction that abrades the skin). The Physician's plan included turning and repositioning per facility protocol and optimize nutrition. Review of Resident #1's Physician Order, dated 1/05/23, indicated to cleanse the coccyx wound with a wound cleaner, pat dry, apply calcium alginate (an absorbent dressing) to fit in the wound bed, and cover with a foam dressing every other day, and to start the dressing change on 1/07/23. Review of Resident #1's Treatment Administration Record (TAR), for January 2023, indicated there was no documentation to support that dressing changes were performed by nursing on 1/07/23, and 1/19/23. Review of Resident #1's Documentation Flow Sheets for Turning and Repositioning (completed by the Certified Nurse Aides), dated November 2022, indicated that he/she required staff to physically turn and reposition him/her every 2 hours. Further review of Resident #1's repositioning sheets for November 2022, indicated there was insufficient documentation to support he/she was repositioned as needed by nursing staff and the following dates and times were left blank: Flow sheet documentation on the Day shift (7:00 A.M. to 3:00 P.M.) on the following dates and times were left blank; - 11/01/22, at 2:00 P.M., left blank - 11/06/22, the entire shift - 11/11/22, the entire shift - 11/21/22, the entire shift - 11/22/22, the entire shift - 11/25/22, the entire shift - 11/28/22, the entire shift Flow sheet documentation for Evening shift (3:00 P.M. to 11:00 P.M.) on the following dates and times were left blank; - 11/03/22, the entire shift - 11/04/22, the entire shift - 11/05/22, the entire shift - 11/06/22, at 8:00 P.M. and 10:00 P.M. - 11/07/22, the entire shift - 11/09/22, at 6:00 P.M. and 8:00 P.M. - 11/10/22, the entire shift - 11/11/22, the entire shift - 11/12/22, the entire shift - 11/13/22, the entire shift - 11/15/22, at 6:00 P.M., 8:00 P.M., and 10:00 P.M. - 11/16/22, the entire shift - 11/17/22, the entire shift - 11/18/22, the entire shift - 11/19/22, at 8:00 P.M. and 10:00 P.M. - 11/20/22, at 8:00 P.M. and 10:00 P.M. - 11/21/22, the entire shift - 11/22/22, the entire shift - 11/23/22, the entire shift - 11/24/22, at 4:00 P.M. and 6:00 P.M. - 11/26/22, the entire shift - 11/27/22, the entire shift - 11/29/22, at 6:00 P.M., 8:00 P.M., and 10:00 P.M. - 11/30/22, the entire shift Flow sheet documentation for the Night shift (11:00 P.M. to 7:00 A.M.) on the following dates and times were left blank; - 11/01/22, the entire shift - 11/03/22, at 2:00 A.M., 4:00 A.M., and 6:00 A.M. - 11/05/22, the entire shift - 11/06/22, at 2:00 A.M. and 6:00 A.M. - 11/11/22, at 2:00 A.M., 4:00 A.M., and 6:00 A.M. - 11/12/22, at 6:00 A.M. - 11/13/22, the entire shift - 11/14/22, at 2:00 A.M., 4:00 A.M., and 6:00 A.M. - 11/16/22, at 6:00 A.M. - 11/18/22, at 2:00 A.M., 4:00 A.M., and 6:00 A.M. - 11/19/22, the entire shift - 11/20/22, the entire shift - 11/21/22, the entire shift - 11/22/22, the entire shift - 11/23/22, the entire shift - 11/24/22, at 6:00 A.M. - 11/25/22, at 6:00 A.M. - 11/26/22, at 6:00 A.M. - 11/27/22, the entire shift - 11/28/22, the entire shift Review of Resident #1's Documentation Flow Sheets for Turning and Repositioning, dated December 2022, indicated he/she was not consistently turned and repositioned by nursing staff and the following dates and times were left blank: Flow sheet documentation on the Day shift (7:00 A.M. to 3:00 P.M.) on the following dates and times was left blank; - 12/01/22, the entire shift - 12/02/22, the entire shift - 12/11/22, the entire shift - 12/18/22, the entire shift - 12/22/22, the entire shift - 12/23/22, the entire shift - 12/26/22, the entire shift - 12/27/22, the entire shift - 12/28/22, at 2:00 P.M. - 12/30/22, the entire shift Flow sheet Documentation on Evening shift (3:00 P.M. to 11:00 P.M.) on the following dates and times were left blank; - 12/01/22, the entire shift - 12/02/22, the entire shift - 12/03/22, the entire shift - 12/04/22, at 8:00 P.M. and 10:00 P.M. - 12/05/22, the entire shift - 12/06/22, the entire shift - 12/07/22, the entire shift - 12/08/22, the entire shift - 12/09/22, the entire shift - 12/10/22, the entire shift - 12/11/22, the entire shift - 12/13/22, at 10:00 P.M. - 12/14/22, the entire shift - 12/15/22, the entire shift - 12/16/22, the entire shift - 12/17/22, at 8:00 P.M. and 10:00 P.M. - 12/18/22, the entire shift - 12/19/22, at 4:00 P.M. and 6:00 P.M. - 12/20/22, at 4:00 P.M., 6:00 P.M., and 8:00 P.M. - 12/21/22, the entire shift - 12/22/22, the entire shift - 12/23/22, the entire shift - 12/24/22, at 4:00 P.M. and 6:00 P.M. - 12/26/22, the entire shift - 12/27/22, the entire shift - 12/28/22, at 4:00 P.M. and 6:00 P.M. - 12/29/22, at 4:00 P.M. and 6:00 P.M. - 12/30/22, the entire shift - 12/31/22, the entire shift Flow sheet documentation for Night shift (11:00 P.M. to 7:00 A.M.) on the following dates and times was left blank; - 12/01/22, at 6:00 A.M. - 12/02/22, the entire shift - 12/03/22, the entire shift - 12/04/22, the entire shift - 12/05/22, the entire shift - 12/06/22, the entire shift - 12/07/22, the entire shift - 12/10/22, the entire shift - 12/11/22, the entire shift - 12/12/22, the entire shift - 12/15/22, at 12:00 A.M., 2:00 A.M., and 4:00 A.M. - 12/16/22, the entire shift - 12/20/22, at 4:00 A.M. and 6:00 A.M. - 12/21/22, the entire shift - 12/26/22, the entire shift - 12/27/22, the entire shift - 12/28/22, the entire shift - 12/31/22, the entire shift Review of the Medical Record indicated Resident #1 was transferred to the hospital three different times during January 2023, therefore there he/she was only in the facility for 22 full days that month. Review of Resident #1's Documentation Flow Sheets for Turning and Repositioning, for January 2023, indicated he/she was not consistently turned and repositioned by nursing staff and the following dates and times were left blank: . Flow sheet documentation for the Day shift (7:00 A.M. to 3:00 P.M.) for the following dates and times were left blank; - 01/03/23, the entire shift - 01/06/23, the entire shift - 01/12/23, the entire shift - 01/13/23, the entire shift - 01/14/23, the entire shift - 01/16/23, the entire shift - 01/19/23, the entire shift - 01/20/23, the entire shift - 01/23/23, the entire shift - 01/29/23, the entire shift On the Evening shift (3:00 P.M. to 11:00 P.M.), only the 4:00 P.M. Turning & Positioning Flow Sheet, was made available to the Surveyor for January 2023. The remaining flow sheets for January 2023 Evening shift times of 6:00 P.M., 8:00 P.M. and 10:00 P.M. were not made available to the surveyor. Flow sheet documentation for the Evening shift (for 4:00 P.M.) on the following dates were left blank; - 01/01/23 through 01/07/23 - 01/10/23 through 01/16/23 - 01/18/23 through 01/23/23 Flow sheet documentation for Night shift (11:00 P.M. to 7:00 A.M.)for the following dates and times were left blank; - 01/01/23, the entire shift - 01/04/23, the entire shift - 01/06/23, the entire shift - 01/14/23, the entire shift - 01/19/23, the entire shift - 01/20/23, the entire shift - 01/22/23, at 6:00 A.M. - 01/23/23, at 6:00 A.M. Review of Resident #1's Skin Integrity Care Plan, updated on 1/11/23, indicated a new intervention included, an air mattress was applied