**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, policy review, and interview, the facility failed to timely report and provide adequate, necessary and timely care for Resident #72 following a fall during a staff assisted transfer resulting in a delay of treatment for newly diagnosed compression vertebra fractures. This affected one resident (#72) of three residents reviewed for accidents. The census was 71. Actual Harm occurred on 05/06/25 at approximately 9:00 A.M. when Certified Nurse Assistant (CNA) #34 failed to notify the licensed nurse that Resident #72 sustained a fall during a staff assisted transfer resulting in a delay in treatment. The resident complained of back pain (intermittent, aching, moderate pain with protective body movements/posture associated with the pain) following the incident. However, the resident was not transferred to the hospital until 2:30 P.M. (five and a half hours after the incident) where he was diagnosed with and received treatment for compression fractures of his thoracic spine. Findings include: Closed medical record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including cancer, history of falls, impaired mobility and paraplegia. The resident discharged to home on [DATE]. Review of the Fall Risk Evaluation dated 03/03/25 revealed Resident #72 was at high risk for falls. Review of the care plan: At Risk for Falls revised 04/14/25 revealed Resident #72 was at risk for falls and required one to two staff assist with toileting and transfers. The resident's level of assistance with transfers was changed to two staff assistance following a fall that occurred on 05/06/25) per the Director of Nursing. Review of the discharge Minimum Data Set 3.0 dated 05/02/25 revealed Resident #72 was cognitively intact for daily decision-making and required partial to moderate (staff) assist with sit-to-stand (the ability to come to a standing position from sitting in a wheelchair, chair or side of the bed. Review of the [NAME] dated 05/03/25 revealed staff were to implement the following for Resident #72: one to two assistance with toileting, avoid clutter, encourage non-slip footwear when out of bed, ensure walker/cane within reach, call light in reach, adequate low glare light, frequent items within reach, two person assist with transfers and use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surfaces. Review of the ADL Task List-Transferring dated 05/03/25 through 05/06/25 revealed Resident #72 required limited to extensive (staff) assistance with transfers. Review of the Incident Report: Fall During Staff Assist dated 05/06/25 revealed Certified Nurse Aide (CNA #34) had reported to the nurse that Resident #72's knees gave out while helping him transfer from toilet to wheelchair earlier in the shift. Injury resulting from the fall was a small abrasion to the left knee and complaints of slight back pain that worsens with movement. Predisposing physiological factors included gait imbalance and situation factors included ambulating with assist during transfer. The resident's physician was notified of the incident at 12:52 P.M. on 05/06/25. Further review revealed no documented evidence as to why the CNA did not notify the nurse immediately or when the family/responsible party was notified. Review of the Vitals and Pain Only Evaluation dated 05/06/25 at 12:52 P.M., revealed Resident #72 complained of intermittent, aching, moderate pain rated five out of 10, the resident had exhibited protective body movements/posture vocal complaints of pain. Non-medicated interventions included change in position and PRN medication administered. Review of the electronic Medication Administration Record (MAR) dated May 2025 revealed Resident #72 received Tramadol (pain medication) 50 milligrams for pain rated a six out of 10 (1-10 pain scale). Review of Resident #72's hospital documentation dated 05/06/25 revealed the resident was undergoing chemotherapy and radiation therapy for the last nine days with back pain associated with his treatment. Today he slipped in front of the toilet, sliding down and hitting his back. The resident reported his back pain was worse than baseline at that time. Review of the computed tomography (CT) results including thoracic spine revealed new changes involving superior endplate of T12 and T11 as well as inferior endplate of T 10 with background of substantial osteopenia. Findings were compatible with acute/subacute mild compression fracture of T12 and more mild-to-moderate acute/subacute compression fracture of the superior endplate of T11 and inferior endplate of T10. There may be some progression of bony metastasis with some ill-defined lucencies seen along the inferior endplate of T10 and superior endplate of T 11 which was questioned as well although findings may all just be posttraumatic with bony fragmentation. Recommendations included to wear back brace due to several fractures of the back and follow up with physician within a week. Review of CNA #34's incident statement dated 05/06/25 revealed during the transfer from Resident #72's chair to the toilet, his knees 'lost strength' bending very fast and hard hitting the wall. After that incident he was feeling a lot of pain on his lower back and during the transfer to his bed at. At 12:00 P.M. Resident #72 expressed much pain during the transfer. Review of an incident statement dated 05/14/25 revealed at approximately 1:30 P.M., Licensed Practical Nurse (LPN) #44 informed Registered Nurse (RN) #46 that Certified Nurse Aide (CNA) #34 had just reported to her that Resident #72 was complaining of a backache and that earlier in the day while in the bathroom, she had assisted him to stand up from the wheelchair and as he was holding onto the grab bar his knees buckled and he sat back down in the wheelchair. The statement included RN #46 spoke with CNA #34 and reminded her that all incidents were to be reported when they happen. On 05/14/25 at 11:50 A.M., interview with the Director of Nursing (DON) verified the above incident was a fall and should have been reported immediately. The DON verified CNA #34 did not immediately report the resident's fall, she moved the resident without the nurse assessing him first and it wasn't until approximately 1:30 P.M. per Registered Nurse (RN) #46's statement that LPN #44 was notified of the incident. Once CNA #34 went to LPN #44 and told her what had happened earlier in her shift, the nurse assessed the resident and the resident was transferred to the hospital for evaluation (at approximately 2:30 P.M. on 05/06/25). The DON verified the investigation had contradictions in the time frames and statements. The DON verified she did not have the investigation completed, was educating staff and obtaining statements as of today during the survey in regards to Resident #72's fall. On 05/14/25 at 1:37 P.M., interview with CNA #34 revealed on 05/06/25 just after breakfast around 9:00 A.M. she was assisting Resident #72 to the bathroom. While assisting the resident to stand she asked him to hold onto the grab bar, at which time his knees buckled and he fell back into the wheelchair. CNA #34 stated she called for assistance and CNA #50 helped to stand the resident up and sat him back on the toilet. CNA #34 stated she asked CNA #50 if she should report this incident and was told if he didn't end up on the floor, it was not considered a fall. At that point, CNA #34 stated she finished toileting the resident and assisted him back into his wheelchair. CNA #34 stated when she went to check on him after lunch he stated he was having more back pain that normal and had facial grimacing. At that point, CNA #34 informed the nurse of what had happened that morning after breakfast and the nurse went to the resident's room. CNA #34 stated she could not remember if she was using a gait belt or had a hold of the gait belt at the time of the fall. CNA #34 stated Resident #72 had been improving and able to transfer with just one assist; however, he had started some radiation chemotherapy treatments and seemed to be weaker and required more staff assistance. CNA #34 stated Resident #72 was not a fall risk but if he was there were to always be two caregivers. CNA #34 verified she did not report Resident #72's fall immediately to her charge nurse as the fall was not reported for over four hours. On 05/14/25 at 2:35 P.M., interview with CNA #50 revealed on 05/06/25 she was asked to help get Resident #72 to the bathroom but when she entered the room he was already sitting on the toilet completely dressed. CNA #50 stated the resident did not have a gait belt on and she helped stand him up so they could pull down his pants. CNA #50 stated once on the toilet she left the room. CNA #50 verified there was no gait belt used and did not know at the time that Resident #72 had fallen back into his wheelchair prior to or after CNA #34 asking for her help. Review of the policy: Falls Management dated 01/14/14 revealed if a resident falls, despite interventions, the following was to occur: Resident will be fully assessed by a licensed nurse and if deemed safe by a nurse, the resident would be lifted/assisted into bed or wheelchair to be further assessed. The facility would notify the physician and resident family member as soon as practicable. In the event of a head injury or suspected fracture, the physician and family member will be notified immediately. Staff were then to determine what preventable measures were to be put into place to protect resident against another fall and implemented as soon as possible. This deficiency represents non-compliance investigated under Complaint Number OH00165620.