**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #81's record revealed she was admitted to the facility on [DATE]. Her diagnoses were complete traumatic amputation between knee and ankle, atrial fibrillation, Crohn's disease, aortic insufficiency, venous insufficiency, hypertension, hyperlipidemia, vitamin D deficiency, other primary thrombophilia, hypokalemia, anxiety disorder, depression, pressure ulcer to right heel (stage II), polyosteoarthritis, edema, and dementia. Review of Resident #81's Minimum Data Set (MDS) assessment dated [DATE] revealed she had a severe cognitive impairment. Review of Resident #81's weights dated 11/25/24 to 01/03/25, revealed the following were the only weights obtained: 11/25/24 (233.4 pounds), 12/30/24 (238 pounds), and 01/03/25 (237.4 pounds). There was no documented evidence that Resident #81 had weekly weights obtained for the first four weeks after admission to the facility. Review of Resident #81's nutritional notes dated 11/25/24 to 01/03/25 revealed no evidence of nutritional notes documenting weekly weights for four weeks upon admission, as expected. Review of Resident #81's weights dated 01/03/25 to 02/05/25 revealed the following were obtained: 01/03/25 (237.4 pounds), 02/04/25 (198.4 pounds), and 02/05/25 (199.4 pounds). Review of Resident #81's progress notes dated 01/13/25 to 01/31/25 revealed Resident #81 was admitted to the hospital on [DATE] due to a declining right heel pressure ulcer. Resident #81 was readmitted to the facility on [DATE] after having a below the knee amputation on her right leg. Review of Resident #81's progress and nutritional notes dated 01/29/25 to 02/07/25 revealed no weights or nutritional assessments were completed until 02/07/25. On 02/07/25, Resident #81 had a significant weight change; her current body weight was 199.4 pounds. There was no documentation to support Resident #81's weight was obtained upon readmission to the facility after the amputation. Interview with Regional Dietitian #210 on 02/27/25 at 9:01 A.M. confirmed weights should have been obtained upon admission, each week for the first four weeks. She confirmed the initial weekly weights upon Resident #81's admission were not obtained as they should have been for proper monitoring of new admissions to the facility. Regional Dietician #210 also stated the facility should have received Resident #81's weight upon readmission, since she had a below the knee amputation completed. She confirmed she was not sure why the weights were not obtained. She confirmed there was a 38 pound decrease (16 percent (%)) from Resident #81's weight obtained prior to the hospital admission, and the first weight taken after readmission. She confirmed the typical below the knee amputation on one leg would be between six and seven percent weight decline, which would have been a total body weight for Resident #81 between 220.6 pounds and 223.2 pounds She confirmed she did not know how much weight was actually lost after Resident #81's amputation due to her not having a readmission weight obtained. Review of the facility policy titled Weights, dated 02/01/24, revealed residents were to be weighed upon admission and then weekly for a total of four weeks. readmitted residents may or may not need weekly weights and this may be determined by the interdisciplinary team. The registered dietitian or designee was responsible for the weight management program to include compliance with weights being obtained, tracking and trending, nutritional assessments, interventions, care plans, and follow ups. Based on medical record review, staff interview, review of hospital records, and review of the facility policy, the facility failed to ensure a resident, who was identified at risk of malnutrition and dehydration, maintained acceptable parameters of nutritional status, failed to initiate appropriate nutritional interventions, and address significant and severe weight loss for Resident #52. This resulted in Actual Harm for one (Resident #52) resident who experienced a significant weight loss of 5.1 percent (%) in four weeks and had ongoing severe weight loss of 13.6% over less than three months, when on 12/10/24 was noted with increased lethargy, malaise and was difficult to arouse, resulting in hospitalization for failure to thrive and percutaneous endoscopic gastrostomy (PEG) tube placement for enteral nutrition support. Additionally, the facility failed to complete weight monitoring as required for a second (Resident #81) resident who was identified at risk for nutrition, placing the resident at risk for the potential for more than minimal harm. This affected two (#52 and #81) of five (#7, #22, #26, #52, #81) residents reviewed for nutrition. The facility identified a total of ten (#5, #31, #35, #44, #48, #52, #66, #74, #81, #140) residents as being at nutritional risk. The facility census was 84 residents. Findings include: 1. Review of the medical record for Resident #52 revealed that he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, protein calorie