to his/her bed, for the open area on the coccyx. Review of Resident #1's Wound Physician Notes, dated 1/12/23, indicated he/she had a coccyx pressure injury, staged as unstageable (full thickness tissue loss) due to necrosis (death of most or all cells in tissue), the open wound measured 2 cm in length by 2 cm in width, and 0.8 cm in depth, with the wound bed containing 100% slough (dead tissue). The Note indicated around this wound was Deep Tissue Injury measuring 5 cm in length by 10 cm. in width, with tunneling which measured 0.2 cm at 10 and 11 o'clock. The Physician's plan included turning and repositioning per facility protocol and to optimize nutrition. The Note indicated this wound was worsening with increased necrosis and increased size. Review of Resident #1's Wound Physician Notes, dated 1/19/23, indicated he/she had a coccyx pressure injury, staged as Deep Tissue Injury, open wound measured 2 cm in length by 2.2 cm in width, and 1 cm in depth, with the wound bed containing 90% eschar (dried dark dead skin ). The Note indicated around this wound was Deep Tissue Injury measuring 9 cm in length by 10 cm. in width, with tunneling which measured 0.3 cm. The Note indicated this was a worsening pressure injury, with increased necrosis and increased size. The Physician's plan included turning and repositioning per facility protocol and to optimize nutrition. Resident #1's Hospital Emergency Department (ED) Physician's Progress Note, dated 1/30/23, indicated Resident #1 had a sacral pressure injury with tunneling, which had purulent drainage with redness, measuring approximately 2 cm in length by 2 cm in width. A Computerized Scan (CT) of the pelvis and sacral pressure injury indicated there was sacrococcygeal (of the sacral and coccyx bone) osteomyelitis (a bone infection) with soft tissue infection. During an interview on 3/07/23 at 3:25 P.M., the Nursing Supervisor said Resident #1 developed a Facility acquired pressure injury three months after his/her admission, and that the Facility expectation was that nurses would complete weekly skin checks and wound treatments as ordered, and nurses also were responsible for making sure Certified Nurse Aides had turned and repositioned him/her, per the Plan of Care in an effort to prevent skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who had gastrostomy tubes (G-Tube, tube placed through the abdomen into the stomach, for feedings, liquids and medications), in place to meet their nutritional care needs, the Facility failed to ensure their nutritional status' including body weights, were adequately monitored by nursing in an effort to maintain acceptable parameters related to nutrition to prevent unplanned/undesired weight loss, when Resident #1 experienced an unplanned significant weight loss of 15% in three months, and Resident #2 experienced an unplanned significant weight loss of 20% in a six month period. Findings include: The Facility Policy titled Weight Monitoring, dated 12/22/22, indicated that the Facility will: - Ensure that residents maintain acceptable parameters of nutritional status. - The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss. - The nursing staff will measure weights on admission, and weekly for three weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria for a time period of : - One month - 5% weight loss is significant - Three months - 7.5 % weight loss is significant - Six months - 10% weight loss is significant The Facility Policy titled Intake and Output, dated 12/06/22, indicated that intake and output amounts (the measurement of the fluids that enter the body (intake) and the fluids that leave the body (output), which is essential in assessing calorie intake and fluid balance), will be performed when a resident has a tube feeding, and which will include the amount administered. 1. Resident #1 was admitted to the Facility in August 2022, diagnoses included acute respiratory failure, pneumonia, asthma, a cerebrovascular accident with dysarthria (difficulty speaking), and dysphagia (difficulty swallowing). Resident #1's Nutrition Care Plan, dated 9/02/22, indicated he/she was at risk for unintended weight changes due to medical co-morbidities of dysarthria, dysphagia and diuretic usage. Nutrition interventions included to tolerate diet texture without difficulty, he/she will have an oral intake of 50% or more. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact, required supervision with eating, did not have malnutrition, and had generalized muscle weakness. The MDS indicated Resident #1 weighed 146 lbs., had no weight loss, was treated with a mechanically altered diet, and did not have a feeding tube. During an interview on 3/08/23 at 1:55 P.M., the Dietician said she had identified on 9/09/22, that Resident #1 had been assessed as being at risk for weight loss, that weekly weights should have been obtained by nursing to help monitor and identify any weight loss, but that weights were not being obtained consistently. Review of Resident #1's medical record indicated that based on blood laboratory work his/her baseline albumin levels (an indicator of nutritional status, normal range 3.2 to 5 g/dl) were 3.1 grams/deciliter (g/dl) on 8/31/22 and 3.3 g/dl on 9/08/22, both of which were within normal limits. Review of Resident #1's Comprehensive Nutrition Assessment, dated 9/09/22, indicated that his/her admission weight was 146.2 lbs., with a Body Mass index (BMI - weight in kilograms divided by height squared, an indication of body fat & to identify weight problems) of 26.7. The Assessment indicated an identified risk factor for weight loss, was a BMI between 18 to 26, and no unplanned weight loss was desired for him/her. The Assessment indicated Resident #1's food intake was less than 50% of his/her required need, and that Resident #1 had swallowing and chewing difficulties. The Assessment indicated Speech Language Pathologist recommended he/she required puree consistency (foods that have soft pudding like consistency/nectar) with thickened liquids (a thick liquid), that both were needed for residents with swallowing problems to prevent the liquids from entering the lungs. The Assessment indicated Resident #1 had failed a modified barium swallow (a type of X-ray to evaluate swallowing problems), indicating he/she was unable to adequately swallow. Review of Resident #1's Comprehensive Nutrition Assessment, dated 12/19/22, indicated he/she weighed 124.6 lbs. on 12/07/22 (a significant weight loss of 22 lbs. in 3 months), and he/she had a BMI of 22.8 (previously 26.7, a 14.6 % decrease in BMI). The Assessment indicated Resident #1's appetite had been poor, he/she was not eating meals consistently, insertion of a G-tube had been discussed with Resident #1, and was being placed 12/20/22. Review of Resident #1's Weights and Vital Sign Summary indicated his/her weights were recorded as follows: - 8/30/22 documented as 146.2 lbs. - 11/02/22 documented as 140.8 lbs. - 12/07/22 documented as 124.6 lbs. There was no documentation to support Resident #1's weekly weight was obtained on: 11/09/22, 11/16/22, 11/23/22, or 11/30/22. Review of Resident #1's Nursing Progress Note, dated 12/20/22, indicated he/she returned from a Gastrointestinal