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, and interview, the facility failed to develop and implement a comprehensive and individualized fall prevention program to ensure fall interventions were implemented for Resident #28 and to ensure Resident #72 and Resident #75 were provided adequate assistance with transfers. This affected three residents (#28, #72, and #75) of three residents reviewed for accidents. The census was 71. Actual Harm occurred on 05/06/25 at approximately 9:00 A.M. when Certified Nurse Assistant (CNA) #34 was transferring Resident #72, who was a high risk for falls and increased risk of injury related to falls, to the toilet by herself without the use of a gait belt, the resident's knees buckled and the resident fell back into the wheelchair resulting in new compression fractures to the thoracic spine with associated increased complaints of intermittent, aching, moderate pain with protective body movements/posture. Findings include: 1. Closed medical record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including cancer, history of falls, impaired mobility and paraplegia. The resident discharged to home on [DATE]. Review of the Fall Risk Evaluation dated 03/03/25 revealed Resident #72 was at high risk for falls. Review of the care plan: At Risk for Falls revised 04/14/25 revealed Resident #72 was at risk for falls and required one to two staff assist with toileting and transfers. The resident's level of assistance with transfers was changed to two staff assistance following a fall that occurred on 05/06/25) per the Director of Nursing. Review of the discharge Minimum Data Set 3.0 dated 05/02/25 revealed Resident #72 was cognitively intact for daily decision-making and required partial to moderate staff assist with sit-to-stand (the ability to come to a standing position from sitting in a wheelchair, chair or side of the bed). Review of the [NAME] dated 05/03/25 revealed staff were to implement the following for Resident #72: one to two assistance with toileting, avoid clutter, encourage non-slip footwear when out of bed, ensure walker/cane within reach, call light in reach, adequate low glare light, frequent items within reach, two person assist with transfers and use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surfaces. Review of the ADL Task List-Transferring dated 05/03/25 through 05/06/25 revealed Resident #72 required limited to extensive assistance with transfers. Review of the Incident Report: Fall During Staff Assist dated 05/06/25 revealed Certified Nurse Aide (CNA #34) had reported to the nurse that Resident #72's knees gave out while helping him transfer from toilet to wheelchair earlier in the shift. Injury resulting from the fall was a small abrasion to the left knee and complaints of slight back pain that worsens with movement. Predisposing physiological factors included gait imbalance and situation factors included ambulating with assist during transfer. The resident's physician was notified of the incident at 12:52 P.M. on 05/06/25. Further review revealed no documented evidence as to if a gait belt was used during the transfer or when the family/responsible party was notified. Review of the Vitals and Pain Only Evaluation dated 05/06/25 at 12:52 P.M., revealed Resident #72 complained of intermittent, aching, moderate pain rated five out of 10, the resident had exhibited protective body movements/posture vocal complaints of pain. Non-medicated interventions included change in position and PRN medication administered. Review of the electronic Medication Administration Record (MAR) dated May 2025 revealed Resident #72 received Tramadol (pain medication) 50 milligrams for pain rated a six out of 10 (1-10 pain scale). Review of Resident #72's hospital documentation dated 05/06/25 revealed resident was undergoing chemotherapy and radiation therapy for the last nine days with back pain associated with his treatment. Today he slipped in front of the toilet, sliding down and hitting his back. The resident reported his back pain was worse than baseline at that time. Review of the computed tomography (CT) results including thoracic spine revealed new changes involving superior endplate of T12 and T11 as well as inferior endplate of T10 with background of substantial osteopenia. Findings were compatible with acute/subacute mild compression fracture of T12 and more mild-to-moderate acute/subacute compression fracture of the superior endplate of T11 and inferior endplate of T10. There may be some progression of bony metastasis with some ill-defined lucencies seen along the inferior endplate of T10 and superior endplate of T11 which was questioned as well although findings may all just be posttraumatic with bony fragmentation. Recommendations included to wear back brace due to several fractures of the back and follow up with physician within a week. Review of CNA #34's incident statement dated 05/06/25 revealed during the transfer from Resident #72's chair to the toilet, his knees 'lost strength' bending very fast and hard hitting the wall. After that incident he was feeling a lot of pain on his lower back and during the transfer to his bed at. At 12:00 P.M. Resident #72 expressed much pain during the transfer. Review of an incident statement dated 05/14/25 revealed at approximately 1:30 P.M., Licensed Practical Nurse (LPN) #44 informed Registered Nurse (RN) #46 that Certified Nurse Aide (CNA) #34 had just reported to her that Resident #72 was complaining of a backache and that earlier in the day while in the bathroom, she had assisted him to stand up from the wheelchair and as he was holding onto the grab bar his knees buckled and he sat back down in the wheelchair. The statement included RN #46 spoke with CNA #34 and reminded her that all incidents were to be reported when they happen. On 05/14/25 at 11:50 A.M., interview with the Director of Nursing (DON) verified the above incident was a fall and should have been reported immediately. The DON verified CNA #34 did not immediately report the resident's fall, she moved the resident without the nurse assessing him first and it wasn't until approximately 1:30 P.M. per Registered Nurse (RN) #46's statement that LPN #44 was notified of the incident. Once CNA #34 went to LPN #44 and told her what had happened earlier in her shift, the nurse assessed the resident and the resident was transferred to the hospital for evaluation (at approximately 2:30 P.M. on 05/06/25). The DON verified the investigation had contradictions in the time frames and statements. The DON verified she did not have the investigation completed, was educating staff and obtaining statements as of today during the survey in regards to Resident #72's fall. On 05/14/25 at 1:37 P.M., interview with CNA #34 revealed on 05/06/25 just after breakfast around 9:00 A.M. she was assisting Resident #72 to the bathroom. While assisting the resident to stand she asked him to hold onto the grab bar, at which time his knees buckled and he fell back into the wheelchair. CNA #34 stated she called for assistance and CNA #50 helped to stand the resident up and sat him back on the toilet. CNA #34 stated she asked CNA #50 if she should report this incident and was told if he didn't end up on the floor, it was not considered a fall. At that point, CNA #34 stated she finished toileting the resident and assisted him back into his wheelchair. CNA #34 stated when she went to check on him after lunch he stated he was having more back pain that normal and had facial grimacing. At that point, CNA #34 informed the nurse of what had happened that morning after breakfast and the nurse went to the resident's room. CNA #34 stated she could not remember if she was using a gait belt or had a hold of the gait belt at the time of the fall. CNA #34 stated Resident #72 had been improving and able to transfer with just one assist; however, he had started some radiation chemotherapy treatments and seemed to be weaker and required more staff assistance. CNA #34 stated Resident #72 was not a fall risk but if he was there were to always be two caregivers. CNA #34 verified she did not report Resident #72's fall immediately to her charge nurse as the fall was not reported for over four hours. On 05/14/25 at 2:35 P.M., interview with CNA #50 revealed on 05/06/25 she was asked to help get Resident #72 to the bathroom but when she entered the room he was already sitting on the toilet completely dressed. CNA #50 stated the resident did not have a gait belt on and she helped stand him up so they could pull down his pants. CNA #50 stated once on the toilet she left the room. CNA #50 verified there was no gait belt used and did not know at the time that Resident #72 had fallen back into his wheelchair prior to or after CNA #34 asking for her help. Review of the policy: Falls Management dated 01/14/14 revealed if a resident falls, despite interventions, the following was to occur: Resident would be fully assessed by a licensed nurse and if deemed safe by a nurse, the resident would be lifted/assisted into bed or wheelchair to be further assessed. The facility would notify the physician and resident family member as soon as practicable. In the event of a head injury or suspected fracture, the physician and family member will be notified immediately. Staff were then to determine what preventable measures were to be put into place to protect resident against another fall and implemented as soon as possible. 2. Medical record review revealed Resident #75 was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia and osteoarthritis. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #75 was severely impaired for daily decision-making and was dependent on staff for transfers. Review of the care plan; ADL (Activities of Daily Living) self-care performance deficit related to dementia and Alzheimer's disease dated 06/12/24 revealed the resident required extensive assistance of two staff for transferring chair-to-chair, and may use mechanical lift devices to and from bed. On 05/14/25 at 9:23 A.M., observation on the secured unit revealed CNA #35 and CNA #37 transferred Resident #75 by placing their arms under the residents axillary. CNA #35 and CNA #37 were then observed lifting the resident out of her wheelchair and placed her into a recliner chair in the lounge area. No gait belt was observed being used to transfer the resident. On 05/14/25 at 9:30 A.M., interview with LPN #52 stated staff were issued a gait belt and gait belts were readily available on the unit and in the residents' rooms. On 05/14/25 at 2:15 P.M., interview with CNA #37 verified Resident #75 was transferred without the use of a gait belt as described above. On 05/14/25 at 2:18 P.M., interview with CNA #35 verified Resident #75 was transferred without the use of a gait belt as described above. 