malnutrition, vascular dementia, psychotic disorder with delirium, muscle weakness, adjustment disorder with depressed mood, dysphagia, and cognitive communication deficit. Review of Resident #52's nutrition care plan dated 04/12/23 revealed that Resident #52 was at risk of malnutrition related to dementia and dysphagia, and he was at risk of dehydration related to dementia. Care planned interventions included monitoring meal intakes, monitoring for signs of malnutrition, and monitoring and recording weights per the facility policy. The goal was for Resident #52 to eat over 50% of his meals and not to have any significant weight losses. Review of Resident #52's nutrition assessment revealed the dietitian completed an assessment for the resident which was dated 04/18/24. The assessment revealed that Resident #52 was at risk for malnutrition related to dementia, which could contribute to a decreased hunger and thirst sensation. The dietitian recommended a Magic Cup supplement twice daily, which was put into place on 04/18/24. The goal was for the resident to be hydrated and nourished as his condition allowed. Review of Resident #52's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicative of moderately impaired cognition. He was able to walk ten feet with supervision and touch assistance. The MDS stated that Resident #52 weighed 189 pounds and had not had any significant weight loss in the 1 month look back or 6 month look back periods. Review of Resident #52's weights revealed that he weighed 196.8 pounds (lbs) on 09/03/24 and on 10/02/24 he experienced a significant 5.1% (10 lb) weight loss, weighing 186.8 lbs. Additionally, Resident #52 weighed 189.2 lbs on 11/08/24. He experienced a severe 13.6% (25.8 lbs) weight loss on 12/10/24, weighing 163.4 lbs. Review of Resident #52's medical record revealed the record lacked documented evidence of a nutritional assessment and nutritional recommendations for Resident #52 in October 2024 or November 2024, and a Registered Dietitian Nutritionist (RDN) did not evaluate, assess, or address his significant weight losses in October 2024 or November 2024. Resident #52's medical record also lacked evidence of the psychiatric Nurse Practitioner (NP), the primary NP or the physician addressing any weight changes. Review of Resident #52's orders and medical record revealed that no new interventions were put into place for Resident #52's significant weight loss from 10/02/24. Review of Resident #52's meal intake records revealed that in September 2024, he consumed less than 50% of his meals on 11 occasions. In October 2024, he consumed less that 50% of his meals on 17 occasions. In November 2024, he consumed less than 50% of his meals on 14 occasions. From 12/01/24 until his hospitalization on 12/10/24, he consumed less than 50% of his meals on six occasions. Review of Resident #52's nutrition progress notes on 12/06/24 revealed that Dietitian #215 completed a note that Resident #52 previously had weight fluctuations and that he was trending down with his weight; however, Dietitian #215 did not address the root cause of the weight loss. Dietitian #215 did note that Resident #52 had a history of edema and that he was on a diuretic. Dietitian #215 did not address Resident #52's current edema status on 12/06/24. Review of Resident #52's progress notes revealed that on 12/10/24, he had lethargy and decreased alertness. His weight was recorded at 7:25 A.M. on 12/10/24 as 163.4 lbs. He experienced a severe 13.6% (25.8 lb) weight loss. The NP was notified of his decreased alertness, and emergency laboratory (lab) tests were ordered. As the morning progressed on 12/10/24, the NP made the decision to send Resident #52 to the emergency room due to difficulty to arouse, lethargy and malaise. Review of Resident #52's hospital record from 12/10/24 to 12/21/24 revealed that he was admitted to the emergency room on [DATE]. His hospital lab results revealed on 12/10/24 the resident had a serum sodium level of 166 millimoles per liter (mmol/L) [normal range from 135 to 147 mmol/L], a serum Blood Urea Nitrogen (BUN) level of 51 milligrams per deciliter (mg/dL)[normal range from 10 to 20 mg/dL], and a serum Creatinine level of 1.78 mg/dL (normal range from 0.6 to 1.2 mg/dL). The results revealed the resident ' s lab levels were all clinically elevated and could clinically indicate that Resident #52 was dehydrated on 12/10/24. The hospital physician noted that Resident #52 was hypovolemic, his blood pressure was low and that he had dry lips, which could also be clinical indications that Resident #52 was dehydrated on 12/10/24. Intravenous fluids were started on Resident #52 at the hospital. Review of Resident #52's 12/21/24 re-admission nursing progress note revealed that on 12/21/24, he was readmitted to the facility with orders for a continuous enteral feeding of Jevity 1.5 calories via his PEG tube and a pureed diet with nectar thickened liquids. Review of Resident #52's nurse practitioner progress notes on 12/24/24 revealed that Resident #52 was