appointment with the placement of a G-tube. Review of Resident #1's Physician's Order, dated 12/21/22, indicated to maintain the G-tube feeding at 85 milliliters (ml) an hour continuously with water flushes 85 ml every four hours. Review of Resident #1's Nursing Progress Note, dated 12/26/22, indicated that Resident #1's continuous G-tube feeding had been disconnected at 9:00 P.M., without an order for the tube feeding to be stopped. The Note indicated that the nurse who found the disconnected tube feeding attempted to flush his/her G-tube and found that it was clogged. The Note indicated the Physician Assistant was notified and Resident #1 was sent to the Hospital to have his/her G-tube unclogged. Review of Resident #1's Significant Change Minimum Data Set (MDS), dated [DATE], he/she weighed 124 lbs. (a significant weight loss of 15% of body weight over the past 3 months, a weight loss of 22 lbs.). The MDS indicated his/her percent intake by a tube feeding or parenteral route was 51% or more. Review of Resident #1's Weights and Vital Sign Summary indicated that on 1/18/23, he/she weighed 118 lbs. There was no documentation to support Resident #1's week weight was obtained on 12/14/22, 12/21/22, 12/28/22, 1/04/23, and 1/11/23. During an interview on 3/08/23 at 10:20 A.M., the Director of Nursing said nursing had not obtained weekly weights for Resident #1, as required. Review of Resident #1's Nutritional Care Plan, updated, 1/16/23, after he/she had a G-tube placed indicated interventions included, to monitor the intake and output and record each meal. However, Resident #1's G-tube feedings started on 12/21/22, and Intake and Output should have monitored and documented affective 12/21/22, per facility policy. During an interview on 3/07/23 at 11:10 A.M., Nurse #1 said during the 11:00 P.M. to 7:00 A.M. shift, when the G-tube feeding bottles needed to be replaced with a new bottle, the nurses on that shift, were not consistently hanging a new bottle, and that nurses needed to know how to manage and care for residents with tube feedings. Nurse #1 said the nurses were also not consistently flushing the G-tube, which resulted in the G-tubes becoming frequently clogged, the G-tube feedings not being delivered, and the residents' not receiving adequate hydration and nutritional intake. Review of Resident #1's Social Service Note, dated 1/09/23, a late entry for 1/08/23, indicated Resident #1 was transferred to the hospital on 1/08/23, after not receiving his/her G-tube feeding back to 1/05/23 (1/06/23 at 2:10 P.M. until 1/8/23 at 2:10 P.M.). Review of Resident #1's Nursing Progress Note, dated 1/08/23, indicated Resident #1's G-tube feeding bottle, dated 1/05/23 (indicating when it was first hung for administration, and should be removed 24 hours later, on 1/06/23 at 2:10 P.M., and replaced with a new tube feeding bottle) was empty and still attached to the G-tube. Resident #1 was transferred to the Emergency Department for a (clogged) G-tube. Review of Resident #1's Dietary Nutrition Note, dated 1/30/23, indicated that the Nurse Progress Note on 1/08/23 indicated the tube feed bottle from 1/05/23 was still hanging (it was empty), he/she was sent out to the hospital. Review of Resident #1's Hospital blood laboratory work, dated 1/08/23, indicated that his/her albumin level (a marker that reflects malnutrition) was low at 2.5 g/dl (normal range 3.2 to 5.0 g/dl) Review of Resident #1's Facility Physician Progress Note, dated 1/12/23, indicated he/she was alert, oriented to person, place and situation, was thin cachectic (wasting of the body) with severe dysarthria, and dysphagia with severe malnutrition. Review of Resident #1's medical record, from December 2022 through March 2023 (up to and including the dates of this survey) indicated there was no documentation to support intake and output was monitored or recorded by nursing regarding his/her continuous G-tube feedings. Review of Resident #1's Physician Progress Note, dated 1/19/23, indicated a G-tube insertion was recently performed due to his/her malnutrition and dysphagia, continue tube feedings, with dietary services to follow for adequate nutrition. Review of Resident #1's Dietary Nutrition Note, dated 1/30/23, indicated that per the Nursing staff, it was reported that Resident #1 did not receive 100% of his/her nutrition on 1/18/23 and 1/19/23. The Note also indicated that staff said that Resident #1's tube feeding bottle was not replaced on the overnight shift the previous night on 1/17/23 into 1/18/23. The Note indicated that on 01/19/23, both Resident #1 and Resident #4 (Resident #1's roommate) reported that the feeding tube machine was beeping all night, indicating there was an issue with the tube feeding, such as being empty or occluded (blocked) G-tube. The Dietary Note indicated a new tube feeding bottle was hung on 1/20/23 at the start of the 7:00 A.M. to 3:00 P.M. shift. The Dietary Note indicated there were no nurse progress notes reporting issues with the tube feeding on either occasion (as required for accurate documentation of changes in intake). The Note indicated Resident #1 continued documented weight loss even with multiple increases in tube feed rates and volumes to provide gradual weight gain. Review of Resident #1's blood laboratory work, dated 1/30/23, indicated he/she had a severely low albumin level of 1.9 g/dl (indicative of severe malnutrition). During an interview on 3/08/23 at 1:30 P.M., the Dietician said in January 2022, Resident #1's oral intake was not significant, that he/she took in only a cup of coffee or ginger ale for pleasure, his/her primary intake was the G-tube feedings. The Dietician said Resident #1 had severe weight loss of 11.5% in a month from November 2022 to December 2022. The Dietician said she was concerned that Resident #1 was not getting his/her tube feeds and informed the Director of Nurses. 2. Resident #2 was admitted to the Facility in June 2022, diagnoses included a cerebrovascular accident with hemiplegia (paralysis on one side of the body) with severe aphasia, dysphagia and congestive heart failure. Resident #2's Nutrition Care Plan, dated 6/20/22, indicated he/she required tube feedings, secondary to dysphagia, and was at risk of malnutrition, and to maintain stable weights. The Care Plan indicated interventions included he/she was dependent with G-tube feedings and required water flushes (for maintaining patency & hydration) and to obtain weights as ordered. Administer continuous G-tube feedings, with G-tube flushes of water flushes every 4 hours. Review of Resident #2's admission Minimum Data Set (MDS), dated [DATE], indicated he/she was moderately cognitively impaired, and with eating he/she required extensive assist of one person. The MDS indicated Resident #2 had a feeding tube and the percent of intake by a tube feeding or parenteral route was 51% or more. Review of Resident #2's Weights and Vital Sign Summary indicated his/her weights were recorded as follows: - 7/19/22 documented as 265.7 lbs. - 8/14/22 documented as 256 lbs. - 9/10/22 documented as 240.5 lbs. - 10/05/22 documented as 230.4 lbs. Review of Resident #2's Quarterly MDS, dated [DATE], he/she weighed 211 lbs., had a 5% of body weight loss