3. Medical record review revealed Resident #28 was re-admitted on [DATE] with diagnoses including fracture, cancer, atrial fibrillation and high blood pressure. Review of the care plan: At Risk for Falls revised 04/23/25 revealed interventions including to wear his back brace as needed, keep frequent items in reach, foot buddy to wheelchair, keep walker/cane in reach and call for assist for all transfers. A new intervention to place a food buddy to wheelchair was implemented on 05/06/25. Review of the Fall Risk assessment dated [DATE] revealed Resident #28 was at high risk for falls. Review of the late entry dated 05/06/25 at 4:30 P.M. Progress Note revealed resident returned from emergency room with the following injuries after his fall this morning: lumbar (L-5) , thoracic 11 (T-11) and maxillary sinus fractures. Review of the Fall Evaluation dated 05/11/25 revealed resident was attempting to ambulate himself, was exit seeking and the nurse witnessed the fall. There was no injury and the resident was sent to the emergency room per physician order. Review of CNA #50's staff statement regarding Resident #28's fall revealed CNA #50 was sitting at the nurses' desk with LPN #44 and LPN #55 when they heard a noise (oxygen tank fell over) and when they went into the room the resident was laying on the floor. When the resident sat up, his nose was bleeding. The resident was sent to the hospital for evaluation. The staff statements dated 05/06/25 revealed no evidence the fall was witnessed. Review of the hospital documentation dated 05/06/25 revealed the HPI indicated the resident was being evaluated after a fall. The resident stated he was turning and caught his foot on his walker, tripping him and causing him to fall forward striking his face, head and left knee on the floor. Review of the Facial CT results dated 05/06/25 revealed displaced and comminuted fracture of the left maxillary sinus and mildly comminuted fracture of the intraorbital rim with a large amount of hemorrhage. Review of the T/L spine revealed acute moderate compression of the T-11 vertebrae compared to a previous scan completed on 04/12/25. On 05/14/25 at 10:38 A.M., interview with the DON verified the new intervention was for a foot buddy, she thought he tripped over the wheelchair not the walker and this intervention was not immediately implemented. The DON stated she needed to review and ensure appropriate interventions were in place for the resident to prevent future falls. On 05/14/25 at 10:47 A.M., observation revealed Resident #28 was in bed in the high position. The resident's eyes were closed and his walker was observed across the room next to his room door. The walker was not within reach of the resident. This was verified by the DON at the time of the observation. On 05/14/25 at 2:45 P.M., observation revealed Resident #28 was laying in bed with his bed in a high position, his walker was next to the door towards the hallway and personal items on over-bed table was against the wall near the bathroom. Neither of these things were within the resident's reach. Interview with CNA #50 verified the above at the time of the observation. This deficiency represents non-compliance investigated under Complaint Number OH00165620.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, vascular dementia, cognitive communication deficit, delusional disorder, depression, and a malignant neoplasm of the right breast. Review of Resident #7's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was severely impaired. She was known to have other behaviors not directed at others, but was not known to reject care. She was independent with eating. Her height was 60 inches and her weight was 111 pounds. She was not indicated to have had a significant weight loss during that time. Review of Resident #7's care plans revealed the resident had a care plan in place for having a nutritional problem or the potential for nutrition problems related to her advanced age, chronic disease, variable meal acceptance, and psychoactive medication use that may alter her appetite and weight. The care plan was updated on 02/13/25 to reflect a significant weight loss at 30, 90, and 180 days. The goal was for the resident to maintain adequate nutritional status as evidenced by maintaining weight with no significant weight changes. The interventions included providing her diet as ordered, monitor intake and record every meal, and provide and serve supplements as ordered. Review of Resident #7's physician's orders revealed the resident was to receive a regular diet. She was ordered to receive Boost (a nutritional supplement) twice a day as a supplement. The Boost order had been in place since 01/18/25. She was to be weighed weekly. Review of Resident #7's weekly weights revealed the resident's weights were trending down. She weighed 111.8 pounds on 01/28/25. Her weight on 02/12/25 was 105.4 pounds, which reflected a weight loss of 5.7%. Her last recorded weight on 02/19/25 was 103.8 pounds. Review of Resident #7's meal intakes for the past 30 days (01/27/25- 02/24/25) revealed the resident's meal intake was not being consistently recorded, as not all three meals each day were being documented to reflect the percentage of the meal the resident consumed. Seven of the 30 days reviewed only had two of the three meals recorded on those days. Missing meal consumptions were noted for 01/30/25, 02/01/25, 02/06/25, 02/07/25, 02/13/25, 02/20/25, and 02/21/25. Review of Resident #7's medication administration record (MAR's) for February 2025 revealed the nurses were recording the resident's consumption of her Boost supplement that was ordered twice a day. The times for the administration of Boost was set up for the morning and again in the evening (7:00 P.M.). The nurses were inconsistent in the way they documented the amount of the supplement the resident consumed. The nurses were supposed to document the amount consumed in milliliters (ml). Some were documenting 237, which was the total amount of ml that the Boost bottle contained. Others were documenting 100% or 100. It was not clear if the 100 meant the resident consumed 100% of the supplement or only 100 ml. On 02/25/25 at 10:00 A.M., an interview with RN #417 confirmed Resident #7's meal intakes were not being consistently recorded to reflect the amount she consumed for all three meals per day. She acknowledged that failing to record all three meals a day showed her nutritional intake was being inadequately monitored. She further acknowledged the staff were not consistent in how they were recording the resident's supplement intake, as some would record 237 while others were writing either 100 or 100%. She confirmed it could not be determined if those documenting 100 meant 100% or if they were recording it in ml's. She reported the resident's acceptance of the Boost supplement was to be documented in ml's not a percentage as was recorded for some of the entries. She agreed, with the inconsistencies on how the supplement acceptance was being recorded, it made it difficult to determine what the resident's acceptance was and if it was an effective nutritional intervention. 3. Review of Resident #69's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition, chronic kidney disease, and adult onset diabetes mellitus. Review of Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to display any behaviors and was not known to reject care. Her height was 66 inches and her weight was 174 pounds. She was not indicated to have had any significant weight loss. Review of Resident #69's care plans revealed the resident had a care plan in place for having a nutritional problem or potential nutritional problem related to a decreased intake, therapeutic diet, history of weight changes, diuretic use, and a history of significant weight loss at 30 days, 90 days, and 180 days on 02/04/25. The goal was for the resident to have optimal nutrition within constraints of her disease process as evidenced by accepting a well balanced diet. The interventions included providing her diet as ordered, providing supplements as ordered, and monitor her intake and record every meal. Review of Resident #69's physician's orders revealed the resident was on a consistent carbohydrate diet. She was also supposed to receive Boost three times a day between meals. The Boost was ordered on 02/05/25. The resident also had an order to be weighed weekly. Review of Resident #69's weights revealed the resident weighed 162.4 pounds on 01/15/25. Her weight on 02/12/25 was 153.4 pounds reflecting a 5.5% loss in the past 30 days. Her most recent weight on 02/19/25 revealed a weight of 157 pounds showing her weight was starting to trend back up. Review of Resident #69's meal intakes for the past 30 days (01/22/25- 02/20/25) revealed the resident had an overall poor appetite. She ate less than 50% 39 times and ate more than 50% 28 times. She was known to refuse meals 16 times. Out of the 30 days recorded, the resident did not have all three meals recorded 27 of those 30 days. On 02/16/25 and on 02/17/25, only one of the three meals the resident was provided was recorded on the meal intake record. On 02/19/25, only two of her three meals got recorded that she received that day. Review of Resident #69's MAR for February 2025 revealed the resident was supposed to receive Boost three times a day and they were scheduled for 10:00 A.M., 2:00 P.M., and 7:00 P.M. The nurses were documenting the resident was receiving her supplement three times a day as ordered. On 02/20/25 at 12:23 P.M., an interview and observation with Resident #69 revealed she had not been getting her Boost supplement three times a day between meals as ordered. She reported she had not been given the Boost supplement that should have been given to her at 10:00 A.M. that morning. She was noted to have her lunch tray sitting on the bedside table in front of her while she was sitting up in her recliner at bedside. She was not noted to have ate any of the meal that was sitting in front of her and reported she had no intent on eating it. LPN # 404 was in her room preparing to perform her treatment to the pressure ulcer on her left great toe. The resident asked her to take her tray away. LPN #404 was asked at the time of the observation who was responsible for providing the resident her Boost supplement. She reported the aides provided the Boost supplements to the residents, if ordered, when bringing them their meal trays. She was asked if the resident had received her Boost for that morning. The resident spoke up and told LPN #404 that she had not been given a Boost that day. The nurse asked the resident what flavor she wanted and the resident reported she wanted chocolate. The nurse left the room with the resident's tray to get the resident her Boost that was scheduled to be given at 10:00 A.M. On 02/20/25 at 12:24 P.M., further interview with Resident #69 revealed she was not consistently receiving her Boost as ordered. She reported she would get it on occasion, but denied she was receiving it three times a day and between meals as ordered. She again denied she had been given one that morning. Her roommate was noted to have a Boost sitting on her bedside table, but Resident #69 did not have one in her room or in her trash can. On 02/20/25 at 1:25 P.M., an interview with Certified Nursing Assistant (CNA) #486 revealed Resident #69 was supposed to get Boost at 10:00 A.M. and 2:00 P.M. He was asked why the resident was not given a Boost at 10:00 A.M. that morning as ordered. He stated they were busy at 10:00 A.M. and it must have just slipped his minds. He then reported that he had