admitted to the hospital on [DATE] with failure to thrive, and a PEG tube was placed for nutrition support. Review of the nutrition assessment dated [DATE] noted that Resident #52 had a significant weight loss in the past six months; however, Dietitian #215 did not address the root cause of the weight loss. He noted that Resident #52 did not look like he had physically lost weight. Review of Resident #52's orders revealed that he was admitted to hospice services on 01/10/25 with a terminal diagnosis of cerebral infarction. Review of Resident #52's admitting hospice evaluation dated 01/10/25 revealed that Resident #52 had a general decline in his clinical status related to a weight loss of at least 10% of his weight in the past six months that was not due to reversible causes, such as use of diuretics. It noted that during a hospitalization for Resident #52, he had a PEG tube placed due to poor oral intakes. Review of Resident #52's MDS significant change assessment for 01/17/25 revealed that a BIMS was not completed, as Resident #52 no longer was able to answer questions appropriately. He was no longer able to walk ten feet. The MDS revealed that he weighed 163 pounds and had an unplanned weight loss of over 10% in the past six months. Review of Resident #52's January 2025 to February 2025 weights revealed that Resident #52 maintained a weight between 163 lbs and 164.4 lbs since 12/10/24. Interview on 02/25/25 at 1:39 P.M. with Dietitian #215 revealed that in October 2024 when Resident #52 had a significant weight loss, the weight loss likely got missed by the dietitians responsible for monitoring the weights in the facility, as there was no permanent dietitian coverage for the facility in the month of October 2024. Dietitian #215 confirmed that on 12/10/24, Resident #52 had a significant weight loss, but that a root cause for the weight loss was not investigated. Dietitian #215 explained that he did not know why Resident #52 lost a significant amount of weight, and that to him, Resident #52 did not physically appear to look any different than he did earlier in 2024; however, Dietitian #215 revealed that he had started working in the facility in November 2024. Interview on 02/26/24 at 8:18 A.M. with Regional Dietitian #210 revealed that she had problems with clinical nutrition coverage and documentation throughout most of 2024, until she hired Dietitian #215 in November 2024. Regional Dietitian #210 revealed that she had a Quality Assurance and Performance Improvement (QAPI) project that she started in February 2024 about clinical nutrition documentation. Review of the QAPI clinical nutrition documentation project revealed that there were no audits for October 2024 through December 2024 of clinical nutrition documentation. Interview with Certified Nurse Aide (CNA) #182 on 02/26/25 at 10:35 A.M. revealed that Resident #52 used to walk around the facility and was even exit seeking until he was hospitalized on [DATE]. Interview confirmed that Resident #52 was able to be moved off of the memory care unit when he returned to the facility on [DATE], as he was now bed bound and unable to ambulate. Interview with Licensed Practical Nurse (LPN) #147 on 02/26/25 at 10:37 A.M. revealed that Resident #52 used to walk around the facility and was even exit seeking until he was hospitalized on [DATE]. Interview confirmed that Resident #52 was able to be moved off of the memory care unit when he returned to the facility on [DATE], as he was now bed bound and unable to ambulate. Interview with Hospice Administrator #211 and Hospice Registered Nurse #212 on 02/26/25 at 10:59 A.M. revealed that cerebral infarction was chosen as the terminal diagnosis for Resident #52 by the hospice Medical Director because he felt as it was the catalyst for Resident #52's eventual decline; however, his malnutrition diagnosis and the fact that Resident #52 had a severe weight loss over 10% in the past six months was considered when admitting Resident #52 to hospice services. Interview with Regional Dietitian #210 on 02/27/25 at 8:31 A.M. revealed that although a dietitian could not directly diagnose a disease or condition, on 12/10/24 when Resident #52 had a severe 13.6% weight loss in 30 days, Resident #52 met the American Society of Parenteral and Enteral Nutrition (ASPEN) 2012 standardized guidelines for malnutrition criteria. Regional Dietitian #210 confirmed that Resident #52 did not have any new nutritional interventions put into place from 10/02/24 to 12/10/24 when he lost significant amounts of weight. Regional Dietitian #210 confirmed that Resident #52 did lose a significant amount of weight on 10/02/24 and 12/10/24. Review of facility Weights policy, dated 02/01/24, revealed residents are weighed upon admission and then weekly for a total of four weeks. readmitted residents may or may not need weekly weights and this may be determined by the interdisciplinary team. The registered dietitian or designee is responsible for the weight management program to include compliance with weights being obtained, tracking and trending, nutritional assessments, interventions, care plans, and follow ups.