or greater while not on a physician prescribed diet for a weight loss. Review of Resident #2's Physician's Orders, dated 11/21/22, indicated his/her diet order was for NPO (nothing by mouth), with continuous enteral G-tube feedings Glucerna 1.2, run at 75 milliliters rate per hour. Further review of Resident #2's Weights and Vital Sign Summary indicated his/her weights were recorded as follows: - 12/25/22 documented as 209.5 lbs. - 01/09/23 documented as 212 lbs. - 02/13/23 documented as 204 lbs. - 03/06/23 documented as 200.2 lbs. Further review of Resident #2's Weights and Vital Sign Summary indicated he/she had a 20% weight loss over 6 months (between 7/19/22 to 1/09/23), a total of 53.7 lbs. weight loss. Review of Resident #2's Comprehensive Nutrition Assessment, dated 2/13/23, indicated that he/she weighed 204 lbs. on 2/13/23, which was a significant weight loss. During an interview on 3/08/23 at 2:10 P.M., the Dietician said Resident #2 had significant unintentional weight loss of greater than 7.5% in three months. Review of Resident #2's medical record, from November 2022 through March 2023 (up to and including the dates of this survey) indicated there was no documentation to support intake and output was monitored or recorded by nursing regarding his/her continuous G-tube feedings. During an interview on 3/08/23 at 10:10 A.M., the Director of Nurses said Resident #1's weights should have been obtained and recorded as ordered by the Physician. The DON said that Resident #1 and Resident #2 would not have experienced significant weight loss while receiving nutrition via G-tubes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who had gastrostomy tubes (G-tube, placed through the abdomen into the stomach, for feedings, liquids and medications) in place to meet their nutritional and fluid intake needs, and whose physician's orders included parameters for daily administration of formula feeds and water flushes, the Facility failed to ensure that Resident #1 and Resident #2 were provided with appropriate treatment and services in an effort to prevent potential complications associated with G-tubes (such as clogged G-tubes, dehydration, aspiration pneumonia, diarrhea, vomiting, metabolic abnormalities). Resident #1 experienced multiple complications associated with having a G-tube including dehydration, clogged G-tube, weight loss, and required transfer and admission to the Hospital. Resident #2 experienced multiple complications associated with having a G-tube including dehydration, clogged G-tube, vomiting, diarrhea, and also required transfer and admission to the Hospital. Findings include: The Facility Policy titled Enteral Feedings (nutrition administered via the gastrointestinal tract), dated 12/06/22, indicated that the Facility was to ensure the following: - Safe administration of enteral nutrition - Closed system enteral nutrition formulas have a hang time of 24-48 hours, per manufacturer's instructions. - Administer only full-strength feeding tube formulas. - Always elevate the head of the bed at least 30 to 45 degrees during tube feeding. - Recognize the risk factors for aspiration, including being in a supine position, and vomiting. The Facility Policy titled Intake and Output, dated 2/06/22, indicated that the Facility will implement intake and output measurements of the tube feeding amounts and water flushes administered. The nursing staff are to observe for fluid deficits, use an intake and output record to track resident's fluid intake and write each resident's fluid recommendations. Nursing Assistants will utilize intake and output worksheets and will total the amount of intake at the end of each shift. 1. Resident #1 was admitted to the Facility in August 2022, diagnoses included acute respiratory failure, pneumonia, asthma, a cerebrovascular accident with dysarthria (difficulty speaking), and dysphagia (difficulty swallowing). Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact, required supervision with eating, did not have malnutrition, had generalized muscle weakness. The MDS indicated Resident #1 had no weight loss, was treated with a mechanically altered diet and did not have a feeding tube. Review of Resident #1's Comprehensive Nutrition Assessment, dated 12/19/22, indicated he/she required an estimated minimum of fluid intake of 1,403 milliliters (ml) daily. Review of Resident #1's Nursing Progress Note, dated 12/20/22, indicated he/she returned from a Gastrointestinal appointment, with the placement of a G-tube (secondary to severe dysphagia). Review of Resident #1's Physician's Order, dated 12/21/22, indicated to maintain the G-tube feeding at 85 ml an hour continuously with water flushes of 85 ml every four hours. Review of Resident #1's Physician's Order, dated 12/22/22, indicated he/she was to receive nothing by mouth (NPO). Review of the Physician's Order, dated 12/26/22, indicated to administer Osmolite 1.2 via a tube feed continuously, at 54 ml an hour. Review of Resident #1's Nursing Progress Note, dated 12/26/22, indicated that Resident #1's continuous feeding had been disconnected at 9:00 P.M., without an order for the tube feeding to be stopped. The Note indicated that the nurse who found the disconnected tube feeding, attempted to flush his/her G-tube and it was clogged. The Note indicated the Physician Assistant was notified and Resident #1 was sent to the Hospital to have his/her G-tube unclogged, and he/she was transferred back to the Facility. Review of Resident #1's Dietician's Recommendations, dated 1/06/23, indicated to increase Osmolite 1.2 continuous tube feed to 64 ml an hour, with water flushes increased to 90 ml an hour, six times a day. Further review of the Dietician's Recommendations indicated that the Nursing Supervisor verified the recommendations by signing it, and the new order was supposed to be transferred to the electronic order entry system. Review of Resident #1's Physician's Order, dated 1/06/23, indicated the following; - the previous physician's orders for Osomolite 54 ml an hour and water flushes were discontinued. - however, although there were new orders for Osmolite 1.2 tube feeding to be administered continuously at an increased rate of 64 ml an hour and water flushes of 90 ml six times a day, the new orders had not been not activated. Review of Resident #1's Nursing Progress Note, dated 1/08/23, indicated Resident #1's G-tube feeding bottle, dated 1/05/23 (indicating when it was first hung for administration, and should be removed 24 hours later, on 1/06/23 at 2:10 P.M., and replaced with a new tube feeding bottle) was empty and still attached to the G-tube. Resident #1 was transferred to the Emergency Department for a (clogged) G-tube. Review of Resident #1's medical record from December 2022 through March 2023 (up through and including the dates of this survey) indicated there was no documentation to support that his/her intake and output was monitored or recorded by nursing for his/her continuous G-tube feeding and water flushes. Review of Resident #1's Hospital Emergency Department Physician's Progress Note, dated 1/08/23, indicated he/she was evaluated for a clogged G-tube which resolved with warm saline flushes. The Emergency Medical