just been told by LPN #404 that Resident #69 was to receive a Boost supplement at 10:00 A.M. and 2:00 P.M. He was not previously aware of the resident was supposed to get a Boost at 10:00 A.M. until he was told by the nurse. He confirmed the aides were supposed to provide the Boost supplements to the residents. They kept them in the refrigerator located in the dining room just off the unit. He was not sure where it was listed to show what residents were to receive supplements or when. LPN #404 was in the general area and informed CNA #486 that information was on the clipboard that had their assignment sheet on it. He reviewed the assignment sheet and noted Resident #69's name was not on it to show she was supposed to be receiving a supplement. There was a report book at the nurses' station that included a few copies of physician's orders that pertained to supplements. One of the three copies of orders pertained to Resident #69 dated 02/05/25 and indicated she was to receive Boost three times a day between meals. The staff reported those were recent orders that had not made their way onto their assignment sheet yet. The assignment sheet only showed supplements that were to be given with meals, as was identified within boxes titled breakfast, lunch, and dinner. There were no residents on that list who were receiving any supplements between meals. Review of the facility's policy on Dietary Supplements (revised February 1999) revealed dietary supplements would be given to residents when recommended by the dietician and ordered by the physician. Dietary supplements would be given to residents for weight loss, decreased appetite as recommended by the dietician. Dietary supplements would be given to the residents at 10:00 A.M., 2:00 P.M., and 8:00 P.M., or as requested. The nurse would then chart the supplement intake. Based on observation, record review, policy review and interview the facility failed to ensure residents were properly assessed, monitored, and provided adequate nutrition to prevent weight loss. This affected three residents (#5, #7, and #69) of five residents reviewed for nutrition. Actual harm occurred on 01/29/25 when Resident #5, who required staff set-up assistance with meals was assessed to sustain a 12.1 pound severe weight loss (in approximately 30 days) as a result of the facility's failure to revise and/or implement comprehensive and individualized care plan interventions to address changes in the resident's nutritional status (decrease in oral intake) and impaired wound healing (of a Stage III pressure ulcer). On 12/26/24 Resident #5 weighed 157.4 pounds and on 01/29/25 the resident weighed 145.3 pounds without evidence the facility accurately assessed, monitored, and provided adequate nutrition/interventions timely to prevent the weight loss and support healing of the resident's pressure ulcer. The resident's decline in weight continued and on 02/25/25 the resident was assessed to sustain an additional weight loss of 10.4 pounds with a recorded weight of 134.9 pounds. Findings include: 1. Medical record review revealed Resident #5 was admitted [DATE] with diagnoses including Alzheimer's disease, dementia, diabetes, chronic obstructive pulmonary disease, heart failure, chronic kidney disease, rheumatoid arthritis, osteoarthritis, hypothyroidism, and anemia. The resident had a history of pressure ulcers. Review of Resident #5's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a five percent weight loss noted and required set up assistance with eating. Review of Resident #5's nutritional plan of care dated 06/05/24 and revised 01/07/25 revealed the resident had nutritional problems or potential nutritional problems related to advanced age, chronic disease, altered diet, variable meal acceptance, increased metabolic demand related to skin alteration, elevated body mass index, history of abnormal lab values, diuretic use, and malnutrition risk. Interventions included consistent carb diet, regular texture, thin liquids, gravy in bowl on side for moisture as well as appropriate condiments. Fluids intake and toss cup, document/monitor/report signs and symptoms of dysphagia, refusing to eat, and appears concerned during meals. Monitor/record/report to physician any signs and malnutrition including significant weight loss of three pounds in one week, greater than 5% in one month, greater than 7.5% in three months, and greater than 10% in six months. Occupational Therapy (OT) to screen and provide adaptive equipment for feeding as needed. Provide and serve supplements as ordered. Provide, serve diet as ordered. Monitor intakes and record every meal. RD to evaluate and make diet changes recommendation as needed. Take and toss cup (toddler sippy cup) and weights as ordered. Review of Resident #5's current orders dated 02/2025 revealed the resident was receiving Toresmide (diuretic) 20 milligrams daily for edema. Review of Resident #5's physician notes dated 12/17/24, 01/10/25, 01/16/25, and 02/08/25 revealed no evidence the resident had edema. Review of Resident #5's nursing notes dated 11/24/24 to 02/25/25 revealed no evidence the resident had edema. Review of Resident #5's weekly skin assessments dated 12/2024 to 02/25/25 revealed no evidence the resident had edema noted. Review of Resident #5's current orders dated 02/2025 revealed to weigh monthly, Ensure Clear two times a day (active 02/11/25), nutritional treat with lunch and dinner for decreased intake (active 09/30/24), consistent carb diet, regular texture, thin consistency (referring to liquids) (active 09/27/24). Review of the aide assignment sheet (undated) revealed Resident #5 was to receive an Ensure Clear at breakfast and dinner. There was no evidence of the nutritional treat on the assignment sheet. a. Observation on 02/19/25 at 12:32 P.M., revealed Resident #5's lunch tray had been picked up and was sitting in the hallway on a cart. The lunch tray contained lima beans, chicken, dessert, and coffee had not been touched. There was no evidence of nutritional treat. Observation on 02/20/25 at 8:55 A.M., of Resident #5 revealed the resident was in bed and her breakfast tray had not been touched. The tray had ham, eggs, and a bowl of cereal on it. There was no evidence of Ensure Clear supplement or staff assisting the resident with the meal. Observation on 02/24/25 at 9:20 A.M., revealed Resident #5 was in bed and her breakfast tray had not been touched. The resident's lips were dry and flaky. Resident #5 had dried blood on her top lip and in her bilateral nasal passages. There was no evidence of Ensure Clear supplement. There was no evidence of staff assisting the resident with her meal. There was a sign above the resident's bed dated 10/18/24 that indicated the resident's diet was regular. Liquids were thin and liquids were to be in take-n-toss cups. Swallowing Guidelines included small bites/sips, upright at 90 degrees for all intakes, and liquids removed from reach when head of bed was not all the way up. The sign was signed by OT staff. Observation and interview on 02/24/25 at 9:40 A.M., with Certified Nursing Assistant (CNA) #606 revealed she was the aide that set up Resident #5's breakfast tray, however, she did not provide the drinks to the resident. The CNA reported the resident was not receiving a supplement and believed the drinks on her tray were water and cranberry juice. The CNA reported she was told the resident didn't require assistance with meals. The CNA confirmed the resident had not touched her breakfast tray and had sipped her cranberry juice on her meal tray. Observation and interview on 02/24/25 at 9:56 A.M., of Resident #5 with Nurse Practitioner (NP) #337 confirmed the resident's lips and nasal passages were dry. The NP confirmed she was not aware the resident was not eating. The NP confirmed there was a sign hung near the resident's bed that indicated small bites and sips, however the resident's banana and toast, were not cut up in small bites. The NP confirmed the resident had not touched her cereal, banana, toast or eggs. The NP started assisting the resident with breakfast. The resident accepted the NP's assistance and began to eat. Interviews were attempted on 02/19/25 at 12:32 P.M., 02/20/25 at 8:55 A.M., 02/24/25 at 9:20 A.M., 02/24/24 at 9:56 A.M., and 02/25/25 at 11:09 A.M., with Resident #5 revealed the resident was not able to provide reliable information. Interview on 02/24/25 at 10:12 A.M. and 1:09 P.M. with Licensed Practical Nurse (LPN) #487 reported a nutritional treat would be ice cream, magic cup, and the aides administer the supplement according to aide assignment sheet. The LPN confirmed nutritional treat was not on the aide's sheet. LPN #487 confirmed the nurses document the nutritional treat and supplement intakes on the resident treatment administration records (TAR), however the aides were the ones administering the treat and supplement. The LPN confirmed the facility has not had Ensure Clear for months and staff were giving Resident #5 a Boost Breeze which looks like cranberry juice, however, the order was for Ensure Clear. The LPN confirmed staff were signing off they were administering Ensure Clear even though it was not available. LPN #487 confirmed she had signed off the amount given this morning before the resident had consumed the supplement. The LPN measured the remainder of the supplement at 1:09 P.M. and the amount remaining from the breakfast supplement was 100 ml and it was unclear of how much was spilled on her breakfast tray this morning. The LPN reported she documented 120 ml because that was the amount the resident had taken when she observed the resident this morning during her medication pass. On 02/25/25 at 7:39 A.M. interview with Speech Therapist #309 revealed she had not seen Resident #5 since October 2024. She had placed a sign in the room for small bites and sips, however it was more for the liquids due to resident was coughing when she was taking fluids. Speech Therapist #309 also recommended sippy cups. The resident used to feed herself. Speech Therapist #309 was unaware the resident had declined. b. Review of Resident #5's weights dated 10/23/24 to 02/05/25 revealed the following weights: 10/23/24 160.3 pounds 10/30/24 158.2 pounds 11/01/24 158.2 pounds 11/06/24 159.1 pounds 12/26/24 157.4 pounds 01/02/25 153.2 pounds 01/15/25 153.2 pounds 01/22/25 153.2 pounds 01/29/25 145.3 pounds 02/05/25 145.3 pounds. There was no documented evidence that the resident was weighed after 02/05/25. Observation on 02/25/25 at 11:09 A.M., of Resident #5 weight with LPN #487 and CNA #421 per the surveyor's request revealed the resident weighed 134.9 pounds via mechanical lift. The resident had lost an