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident guardian interview, staff interview, facility Self-Reported Incident (SRI) review, and review of facility investigation, the facility failed to investigate and implement psychiatric recommendations to ensure Resident #82 had the ability to attain or maintain their highest physical, mental, and psychosocial wellbeing. Actual Harm occurred when the facility failed to fully investigate the root cause of Resident #82's potential hallucinations/behaviors, which contributed to the facility being unable to meet the residents behavioral health needs, resulting in a discharge from the facility. This affected one (Resident #82) of one resident reviewed for behavioral/emotional needs. The facility census was 84. Findings include: Review of medical record for Resident #82 revealed an admission dated of 12/06/24 and diagnoses including vascular dementia, anxiety disorder, adult failure to thrive and primary hypertension. Review of Resident #82's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) of 10. Review of Resident #82's comprehensive care plan dated 12/13/24 revealed the resident had impaired safety awareness. Further review documented a goal that the interdisciplinary team would work to address risk factors and provide for safety. The care plan included an intervention for staff to implement safety measures as indicated by fluctuations in cognitive status. The care plan revealed no evidence of interventions put in place by the facility to address her fear of others coming into her room to allegedly harm her. Review of Resident #82's nursing note dated 12/10/24 revealed she had barricaded herself in her room due to her reporting that two men were coming into her room and stealing her things. Review of the Resident #82's Nurse Practitioner #110 note, dated 12/13/24, revealed treatment recommendations for the unit manager to obtain clarification of the resident's statements of the men entering her room at night as it may have been another resident, who lived across the hall and had a history of wandering into other rooms. There was no evidence provided that the facility addressed Nurse Practitioner #110's recommendations to investigate and determine the validity of the resident's claims. Review of Resident #82's nursing note dated 12/23/24 revealed she barricaded herself in her room again due to her alleging that two people entered her room, attacked her, and had the intent to [NAME] her. Resident #82 called the police to report the attack. Resident #82 requested a medical evaluation and treatment because her arm was hurting after the attack. A medical evaluation was completed that night and there was no injury determined. Review of the facility SRI Investigation, dated 12/23/24, revealed the facility filed and investigated the allegation of someone coming in Resident #82's room and attacking her. They determined the allegation of abuse was unsubstantiated. Review of the facility investigation dated 12/23/24 revealed like residents were interviewed with no negative findings, head-to-toe assessments were completed on residents who were unable to be interviewed, staff were interviewed with no negative findings, and abuse education was provided to all staff. The investigation determined there was no evidence to support Resident #82's allegation of being attacked in her room. The investigation further revealed no evidence of a root cause analysis as to why the resident continued to make the allegations and the facility did not implement any new interventions to reduce Resident #82's fear of being attacked in her room. Review of Resident #82's Nurse Practitioner #110 note dated 12/27/24, revealed Resident #82 told Nurse Practitioner #110, The two men keep coming into my room, and she was worried about them returning. Review of Resident #82's nursing note dated 01/22/25 revealed the resident called the police to report a group of women coming into her room to [NAME] her and beat her up. There was no documented evidence that the facility took action to address Resident #82's claims. Interview with Director of Nursing (DON) on 02/26/25 at 2:39 P.M. confirmed no further investigations were completed related to Resident #82's allegations, and there was no monitoring of Resident #82's behaviors regarding hallucinations, false allegations, or whether there was anyone who went into her room, to determine the validity of her allegations. The DON stated the facility spoke with Resident #82's guardian to let her know they could not meet the resident's needs due to her continued hallucinations and behavioral health issues. From that point, Resident #82's guardian found another nursing home to move her to. Interview with Resident #82's guardian on 02/27/25 at 1:42 P.M. revealed because of the hallucinations and the residents reports of residents going in/out of her room constantly, the guardian wanted to find a new place for Resident #82 to live. She stated the facility did not give them a 30-day notice, but the facility did tell her that she would be better off in an in-patient psychiatric unit. She confirmed the facility did not implement any new interventions or aid with Resident #82's hallucinations of residents going in and out of her room. Resident #82's guardian confirmed she was not aware of the facility completing any investigation to determine the validity of Resident #82 claims of others going into her room. She would have preferred those interventions to have occurred, rather than Resident #82 being moved to another facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a fall investigation, and staff interviews, the facility failed ensure staff utilized proper precautions while ambulating with residents. Actual harm occurred when State Tested Nurse Aide(STNA) #126 was ambulating with Resident #64, while not using a gait belt, and Resident #64 fell resulting in a left hip fracture and subsequent hospitalization. This affected one (Resident #64) out of seven residents reviewed for falls. The facility census was 74. Findings include Review of the medical record for Resident #64 revealed an admission date of 11/19/21. Diagnoses included dementia, weakness, spinal stenosis, and depression. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had significant cognitive impairment, and required extensive assistance of two staff members for bed mobility and transfers. Review of the Care Plan dated 12/03/21, with handwritten updates, revealed Resident #64 was at risk for falls with interventions for staff to use a gait belt (an assistive device used to assist with transfers) during transfers. Review of the Fall Investigation for Resident #64 dated 04/06/22 revealed Resident #64 was walking with STNA #126 from the bathroom to her bed with the use of her walker. Resident #64 removed her hand from her walker to point at her roommate, fell backward, and hit her head, left leg, and hip. Staff started neurological checks and informed the physician of Resident #64's complaints of pain to her left hip. The physician ordered an x-ray which showed a fractured hip. Resident #64 was then sent out to the hospital and required surgery. Interventions put in place included an all-staff training to always use a gait belt when assisting residents with transfers and ambulation. A skin assessment revealed Resident #64 had a bump to her head as well as a hip injury. A pain assessment determined Resident #64 had pain to the left hip. Review of hospital discharge paperwork revealed Resident #64 was admitted to the hospital with a closed left hip fracture. Further review of the hospital discharge paperwork revealed x-rays were completed and revealed an acute comminuted intertrochanteric fracture of the left femur with surgical revision of a left TFNA (proximal femoral nailing system) for intertrochanteric femoral fracture. Interview on 06/16/22 at 12:45 P.M. with the Director of Nursing (DON) revealed the intervention put in place for Resident #64 after her fall with injury on 04/06/22 was for staff to use gait belts when transferring and ambulating with Resident #64. The DON also revealed this was a standard of care for their corporation and all staff were expected to be using gait belts for all residents prior to Resident #64's fall. The DON revealed an all-staff training was completed due to the incident with Resident #64, since STNA #126 was not using a gait belt during the ambulation when Resident #64 fell and fractured her hip. Interview on 06/16/22 at 3:10 P.M. with STNA #126 revealed Resident #64 was in the bathroom and STNA #126 was assisting Resident #64 back to her bed when Resident #64 looked up, pointed at her roommate, said look, and fell. STNA #126 revealed out of reaction, she looked up, lost her concentration, and Resident #64 fell backwards and hit her head as well as injured her leg and hip. STNA #126 revealed Resident #64 immediately verbalized pain, her foot was turned out in an unnatural position, and Resident #64 was transferred to the hospital. STNA #126 revealed prior to the fall, Resident #64 was a one person assist by staff when using her walker but would use her wheelchair for longer distances. STNA #126 revealed staff were reeducated after the fall that staff should use a gait belt for all residents when assisting with transfers and ambulation. STNA #126 verbalized the use of a gait belt when assisting residents was an expectation for staff prior to the fall. STNA #126 revealed she did not use a gait belt during the event when Resident #64 fell and was injured but could not remember why. STNA #126 revealed since the fall, Resident #64 had been working with therapy on ambulating, but was only able to transfer with staff at that time. Interview on 06/16/22 at 4:30 P.M. with the DON revealed the facility does not have a specific policy related to use of the gait belts, but revealed they use therapy guidelines which recommend using a gait belt for all resident transfers and during ambulation.