Staff reported that Resident #1 has not had a G-tube feeding for the last two days. The Note indicated Resident #1's physical examination indicated he/she had dry oral mucosa (an indicator of dehydration) and an elevated BUN of 32 mg/dl (which is an indicator of inadequate hydration). Review of Resident #1's laboratory work at the Facility, indicated his/her 10/25/22 and 11/15/22 baseline blood urea nitrogen (BUN, indicator of kidney function, normal range 5 milligrams/deciliter, mg/dl) ) on 10/25/22 was 11 mg/dl and on 11/15/22 it was 12 mg/dl, both of which were within normal limits. Review of Resident #1's Blood Laboratory work on 1/09/23, (completed at the facility) indicated his/her BUN remained elevated at 34 mg/dl. During an interview on 3/07/23 at 11:10 A.M., Nurse #1 said during the 11:00 P.M. to 7:00 A.M. shift, when the G-tube feeding bottles needed to be replaced with a new bottle, the nurses on that shift, were not consistently hanging a new bottle, and that nurses needed to know how to manage and care for residents with tube feedings. Nurse #1 said the nurses were also not consistently flushing the G-tube, which resulted in the G-tubes becoming frequently clogged, the G-tube feedings not being delivered, and the residents' not receiving adequate hydration and nutritional intake. During an interview on 3/07/23 at 1:45 P.M., Resident #4 said he/she was Resident #1's roommate and that there were issues with Resident #1's tube feedings, due to Resident #1's feeding pump alarming frequently for approximately two hours during the evening and night shifts, before Resident #1's tube feeding alarm was addressed by the nursing staff. Review of the Facility Investigation, dated 1/08/23, indicated that Nurse #4 found Resident #1's G-tube feeding empty, and dated 1/05/23 at 2:10 P.M. (indicating when this feeding bottle was hung), and to be administered for the next 24 hours (until 1/06/23 at 2:10 P.M.), with no new tube feeding hung on 1/06/23 or on 1/07/23. The Investigation indicated that for these two days (1/06/23 and 1/07/23) Resident #1 was not administered a tube feeding. The Investigation indicated that on 1/06/23 at 5:00 P.M., the Dietician recommended to increase the rate of the Resident #1's Osmolite 1.2 tube feeding from 54 ml an hour to 64 ml an hour. During an interview on 3/08/23 at 10:08 A.M., the Director of Nurses (DON) said that when the Dietician recommended to increase both Resident #1's tube feed rate and water flushes, the old order was discontinued. The DON said that the nurse did not confirm the new G-tube order to activate this order in the Medication Administration Record (MAR) and Treatment Administration Record (TAR), and that were no active orders on his/her MAR or TAR as a result. Review of Resident #1's Dietary Nutrition Note, dated 1/30/23, indicated that per Nursing staff, during the 7:00 A.M. to 3:00 P.M. shift, Resident #1's tube feeding bottle was found completely empty from the 11:00 P.M. to 7:00 A.M. shift, and the Dietician was unsure as to what time Resident #1's G-tube feeding bottle ran out. Review of Resident #1's MAR, dated January 2023, indicated the Osmolite 1.2 continuous G-tube feeding at 54 ml per hour was not administered on: - 1/06/23 during the 3:00 P.M. to 11:00 P.M. shift - 1/07/23 during the 7:00 A.M. to 3:00 P.M. shift - 1/07/23 during the 3:00 P.M. to 11:00 P.M. shift - 1/07/23 during the 11:00 P.M. to 7:00 A.M. shift - 1/08/23 during the early morning of the 7:00 A.M. to 3:00 P.M. shift Review of Resident #1's MAR, dated January 2023, indicated the G-tube flushes of 85 ml ordered to be administered six times a day were not administered on: - 1/06/23 at 8:00 P.M. - 1/07/23 at 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and at 8:00 P.M. During an interview on 3/07/23 at 1:20 P.M., the Director of Nurses (DON) said Resident #1's continuous tube feed that was hung on 1/05/23 at 2:10 P.M. would have finished infusing at 1/06/23 at 2:10 P.M., so from 1/06/23 at 2:10 P.M. until 1/08/23 in the morning, approximately for 42 hours there was no intake for Resident #1 (a deficit of 2,268 ml of feeding formula). The DON said that Resident #1 had not received his/her water flushes of 85 ml six times per day (a deficient 765 ml of water). Review of Resident #1's Physician's Order, dated 1/10/23, indicated to administer intravenous fluids (IV), Normal Saline 0.9% a 500 ml bag at a rate of 60 ml an hour for hydration. The Intravenous Nurse Form, dated 1/10/23, indicated a single lumen catheter was started for the administration of intravenous fluids, due to Resident #1's dehydration. Review of Resident #1's Nursing Progress Note, dated 1/30/23 at 7:35 A.M., indicated this Nurse found that his/her G-tube feeding bottle Osmolite 1.2, was empty (this was a continuous feeding), this Nurse was not sure how long the feeding bottle was empty. The Note indicated the Physician Assistant was notified due to Resident #1 having chest pain and he/she was transferred to the Hospital. The surveyors requested to review Physician Assistant #1's Progress Notes and Resident #1's blood laboratory work from January 2023, that were not located or accessible in the medical record, however despite multiple request made by the surveyors, the documentation was not provided. Review of Resident #1's Blood Laboratory values provided by the Dietician, dated 1/30/23 indicated his/her albumin level (indicator of liver and kidney functions, normal range 3.4 to 5.4 grams per deciliter, g/dl) was severely low at 1.9 grams per deciliter (g/dl), which is indicative of severe malnutrition, and Resident #1's BUN remained elevated at 40 mg/dl, which was indicative of dehydration. Review of Resident #1's Hospital Emergency Department Physician's Progress Note, dated 1/30/23, indicated he/she was in respiratory failure, sepsis and was quite dehydrated, on physical examination had dry mucous membranes, an elevated BUN of 44 mg/dl (indicative of dehydration) and was treated with intravenous fluids. His/her albumin level was extremely low 2.1 g/dl, (indicative of severe malnutrition). Resident #1's CT scans demonstrate atelectasis (a lung condition that happens when the tiny sacs of the lungs don't expand) versus pneumonia, although based on his/her presentation, probably pneumonia, treated with intravenous antibiotics. Resident #1 had hypercapnia (excessive carbon dioxide retention), he/she was offered and declined BiPAP (a non-invasive form of ventilation). Resident #1 also had a sacral wound with sacrococcygeal osteomyelitis (a pressure sore with an underlying bone infection of the sacrum and coccyx). Resident #1 was admitted to the Hospital, and discussion with Resident's and Health Care Agent indicated that if his/he condition declined, they wanted no aggressive therapy, and he/she was treated with comfort care. 2A. Resident #2 was admitted to the Facility in June 2022, diagnoses included a cerebrovascular accident with hemiplegia (paralysis on one side of the body) with severe aphasia, dysphagia and congestive heart failure. Review of Resident #2's Comprehensive Nutrition Assessment, dated 6/16/22, indicated he/she required an estimated minimum of fluid intake of 1,929 milliliters (ml) daily. Review of Resident #2's admission Minimum Data Set (MDS), dated [DATE], indicated he/she was moderately cognitively impaired, required an extensive assist with one person with eating, had a feeding tube, with an average intake by the tube feeding was 501 ml or more per day. Review of Resident #2's Physician's Order, dated 8/21/22, indicated he/she was NPO, and to administer Glucerna 1.2, at a rate of 75 ml per hour every 24 hours continuously via a G-tube, and ensure the feeding is running properly. Review of Resident #2's Physician Orders, dated 9/27/22, indicated for his/her G-tube water flushes to administer 120 ml three times a day. Review of Resident #2's dysphagia and tube feeding care plan, with a revision date of 10/15/22, indicated the goal was for him/her to maintain adequate hydration status, interventions included, administer tube feedings and water flushes as ordered, since he/she was dependent. Ensure that Resident #2's head of the bed is elevated at least 45 degrees during and thirty minutes after the tube feeding. Review of Resident #2's Nursing Progress Note, dated 10/19/22 indicated he/she was readmitted from the Hospital with diagnoses of hypernatremia (an elevated sodium level), acute kidney injury and poor hydration. Review of Resident #2 Physician Orders, dated 10/28/22, indicated for his/her G-tube feeding to administer Glucerca 1.2 at a rate of 90 ml an hour for 14 hours (an overnight feeding). During an interview on 3/08/23 at 1:30 P.M., the Dietician said that Resident #2's oral intake was less than 50 ml per meal, he/she was not eating enough orally. Review of Resident #2's medical record, from November 2022 through March 2023 (up to and including the dates of this survey) indicated there was no documentation to support intake and output (performed to determine fluid deficits, is an essential component in resident assessments inadequate amounts are an indicator of dehydration) was monitored or recorded by nursing regarding his/her continuous G-tube feedings. Review of Resident #2's Blood Laboratory work indicated the following: -8/16/22, sodium level (indicator of hydration, normal range 135 to 145 Milliequivalents per deciliter, MEq/dl) was 138 mEq/dl, and within normal limits. -11/14/22, BUN level (normal range 5 mg/dl to 25 mg/dl) was elevated at 44 mg/dl -11/14/22, his/her sodium level was elevated at 149 mg/dl, -both of which were indicators of dehydration Review of Resident #2's Nursing Progress Note, dated 11/15/22, indicated there was a change in Resident #2's condition, he/she was transferred to the Hospital for abnormal laboratory work, high sodium and (BUN) creatinine levels (both are indicators of dehydration). Review of Resident #2's Hospital Emergency Department Physician's Progress Note, dated 11/15/22, indicated Resident #2 was G-tube dependent for nutrition and presented with abnormal laboratory work, he/she had an elevated sodium level of 149 mg/dl, an elevate BUN level of 45 mg/dl, and an elevated creatinine level of 3.76 (an indication of dehydration and kidney function). The Note indicated Resident #2 was having diarrhea during transport, and physical examination indicated he/she had moderately dry oral mucosa and was hypotensive with systolic blood pressures in the 60's and 90's (normal greater than 100). The Note indicated he/she had a severe acute kidney injury (which can occur from dehydration), he/she was treated and responsive to intravenous fluid resuscitation. The Note indicated Resident #2's hypotension and elevated laboratory work were a concern for significant dehydration. 2B. Review of Resident #2's Physician Order, dated January 2023, indicated water flushes of 120 ml four times a day via the G-tube, and were to be administered starting from 1/01/23 at 5:00 A.M. until 1/22/23 at 6:00 A.M. Review of Resident #2 medical record indicated he/she was hospitalized on [DATE] secondary to vomiting, discharged [DATE] and readmitted to the Facility. Review of Resident #2's Physician's Order, dated 1/24/23, indicated to increase the water flushes, nursing to administer 240 milliliters of water six times a day for four days, via the G-tube for hydration and patency. Review of Resident #2's MAR, dated January 2023, indicated the increased G-tube water flushes of 240 milliliters, six times a day for four days, to be administered from 1/24/23 at 10:00 P.M. until 1/28/23 at 7:00 A.M., as ordered. Further review of Resident #2's MAR for G-tube water flushes, indicated that after being administered additional water flushes for four days as ordered until 1/28/23, his/her previous water flush order for 120 milliliters of water every 6 hours, was not resumed by nursing. Therefore, three water flushes (a total of 360 ml water) were not administered (for hydration and G-tube patency). Review of Resident #2's Nurses Note, dated 1/29/23 at 8:00 A.M., indicated during medication pass, his/her G-tube was clogged, the Nurse unclogged the G-tube with warm water and the tube was flushed. Review of Resident #2's Dietary Note, dated 2/13/23, indicated that Resident #2 was hospitalized for a diagnosis of vomiting (he/she had a history of a neurogenic sigmoid) from 1/21/23 through 1/24/23. He/she was transferred back to the Facility with an order for increased water flushes for four days. The water flushes were not resumed in the physician orders when the increased water flushes were discontinued after four days. During an interview on 3/08/23 at 2:50 P.M., the Director of Nurses said she expected that Resident #2's G-tube flushes of 120 cc every six hours should have been resumed, but three doses (for a total of 360 ml of water) were not administered. 2C. Review of the Nurses Progress Note, dated 1/26/23 at 4:48 P.M., indicated the nurse found Resident #2 vomiting on him/herself, Resident #2's head of the bed was not elevated appropriately, the Nurse reminded the Certified Nurse Aides to keep the head of the bed elevated at 30 degrees, when his/her G-tube feeding was running. During an interview on 3/07/23 at 2:50 P.M., the DON said Resident #2 had his/her tube feeding running when the head of the bed was not elevated, and the staff have been educated regarding appropriately raising the head of the bed greater than 30 degrees. Review of the Educational Records for three Nurses (Nurse #4, Nurse #5 and Nurse #6) who worked the 11 P.M. to 7:00 A.M. shift on Resident #1's and Resident #2's Unit, indicated they did not have education or training with G-tube feedings or hydration. During an interview on 3/07/23 at 1:50 P.M., the Director of Nurses (DON) said that there was a problem with enteral feedings not being administered continuously and water flushes not being administered as ordered. During an interview on 3/08/23 at 10:15 A.M. during review of the audit results, the Director of Nurses said that monitoring resident intake and output was not recognized by the Nursing Supervisor who performed the audit as being needed for G-tube feedings, and that the intake and output documentation had not been performed for the residents with G-tubes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed by nursing as being at an increased risk for falls and who required hands on assistance of one staff member for safe