additional 10.4 pounds since 02/05/25. c. Review of Resident #5's current dietary ticket for breakfast, lunch, and dinner revealed the resident was ordered a regular, consistent carb, thin liquid diet. The resident was on 1500 milliliter (ml) fluid restriction and gravy with meals. There was no evidence of Ensure Clear supplement or nutritional treat. Review of Resident #5's current orders revealed no evidence of an order for 1500 ml fluid restriction or gravy with meals. Review of the supplement list dated 02/24/25 revealed Resident #5 was to receive an Ensure Clear two times a day for weight loss. There was no evidence Resident #5 was to receive a nutritional treat. Interview on 02/24/25 at 10:28 A.M., and 11:23 A.M., with Dietary Manger (DM) #429 confirmed Resident #5's the meal tickets were inaccurate and had not been updated. The resident had not been on a fluid restriction since 09/2024. A nutritional treat would be something the floor staff would provide to the resident such as a yogurt per the Director of Nursing (DON). The DM reported the floor staff were also responsible for administering supplements and he didn't know what the difference between the Boost Breeze and Ensure Clear and he does not order the supplements. d. Review of Resident #5's meal intakes dated 01/26/25 to 02/23/25 revealed on 02/16/25 and 02/17/25, only one of the three meals were documented and 02/19/25 and 02/20/25 only two of the three meals were documented. The resident had refused 20 meals, 42 meals she ate at less than 50%, and 21 meals she ate greater than 50%. The resident was noted to range in ability from independent to dependent at times with meals. Interview on 02/24/25 at 3:12 P.M., with the Administrator revealed staff were not documenting all meal intakes on 02/16/25, 02/17/25, 02/19/25, and 02/20/25. e. Review of Resident #5's skin/wound note dated 06/05/24 revealed the nurse was notified the resident had an open area noted to her coccyx. This nurse and the unit manager Registered Nurse (RN) assessed the resident's coccyx area and a Stage III (full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present pressure area) was noted to the site that resident had previously had a pressure injury where a divot remained. The wound measured 1.0 cm by 0.5 cm by 0.2 cm with 100% granulated tissue noted, scant amount of sanguineous drainage (red) noted. The peri wound was red, blanchable, and intact. Resident reported the area was tender to touch. The Nurse Practitioner was notified and new orders received for treatments, supplements, and a wound consult. Review of Resident #5's telemedication wound visit notes dated 01/08/25 to 02/19/25 revealed the physician had documented the resident's appetite was fair and indicated a protein supplement. Review of Resident #5's current orders revealed no evidence of a protein supplement order. Review of Resident #5's telemedicine wound care note dated 02/19/25 revealed the resident had a Stage III pressure ulcer on the coccyx measuring 1.0 centimeters (cm) by 1.0 cm by 0.1 cm with moderate serous drainage. The wound bed was 80 percent granulation and 20% other viable tissue. The wound has exacerbated due to generalized decline of resident, non-compliance with wound care, and nutritional compromise. (The resident's medical record revealed the resident would at times refuse medications and would refuse an occasional pressure ulcer dressing change). Interview on 02/24/25 at 3:51 P.M., with the Assistant Director of Nursing (ADON), Infection Preventionist (IP), and Wound Nurse (WN) #417 (one staff member with three facility job titles) confirmed Resident #5 had a Stage III pressure ulcer on her coccyx and a diabetic wound on her right foot. The ADON/IP/WN #417 confirmed she had to call the wound physician to get his assessment notes due to the facility did not have them. The wound physician does telemedication visits with her weekly. The ADON/IP/WN #417 confirmed the wound notes indicated the resident needed a protein supplement, however the facility's physician had discontinued Prosource in December 2024 due to the resident had refused four doses. The nurse reported she would call the wound physician today to see what recommendation he had for a protein supplement for Resident #5. f. Review of Resident #5's medication administration record (MAR) and treatment administration record (TAR) dated 01/2025 and 02/2025 revealed the resident was ordered Ensure Clear once daily, however there was no documented evidence of the percent of the intake. The resident consumed 25-50% of the nutritional treat for lunch and dinner. g. Review of Resident #5's dietary note dated 11/26/24 revealed the resident estimate calorie needs were 2250-2620 k/calories and 90-112 grams (gm) of protein. The resident's ideal body weight was 125 pound plus/minus 10%. The resident was on a diuretic for congestive heart failure and weight loss was desired and expected. Review of Resident #5's dietary note dated 12/27/24 revealed the resident's weight was 153.2 pounds which was 10.5% weight loss in 180 days. The resident's diet was consistent carb diet, regular texture, thin liquids, no added salt, 1500 ml fluid restriction, gravy in bowl on side for moisture as well as appropriate condiments. Ensure Clear daily. The resident was able to assist with meals and makes preferences known. No chewing or swallowing difficulties noted at this time. Meal intakes vary. Weight loss desired and expected. Continues to meet Aspen criteria (a table that provides clinical characteristics to support a diagnosis of malnutrition in adults based on consensus statement from the Academy of Nutrition) for malnutrition risk due to chronic disease, weight changes, and decreased po (oral) intakes. Weights as per order. Encourage and assist with meals as needed. Review of Resident #5's dietary note dated 12/31/24 revealed Registered Dietician (RD) reviewed related to pressure injury. Resident noted with increased metabolic needs related to skin integrity as evidenced by pressure injury. The resident ordered consistent carb diet/no added salt diet, 1500 ml fluid restriction, regular texture with thin liquids. Additional support of ProSource twice daily and Ensure Clear daily. Intakes of meals are 25-100%. Current nutritional interventions remain appropriate, no new recommendations. Will continue to monitor. Review of Resident #5's dietary note dated 01/07/25 revealed the resident's weight was 153.2 pounds which was 10.5% weight loss in 180 days. The resident's diet was consistent carb diet, regular texture, thin liquids, no added salt, 1500 ml fluid restriction, gravy in bowl on side for moisture as well as appropriate condiments. Ensure Clear daily. The resident was able to assist self with meals and makes preferences known. No chewing or swallowing difficulties noted at this time. Meal intakes vary. Weight loss desired and expected. Continues to meet Aspen criteria for malnutrition risk due to chronic disease, weight changes, and decreased po intakes. Weights as per order. Encourage and assist with meals as needed. Review of Resident #5's dietary note dated 01/31/25 revealed a weight warning. The resident's weight was 145.3 pounds, which was 5.2% weight loss over 30 days and 13.2% weight loss over 180 days. Requested reweigh for accuracy. Increased metabolic needs relate to skin integrity as evidence by pressure injury. Current nutritional intervention remains appropriate with additional nutritional support in place. Intakes were appropriate. Current body weight indicates a previously identified significant weight loss, Registered Dietician reviewed weight change noted on 01/07/25. No new recommendation and will follow as needed. Review of Resident #5's dietary notes dated 02/06/25 there was a weight change warning indicating the resident weighed 145.3 pounds which was 5.2 % weight loss over 30 days and 14.2% weight loss over 180 days. New recommendation to increase Ensure Clear to twice daily. The resident remains on a consistent carb diet regular texture, thin liquids, no added salt, 1500 ml fluid restriction, gravy in bowl on side for moisture as well as appropriate condiments. The resident was able to assist self with meals and makes preferences known. No chewing or swallowing difficulties noted at this time. The meal intakes vary. The resident meets Aspen criteria for malnutrition as evidenced by chronic disease, weight changes, and decreased by mouth (po) intakes. Weights as per order, encourage and assist with meals as needed. There was documentation regarding the resident's nutritional needs for wound healing. On 02/24/25 at 11:56 A.M., phone interview with Registered Dietitian (RD)#900 revealed she could write down the surveyor's concerns regarding Resident #5's nutrition and weight and follow up with the Dietician Tech due to RD #900 had not been involved with the resident's care recently. Per RD #900, the RDs take turns rotating in the buildings. The Dietician Tech was the one following up with most of Resident #5's care. Interview on 02/24/25 at 2:07 P.M. and 02/25/25 at 10:18 A.M., with Dietary Tech (DT) #339 confirmed her assessments were inaccurate due to the resident was not on a fluid restriction or required gravy with meals. The DT confirmed she had not observed the resident eat and she obtained most of her information from the medical record. The DT reported she looks at the meal intake percentages, however she doesn't look to see if staff were documenting meal intakes for all three meals. The DT confirmed staff were not recording intakes of supplement prior to 02/11/25 and she could not verify the resident intakes an acceptance, however she had increased the supplements on 02/11/25 due to the resident having weight loss. The DT confirmed the supplements should not be given with meals and the nutritional treats should not be given with meals as well due to it may prevent the resident from eating her meals. DT #339 reported she was unaware the facility didn't have Ensure Clear available. The DT confirmed she was not aware the resident was not receiving Ensure Clear and there was a slight difference in the Ensure Clear and Boost Breeze and the facility needed to get a clarification order. The DT reported she had questioned the facility about the nutritional treats and was told it was just a snack. The DT confirmed her assessments didn't include nutritional needs for pressure ulcers and skin alteration and those recommendations usually come from the Registered Dietician. The DT reported if the wound physician recommended a protein supplement, she would probably recommend fortified foods due to the resident's meal intakes being poor and if she refused Prosource (in the past). The DT confirmed the Dietary Note dated 12/31/24 indicated the resident was on Prosource, however the resident was not receiving ProSource due to it had been discontinued on 12/24/24. The DT reported the resident should have been on weekly weights due to the continued weight loss. DT #339 revealed she didn't realize the resident's order was for monthly weights. The DT confirmed there had been some issues with weights not being obtained timely. Review of Resident #5's progress notes dated 02/25/25 revealed Remeron (medication used to treat clinical depression and insomnia) was ordered for weight loss, supplement changed to Boost Breeze, and Prosource 30 ml twice a day was added for supplement and wound healing. Review of Resident #5 dietary note dated 02/25/25 revealed the resident had significant weight loss and skin alteration noted. The resident's diet was consistent carb diet, regular texture, regular thin consistency. Meal intakes were variable with reduced overall average with four noted refusals over the last seven days. ProSource 30 ml started yesterday with acceptance thus far. Boost Breeze twice a day was ordered 02/24/25. The resident's current body weight was 134.9 pounds which was 36.3-pound weight loss from 09/02/24 and 22.5-pound weight loss from 12/26/24. Weight loss was previously identified but the resident continues to lose weight. Remeron ordered on 02/24/25 to aid in appetite. Occupational and Speech therapy screening pending. New intervention started this week and current intervention for wound healing and weight management deemed appropriate at adequate, however recommend changing diet to liberalization to help encourage intak[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident #58's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia with agitation, unspecified psychosis, major depressive disorder, restlessness and agitation, peripheral vascular disease, and osteoarthritis. A review of Resident #58's care plan, dated 12/28/21 revealed she had a care plan in place for being at risk for an alteration to skin integrity related to bladder incontinence, impaired cognition, and poor safety awareness. The goal was for her to have no new areas of skin breakdown. The interventions included skin inspections, preventative treatments as ordered, keep bony prominences from direct contact, encouraging/ assisting her with turning and repositioning with routine nursing rounds and as needed (PRN) for comfort as tolerated or as she would allow. Pillows were to be used to maintain positioning. A review of Resident #58's quarterly pressure ulcer risk assessment dated [DATE] revealed the resident was assessed as being a high risk for pressure ulcers. Her risk factors included having a very limited sensory perception, her skin being very moist, being chair fast, having very limited mobility, and a problem with friction and shearing. The comments in the assessment indicated the resident was a two to one maximum assist to transfer. Preventative interventions/treatments were indicated to be in place. There were no additional quarterly pressure ulcer risk assessments completed after the assessment on 01/04/23. A review of Resident #58's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech. She was sometimes able to make herself understood and was sometimes able to understand others. She had short and long term memory impairment and her cognitive skills for daily decision making was moderately impaired. She displayed verbal behaviors directed at others and other behaviors not directed at others. She was not known to reject care during the assessment reference period of the past seven days. The resident required an extensive assist of two for bed mobility, transfers, and toilet use. Ambulation did not occur. She was always incontinent of her bowel and bladder and was at risk for pressure ulcers, but did not have any unhealed pressure ulcers at the time the assessment was completed. A review of Resident #58's weekly skin assessments revealed the skin inspections were being completed as per the plan of care through 07/01/23. There was no skin assessment completed on 07/08/23, as it should have been. The skin assessments skipped from 07/01/23 to 07/15/23. The skin assessments showed the resident was first noted to have a pink area to her right hip/ bony prominence beginning on 05/20/23. That assessment did not include any measurements of the red area noted to her right hip, nor did it indicate if the pink area was blanchable or not. There was no indication what the pink area was classified as as the type indicated on the assessment was other. The skin assessment defined a Stage I pressure ulcer as intact skin with non-blanchable redness of a localized area usually over a bony prominence. The assessment indicated they did not recognize the red area as pressure and an ulcer tracking tool was not initiated. The comments under the assessment indicated the right hip/ bony prominence was noted to be pinkish with skin intact in the area of her previous right hip surgery. A new order was initiated for Mepilex (foam dressing) to be applied to the area as a preventative measure. Weekly skin assessments through 06/10/23 continued to mention the area to the resident's right hip describing it as a slight pink area each week it was assessed. None of those assessments indicated whether the slightly pink area blanched or not, nor did they include measurements to see if the pink area was increasing in size. They continued the same treatment initiated on 05/20/23 as a preventative measure. A weekly skin assessment dated [DATE] revealed Resident #58 was noted to have a scabbed area to her right hip. It measured 0.3 centimeters (cm) in length x 0.2 cm in width x 0.1 in depth. The area was described under type as other and was not identified as a pressure ulcer with any staging indicated. Subsequent weekly skin assessments completed through 07/15/23 continued to mention the scabbed area to her right hip classified under type as other with no identification as a pressure ulcer or staging. It measured 0.9 cm x 0.5 cm with no depth recorded when measured on 07/15/23. It was not until a skin assessment was done on 07/22/23 that the resident's area to her right hip was assessed as an Unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green, or brown) and/ or eschar (tan, brown, or black) in the wound bed. A review of Resident #58's nurses' progress notes dated 06/29/23 revealed a nurse's note at 3:33 A.M. that indicated the resident was noted to have a scabbed area to her right hip that measured 1 cm in circumference with a dark scab in the center and yellow slough surrounding. The surrounding tissue was pink to extend the total area to about a 3 cm circle. Scant dark exudate (drainage) was noted on the existing dressing. The nurse cleansed it with in house wound cleanser, patted it dry, and placed a Mepilex dressing on it (as was previously ordered as a preventative treatment. The nurses' progress notes did not provide any documented evidence of the physician or hospice being notified of the deteriorating area to her right hip, that met the definition of an Unstageable pressure ulcer. A review of an interdisciplinary team (IDT) note dated 07/13/23 at 2:41 P.M. revealed the IDT met to discuss Resident #58's fall preventions due to changes in her condition, but did not discuss anything about the deteriorating wound she had on her right hip that was then an Unstageable pressure ulcer. The nurses' progress notes were absent for any further documentation pertaining to the area on Resident #58's right hip until a nurse's note dated 07/22/23 at 8:58 P.M. that indicated during a routine skin assessment the Mepilex dressing was removed from her right hip. The previous scabbed area was then noted to be open with slough to wound bed. A treatment was completed as ordered (same treatment initiated on 05/20/23 as a preventative treatment). A message was left for the hospice nurse to return a call and, when the call was returned, the hospice nurse was notified. New orders were received at that time for the resident to avoid lying on her right side. They were to turn her every two hours from her back to her left side due to the pressure ulcer on her right hip. A new treatment order was given for the pressure ulcer to her right hip to include the use of a wet to dry dressing daily and PRN until healed. The physician was not notified of the resident's Unstageable pressure ulcer to her right hip until 07/24/23 at 11:41 A.M. The progress notes indicated they were awaiting a response, but the response was not documented as having been received. A review of Resident #58's ulcer tracking tool for a pressure ulcers revealed an ulcer tracking tool was not initiated for the resident for any pressure ulcers until 07/22/23. The ulcer tracking tool identified the resident as having an Unstageable pressure ulcer to the right hip/ trochanter that measured 4 cm by 4 cm. The date of origin was indicated to be 07/22/23, despite the resident having documentation in her nurses' progress notes as having a wound to her right hip on 06/29/23 that met the definition of an Unstageable pressure ulcer. The assessment indicated the resident had a moderate amount of serosanguinous drainage and the wound bed was covered with white slough. On 07/24/23 the resident's care plan was updated to reflect she had impaired skin integrity as evidenced by a pressure ulcer to her right hip. The goal was for her to exhibit slow healing of the pressure ulcer as exhibited by development of healthy tissue. The interventions included changing the dressing according to the physician's orders, evaluating the wound daily and monitor it for an intact dressing, signs and symptoms of infection, progress and/or changes, initiate a skin grid to document the size, color, odor, drainage and monitor progress weekly and as needed, protein supplementation as per the physician's orders, provide pressure relief for the affected area, avoid lying on her right side while in bed, and reposition her every two hours from her back to her left side, while lying in bed. On 07/27/23 at 10:55 A.M., an interview with STNA #161 revealed Resident #58 had an area to her right hip that had been there for a month or two. She indicated the resident had a hip replacement and had a bony prominence that stuck out on her right hip. The right hip had a red area and normally had a dressing on it. The area was now open and had a different type of dressing on it. She was not sure why the resident had skin breakdown when preventative measures had been in place. On 07/27/23 at 11:00 A.M., an interview with LPN #105 revealed the resident had an