transfers, the Facility failed to ensure staff consistently implemented and followed interventions from his/her plan of care related to his/her individual safety needs related to transfers and mobility. On 12/07/22 during the overnight shift, a Certified Nurse Aide left Resident #1 standing alone in front of the toilet, while she went to get an incontinence brief. Resident #1 lost his/her balance and fell. Resident #1 was later transferred to the Hospital Emergency Department where he/she was diagnosed with a right femur (thigh bone) fracture and was admitted for further treatment. Findings include: Review of the Facility's Policy, titled Fall Reduction, dated as revised 07/26/21, indicated the Facility would implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based on the individual's needs. Review of the Facility's Policy, titled Comprehensive Care Plan, undated, indicated assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition changes. Resident #1 was admitted to the facility in October 2022, diagnoses included syncope (fainting) and collapse, Meniere's disease (disorder of the inner ear that can lead to dizzy spells and hearing loss), osteoarthritis, hypertension, unspecified fall, and personal history of healed traumatic fracture. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 10/31/22, indicated that his/her cognitive patterns were intact, with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS indicated Resident #1 required extensive physical assistance from one staff member for toileting, transfers, and ambulation. Review of Resident #1's Alteration in Ability to Complete Activities of Daily Living (ADL) Care Plan, dated as revised 11/01/22, indicated he/she required use of a rolling walker and assistance of two staff members for toileting, when ambulating and/or transferring. Review of Resident #1's At Risk for Falls Care Plan, dated as revised 11/15/22, indicated he/she was at risk for falls due to deconditioning, gait and balance problems, vision and hearing problems, and a history of falls prior to admission. The Care Plan indicated the goal was for Resident #1 to remain free from falls through 01/30/23. Review of Resident #1's Physical Therapy (PT) Discharge summary, dated [DATE], indicated Resident #1 required contact guard to moderate assistance from one staff member for all functional transfers. Review of the Facility's Incident Report, dated 12/07/22, indicated that Certified Nurse Aide (CNA) #1 called out for help because Resident #1 had fallen in the bathroom. The Report indicated CNA #1 had Resident #1 stand up at the toilet, when suddenly he/she fell in the opposite direction and CNA #1 could not reach over the walker to grab him/her. During an interview on 01/03/23 at 2:57 P.M., Nurse #1 said that CNA #1 called her into Resident #1's room and told her that Resident #1 stood and fell, while she (CNA #1) had gone to get a brief. Nurse #1 said CNA #1 told her she tried to grab Resident #1 to prevent the fall, but that he/she was too heavy, and fell in the opposite direction. Nurse #1 said she assessed Resident #1 and noted his/her right leg was rotated and appeared to be fractured, and he/she was transferred to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated Resident #1 was admitted to the hospital on [DATE] and diagnosed with a right femur fracture for which he/she underwent surgical repair. The Summary Indicated Resident #1's hospital stay was further complicated by hemorrhagic blood loss, likely due to surgery, requiring six units of blood. During an interview on 01/03/23 at 11:30 A.M., Resident #1 said he/she had a fall at the beginning of December that resulted in a broken hip, when a female CNA (later identified as CNA #1) walked him/her to the toilet with his/her walker and said the CNA #1 left the bathroom while he/she stood at the walker unassisted, and tried to pull down his/her brief. Resident #1 said CNA #1 was not in the bathroom with him/her, that CNA #1 was in his/her room near the foot of his/her bed, when he/she lost his/her balance and fell. Resident #1 said CNA #1 could not have reached him/her to prevent the fall, because she (CNA #1) was not even in the bathroom. During an interview on 01/03/23 at 2:35 P.M., Certified Nurse Aide (CNA) #1 said that during her overnight shift on 12/07/22, Resident #1 required toileting every 30 to 45 minutes and said that was unusual. CNA #1 said that she got Resident #1 up from bed around 5:00 A.M. to take him/her to the bathroom and that Resident #1 got dizzy while transferring out of the bed. CNA #1 said she then ambulated Resident #1 to the bathroom with his/her rolling walker and positioned him/her in front of the toilet. CNA #1 said that while Resident #1 stood at the walker and pulled down his/her clothing, she went to a get a clean brief from a dresser (in Resident #1's room ) that was just outside the bathroom door. CNA #1 said she did not provide hands on assistance while Resident #1 stood at the walker in the bathroom and managed his/her clothing. CNA #1 said that in the time it took her to turn around and leave the bathroom to get a brief, said Resident #1 lost his/her balance while trying to sit down on the toilet. CNA #1 said she tried to stop the fall, but Resident #1's walker was in the way, and she only got a hold of Resident #1's hospital gown. On 01/03/23 at 11:30 AM, the surveyor observed that Resident #1's bathroom was located directly across from the foot of his/her bed and a dresser was positioned outside of the bathroom door. During an interview on 01/03/22 at 3:15 P.M., the Director of Rehabilitation (DOR) said that Resident #1 was on PT and OT services prior to the fall and required varying levels of staff assistance with transfers and toileting. The DOR said Resident #1 required minimal assistance of one staff member for ambulation, transfers and toileting with a rolling walker. The DOR said Resident #1 had not been deemed safe for independent or supervised functional transfers and that Resident #1 would be unsafe if hands on assistance was not provided while standing. During an interview on 01/03/23 at 4:40 P.M., the Corporate Director of Clinical Services said Resident #1's ADL Care Plan, that was in effect at the time of the 12/07/22 fall, indicated he/she required physical assistance from two staff members with transfers and toileting. The Corporate Clinical Specialist said the Care Plan should have been updated to reflect the PT recommendations for assistance of one staff member for transfers as recommended by therapy. During the interview the Corporate Clinical Specialist was made aware that both Resident #1 and CNA #1, said in their interviews with the surveyor, that Resident #1 was left standing alone in the bathroom with his/her walker at the toilet, while CNA #1 went to get a brief from the dresser in the room, and that was when Resident #1 lost his/her balance and fell. The Corporate Clinical Specialist said the Care Plan and the PT recommendations indicated hands on assistance was required for safe transfers, therefore the Care Plan interventions were not implemented by CNA #1, when she left Resident #1 standing alone in the bathroom on 12/07/22, resulting in a fall with a fracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records reviewed and interviews for one of three sampled residents (Resident #1), who required hands on assistance of one staff member during transfers and ambulation, the Facility failed to ensure staff provided adequate assistance during a transfer to maintain his/her safety in an effort to prevent an incident and/or accident resulting in an injury, when on 12/07/22 during the overnight shift, a Certified Nurse Aide (CNA) left Resident #1 standing alone, unassisted, in front of the toilet, and left the bathroom to get an incontinence brief. Resident #1 lost his/her balance and fell while the CNA had stepped away. Resident #1 was later transferred to the Hospital Emergency Department where he/she was diagnosed with a right femur (thigh bone) fracture, he/she was admitted and required surgical intervention to repair the fracture. Findings include: Review of the Facility's Policy, titled Fall Reduction, dated as revised 07/26/21, indicated the Facility would implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based on the individual's needs. Resident #1 was admitted to the facility in October 2022, diagnoses included syncope (fainting) and collapse, Meniere's disease (disorder of the inner ear that can lead to dizzy spells and hearing loss), osteoarthritis, hypertension, unspecified fall, and personal history of healed traumatic fracture. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 10/31/22, indicated that his/her cognitive patterns were intact, with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS indicated Resident #1 required extensive physical assistance from one staff member for toileting, transfers, and ambulation. Review of Resident #1's Alteration in Ability to Complete Activities of Daily Living (ADL) Care Plan, dated as revised 11/01/22, indicated he/she required a rolling walker and assistance of two staff for toileting, when ambulating and/or transferring. Review of Resident #1's At Risk for Falls Care Plan, dated as revised 11/15/22, indicated he/she was at risk for falls due to deconditioning, gait and balance problems, vision and hearing problems and a history of falls prior to admission. The Care Plan indicated a goal that Resident #1 would remain free from falls through 01/30/23. Review of Resident #1's Physical Therapy (PT) Discharge summary, dated [DATE], indicated Resident #1 required contact guard to moderate assistance from one staff member for all functional transfers. Review of the Facility's Incident Report, dated 12/07/22, indicated that Certified Nurse Aide (CNA) #1 called out for help because Resident #1 had fallen in the bathroom. The Report indicated CNA #1 had Resident #1 stand up at the toilet, when suddenly he/she fell in the opposite direction and CNA #1 could not reach over the walker to grab him/her. During an interview on 01/03/23 at 2:57 P.M., Nurse #1 said that CNA #1 called her into Resident #1's room and said that Resident #1 stood and fell, while she had gone to get a brief. Nurse #1 said CNA #1 told her she tried to grab Resident #1 to prevent the fall, but he/she was too heavy and fell in the opposite direction. Nurse #1 said she assessed Resident #1, noted his/her right leg was rotated and appeared to be fractured, and he/she was transferred to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated Resident #1 was admitted to the hospital on [DATE] and diagnosed with a right femur fracture for which he/she underwent surgical repair. The Summary Indicated Resident #1's hospital stay was further complicated by hemorrhagic blood loss, likely due to surgery, requiring six units of blood. During an interview on 01/03/23 at 11:30 A.M., Resident #1 said he/she had a fall at the beginning of December that resulted in a broken hip, when a female CNA (later identified as CNA #1) walked him/her to the toilet with his/her walker and CNA #1 left the bathroom while he/she stood at the walker unassisted, and tried to pull down his/her brief. Resident #1 said CNA #1 was not in the bathroom with him/her, that CNA #1 was in his/her room near the foot of his/her bed, when he/she lost his/her balance and fell. Resident #1 said CNA #1 could not have reached him/her to prevent the fall, because she (CNA #1) was not even in the bathroom. During an interview on 01/03/23 at 2:35 P.M., Certified Nurse Aide (CNA) #1 said that during her overnight shift on 12/07/22, Resident #1 required toileting every 30 to 45 minutes and said that was unusual. CNA #1 said that she got Resident #1 up from bed around 5:00 A.M. to take him/her to the bathroom and that Resident #1 got dizzy transferring out of the bed. CNA #1 said she then ambulated Resident #1 to the bathroom with his/her rolling walker and positioned him/her in front of the toilet. CNA #1 said that while Resident #1 stood at the walker and pulled down his/her clothing, she went to a get a clean brief, from a dresser that was just outside the bathroom door. CNA #1 said she did not provide hands on assistance while Resident #1 stood at the walker and managed his/her clothing. CNA #1 said that in the time it took her to turn around and leave the bathroom, Resident #1 lost his/her balance while trying to sit down on the toilet. CNA #1 said she tried to stop the fall, but said the walker was in the way, and she only got a hold of Resident #1's hospital gown. On 01/03/23 at 11:30 AM, the surveyor observed that Resident #1's bathroom was located directly across from the foot of his/her bed and a dresser was positioned outside of the bathroom door. During an interview on 01/03/22 at 3:15 P.M., the Director of Rehabilitation (DOR) said that Resident #1 was on PT and OT services prior to the fall and required varying levels of assistance with transfers and toileting. The DOR said Resident #1 required minimal assistance of one staff member for ambulation, transfers and toileting with a rolling walker. The DOR said Resident #1 had not been deemed safe for independent or supervised functional transfers and said Resident #1 would be unsafe if hands on assistance was not provided while standing. During an interview on 01/03/23 at 4:40 P.M., the Corporate Director of Clinical Services said Resident #1's ADL Care Plan, that was in effect at the time of the 12/07/22 fall, indicated he/she required assistance from two staff members with transfers and toileting. The Corporate Clinical Specialist said the Care Plan should have been updated to reflect the PT recommendations for assist of one staff member for transfers as recommended by therapy. During the interview the Corporate Clinical Specialist was made aware that both Resident #1 and CNA #1, said in their interviews with the surveyor, that Resident #1 was left standing alone in the bathroom with his/her walker at the toilet while CNA #1 went to get a brief from the dresser in the room, and that was when Resident #1 lost his/her balance and fell. The Corporate Clinical Specialist said the Care Plan and the PT recommendations indicated hands on assistance was required for safe transfers, therefore the Care Plan interventions were not implemented by CNA #1, when she left Resident #1 standing alone in the bathroom on 12/07/22, resulting in a fall with a fracture.