area to her right hip. She believed it was classified as a pressure ulcer, but would have to check the medical record to make sure. She too indicated the resident had a bony prominence on her right hip. When she first started working there it had a foam padding over it. She did not think the area was classified or staged as a pressure ulcer when it was first documented as a red area. She was the nurse working on 07/22/23, when the wound to the right hip was found to have the wound bed covered in white slough. She stated she was the one that documented that in the nurses' progress notes. She asked the nurse manager to come and look at it because she was not sure how to document it. It was a 4 cm by 4 cm area at that time. She notified hospice, but was not present when the hospice nurse called back in. Another nurse that came in at 9:00 P.M. would have been the one to speak with hospice and get the new order for treatment. She was not aware of there being a wound on the resident's right hip that had a dark scabbed area in the centered with yellow slough surrounding it as was documented on 06/29/23 in the progress notes. It was not until she discovered the wound on 07/22/23 that she looked back through the nurses' progress notes and seen that was documented on 06/29/23. She confirmed it was not until 07/22/23 that they got new orders for the resident that included an appropriate treatment for an Unstageable pressure ulcer and to turn the resident every two hours from her back to her left side. She was not sure why breakdown occurred with her previous skin prevention interventions in place. She was surprised to find the resident's right hip to have that kind of breakdown in it. She agreed hospice and/ or the resident's physician should have been notified on 06/29/23, when the resident was documented as having a deteriorating skin issue that met the definition of an Unstageable pressure ulcer. She indicated they would have wanted to get a new treatment order that was appropriate for that stage of a pressure ulcer and not continue the same treatment that was initially ordered as a preventative treatment. On 07/27/23 at 2:15 P.M., an interview with the DON revealed she was not able to find any additional information pertaining to the resident's pressure ulcer assessments. She did not see evidence of a more recent pressure ulcer risk assessment being completed after 01/04/23, nor did she find evidence of a weekly skin assessment being completed on 07/15/23. She confirmed the resident's area to her right hip was not assessed as a pressure ulcer, until 07/22/23, when it was identified as an Unstageable pressure ulcer covered with white slough. She did not provide any documented evidence of the redness that was noted to Resident #58's right hip beginning on 05/20/23 being assessed by a nurse for blanching to rule out it being a Stage I pressure ulcer at that time. She also confirmed the nurse that documented the area to the right hip as having had a scabbed center with yellow slough surrounding it should have contacted the physician for a new treatment instead of continuing the same preventative treatment that had been previously ordered. She stated the nurse that documented that was an LPN and was not qualified to assess the staging of pressure ulcers. She acknowledged there was no evidence of another nurse assessing the area or a new treatment being initiated until 07/22/23, when the area was again documented in the progress notes and finally being classified as an Unstageable pressure ulcer. She confirmed the area went from a 1 cm by 1 cm scabbed area with dark scabbing in the center and yellow slough surrounding it to a 4 cm by 4 cm Unstageable pressure ulcer with the wound bed being covered with white slough. A review of the facility's policy on pressure ulcers (revised 04/27/22) revealed a resident who entered the facility without a pressure ulcers should not develop pressure ulcers, unless the resident's clinical condition demonstrated that they were unavoidable. The facility was to provide care and services to promote the prevention of pressure ulcer development and promote healing of pressure ulcers that were present. They were to identify residents at risk for development of pressure ulcers by utilizing pressure ulcer risk assessments per the EHR. Those risk assessments were to be completed quarterly. A licensed nurse was to do a visual head to toe assessment of each resident weekly and document the findings in the EHR. 4. A review of Resident #129's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic neck/ back pain, chronic kidney disease, and neuropathy. A review of Resident #129's skin assessment completed upon his admission [DATE] revealed the resident had a Stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red/ pink wound bed, without slough; may also present as an intact or open/ ruptured serum-filled blister) to the left inner buttock that measured 2.3 cm x 3 cm x 0.01 cm. The skin assessment indicated he was not reviewed for a turning and repositioning program. A review of Resident #129's Minimum Data Set (MDS) assessments revealed his Medicare 5-day MDS assessment and admission MDS assessment was still in progress. A review of Resident #129's care plans revealed he had a care plan in place, dated 07/20/23 for being at risk for an alteration in skin integrity. The goal was for him to not have any new areas of skin breakdown. The interventions included the need to turn and reposition him every two hours. His care plans also indicated he had a Stage II pressure ulcer to his left buttock related to immobility, weakness, and deconditioning. This care plan was also initiated on 07/20/23. The goal was for his pressure ulcer to show signs of healing. The interventions included administering treatments as ordered and assisting him to turn/reposition at least every two hours, more often as needed, or requested. The care plan interventions were reflected on the Kardex (information made available to the aides to identify the resident's care needs/ requirements). A review of Resident #129's physician's orders (dated 07/19/23) revealed the resident had a treatment order in place to cleanse the Stage II pressure ulcer to the left inner buttock with soap and water, rinse, pat dry, and apply an Optifoam dressing. Staff were to complete the dressing change one time a day every three days and as needed (PRN). A review of Resident #129's treatment administration record (TAR's) for July 2023 revealed there was no documented evidence of the resident having his treatment provided to the Stage II pressure ulcer on his left inner buttocks on 07/23/23. A review of Resident #129's nurses' progress notes revealed there was no evidence of the resident refusing any treatments to his pressure ulcer on the left inner buttock or to support why his treatment was not signed off as having been completed on 07/23/23. Observations of Resident #129 on multiple occasions between 07/25/23 at 10:09 A.M. and 07/26/23 at 7:05 A.M. noted him to always be in bed in a supine position lying on his back with direct pressure to the Stage II pressure ulcer to his left inner buttocks. No pillows were being used for positioning and the resident always had his head of the bed raised and the knee [NAME] on the bed raised putting direct pressure on his buttocks. He was not observed to be placed in a side lying position during any of the observations made. On 07/25/23 at 8:22 A.M., an interview with Resident #129 revealed his treatment had only been completed once by the facility in the seven days he had been at the facility. He reported the treatment that was signed off on the TAR as having been completed on 07/25/23 was the only treatment he received to the pressure ulcer he had on his left buttock. He did not recall them doing a treatment on 07/23/23, when no documentation had been made in the TAR showing it had been. He had denied any of the staff were coming in and assisting him with turning and repositioning every two hours as per his plan of care. He denied he had the strength to physically turn himself in bed and would not oppose them coming in and assisting him with that. On 07/26/23 at 8:30 A.M., an interview with STNA #203 revealed she had only worked at the facility for about a month now. She worked on the rehabilitation unit, where Resident #129 resided, and worked there last Sunday. She was familiar with the resident and thought he would be at risk for pressure ulcers as he did not get up much or walked around. She only knew of him having a mark on his buttocks that was the result of sitting on his bedpan on 07/24/23, but denied it was open. She was not aware of him having any other skin issues, but did not work with him all that often. The resident required an extensive assist with rolling/ turning/ dressing etc. She claimed they did rounds every couple of hours and would ask him if he needed anything. They pulled him up in bed and repositioned him when in there. When she worked last Sunday, they placed a pillow behind his back to help shift the weight off his buttocks. She worked Monday, but was assigned to a different section of the rehabilitation unit. She said she would have helped in his section as well, but could not explain why he was observed in the same position all day on Monday (07/24/23). On 07/26/23 at 8:41 A.M., an interview with RN #183 revealed Resident #129 was at risk for pressure ulcers. She was not sure if he had any existing pressure ulcers and had to check the computer to see if he had any areas. She initially denied he had any pressure ulcers reporting he only had yeast on his scrotum, bruising, and blanchable areas to his bilateral buttocks. She was referring to the skin assessment that was completed on 07/24/23. She then noted that he had a Stage II pressure ulcer to his left inner buttocks. She was asked what they were doing to treat that area and to promote healing. She indicated they were performing a treatment to his left inner buttock according to what was included in his physician's orders. The aides were also turning and repositioning him regularly. She claimed she would check the residents regularly to ensure they were being turned. She would also remind the aides regularly that the residents needed turned. She was not sure why a treatment had not been signed off as having been completed on 07/23/23, when due, or why the resident was observed not to have been turned and repositioned the past couple of days when observations were made. On 07/26/23 at 8:50 A.M., the DON was informed of concerns with Resident #129 not being turned and repositioned every two hours as per his plan of care. She was also informed there was no documentation to support his treatment to the pressure ulcer on his left inner buttocks being completed on 07/23/23 as ordered. She was not able to provide any additional information to explain why the treatment had not been signed off as having been completed on 07/23/23. She stated she spoke with the RN #183, who was the nurse that worked on 07/23/23, and the nurse was not able to explain why the treatment was not documented as having been completed. The nurse did not provide her any indication that it was completed as ordered. She stated she would also remind the nursing assistants on the need to ensure the resident was being turned and repositioned. She confirmed he had weakness and needed assistance with turning and repositioning. On 07/26/23 at 1:30 P.M., a follow up interview with RN #183 revealed she had been racking her brain to figure out why she did not document the treatment to the resident's left inner buttock being done on 07/23/23. She reported she was the nurse assigned that day. She recalled she went to do the treatment and did not note any open area at that time. She stated it would have been difficult to get a dressing in that area so she just applied moisture barrier cream instead, which was not the ordered treatment. She denied she had documented such or had updated the physician to get a new treatment order, when she decided not to provide the treatment as ordered. She acknowledged the TAR showed the treatment was provided to the resident as ordered on 07/25/23 and there was no evidence it had been healed. Based on observations, medical record review, staff interview, resident interview, and policy review, the facility failed to prevent the development of pressure ulcers and failed to provide the necessary treatment and services to promote healing. Actual harm occurred to Resident #12, who had impaired mobility and required staff assistance for activities of daily living, on 06/02/23 when the resident's in-house pressure ulcer deteriorated to a Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed) due to a lack of proper interventions ( including repositioning and monitoring of wound vac treatment) being implemented by the facility. Actual harm occurred to Resident #58 on 06/29/23 when the facility failed to identify, assess, and implement the appropriate treatment for a pressure ulcer that started as a Stage I (intact skin with a localized area of non-blanchable erythema (redness) resulting in the ulcer deteriorating to an Unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). This affected four residents (#3, #12, #58, and #129) of four residents reviewed for pressure ulcers. The facility identified 13 residents with pressure ulcers, six of which were facility acquired. The facility census was 75. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 10/31/22 and diagnoses including dementia, diabetes, peripheral vascular disease, and chronic obstructive pulmonary disease. The plan of care dated 11/01/22 stated the resident was at risk for alterations in skin integrity related to generalized weakness, impaired mobility, and requiring assistance with activities of daily living. Interventions included encourage/assist to turn and reposition every two hours as tolerated, or will allow. Use pillow to maintain positioning. A plan of care dated 11/28/22 stated the resident had a current pressure ulcer to the coccyx. It stated to assess/record/monitor wound healing. An admission Minimum Data Set (MDS) 3.0 assessment completed 11/07/22 documented a Brief Interview for Mental Status score (BIMS) of 15, indicating intact cognition. It indicated no pressure ulcers were present. An ulcer tracking tool on 02/21/23 identified the resident as having a Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer on the coccyx measuring 1.2 centimeters (cm) by 0.4 cm by 0.1 cm deep. The resident began being seen by the wound center on 02/24/23. On 02/24/23 the wound center described the wound as a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer of the coccyx measuring 2.1 x 1 x 0.3 cm. The date acquired was listed at 12/24/22. The area was debrided. The wound center recommended turning the resident every two hours and keep turned on her left and on her right as much as possible. On 05/04/23 the pressure ulcer continued as Stage III measuring 0.3 by 0.3 by 0.5 cm. At that time, a PICO Single use negative pressure wound therapy system was ordered with dressing to be changed weekly. It stated a PICO education sheet was sent on 05/04/23. A quarterly MDS 3.0 assessment on 06/02/23 documented a BIMS of 11, indicating moderately impaired cognition. It indicated the resident required extensive assistance from two staff for bed mobility and toilet use. It indicated the resident was totally dependent upon staff for transfers and hygiene and was always incontinent. It indicated the resident had a Stage III pressure ulcer which was not present upon admission. On 06/02/23 the wound center now described the pressure ulcer as a Stage IV measuring 0.3 by 0.2 by 0.4 cm. and the treatment was changed with the PICO wound therapy system being discontinued. On 06/23/23 the wound center described the pressure ulcer as a Stage IV measuring 0.3 by 0.4 by 0.2 cm. The PICO wound therapy system was re-ordered with dressing to be changed weekly. On 07/18/23 the Stage IV pressure ulcer measured 0.5 by 0.2 by 0.4 cm. with bone visible per the wound center. The PICO wound therapy system continued with changing weekly and there were continued recommendations to turn every two hours and keep turned on left and right as much as possible. However, review of facility ulcer tracking tools revealed on 07/18/23 the facility was still categorizing the pressure ulcer as a Stage III and had measurements of 0.5 by 0.3 by 0.2 (which did not match the wound center measurements). Observations on 07/24/23 at 8:58 A.M. and 10:45 A.M. revealed Resident #12 to be in bed on her back. On 07/25/23 at 10:12 A.M., 10:58 A.M., 12:16 P.M., 1:48 P.M., and 3:30 P.M. the resident was in bed on her back. Interview with Resident #12 on 07/26/23 at 8:45 A.M. revealed she stated she was not always turned and repositioned as she should be. She stated she was not turned/repositioned the day before. At that time, she was positioned on her right side. Interview with Nursing Assistant #115 on 07/26/23 at 10:35 A.M. revealed Resident #12 needed staff assistance with repositioning. She stated the resident was cooperative with turning on 07/25/23 but they had only used one pillow under her side instead of two, as they were using on 07/26/23. She stated the resident had asked for two pillows to be used for positioning on 07/26/23. Interview with Licensed Practical Nurse (LPN) #196 on 07/26/23 at 10:40 A.M. revealed she did not know why the resident was not being positioned on her sides instead of just putting a pillow under her with the resident still appearing to be laying on her back. She stated the resident needed to be turned onto her sides every two hours. Observations of Resident #12's PICO wound therapy system on the coccyx on 07/26/23 at 10:20 A.M. revealed the PICO power pump had no lights on to indicate it was functioning properly and the tubing was going under the resident with a potential for pressure to be blocked or to cause pressure to the resident's skin. This was confirmed by LPN #196. She stated that she had not received any training on the PICO wound therapy system and thought there was an audible alarm to alert staff if it was not working properly. She stated she did not know how to check for the proper function of the system. She confirmed there was nothing in place to monitor for the proper functioning of the system. Resident #12 stated, at that time, that the batteries were probably dead. Review of instructions for the PICO single use negative pressure wound therapy system revealed it is used for patients who would benefit from a suction device (negative pressure wound therapy) as it may promote wound healing via removal of low to moderate levels of exudate and infectious materials. The instructions stated the system does not contain any audible alerts and has visual indicators to let you know when there is an issue. It stated dressings should be checked frequently. Instructions stated that a green ok light flashes if the pump is working correctly. (Green light was not on during observation above). The instructions stated that if all lights were off, problems could be dead batteries, pump has completed its course of therapy (contact healthcare professional right away), or the pump is in standby mode (has been paused). Interview with LPN #196 on 07/26/23 at 10:20 A.M. confirmed that the instructions verified no audible alarm and not working properly if no lights are on. Review of the facility policy titled Pressure Ulcer Prevention (dated 06/08/11 and revised 04/27/22) revealed a resident who enters the facility without pressure ulcers should not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable. A licensed nurse will do a visual head to toe assessment of each resident weekly and document findings. Implement individualized interventions to attempt to stabilize, reduce, or remove underlying risk factors such as but not limited to: reposition frequently according to physician order or at resident request. Interview with the Director of Nursing on 07/26/23 at 11:00 A.M. revealed that since the PICO dressing is changed weekly at the wound clinic, the measurements on the facility weekly ulcer tracking tools were obtained from the wound clinic notes. She stated the facility was not routinely observing the wound but this was not noted on the weekly ulcer tracking tools. She confirmed the facility measurements did not match the wound clinic measurements on 07/18/23. She stated she completed the ulcer tracking tool on 07/18/23 but copied the measurements from the previous assessment, which were not accurate. She confirmed the facility was not documenting the wound as a Stage four, even though the wound center was. She confirmed the wound had started in house as a Stage II then progressed to a Stage III and was now being classified as a Stage IV by the wound clinic. 2. Review of the medical record for Resident #3 revealed an admission date of 10/23/18 and diagnoses including dementia and cerebral vascular accident with left sided weakness. A Minimum Data Set assessment completed 05/28/23 documented a Brief Interview for Mental Status score of 2, indicating severe cognitive impairment. The resident had upper extremity impairment on one side and required extensive assistance from two staff with bed mobility and toileting. It indicated the resident had no pressure ulcers. Pressure ulcer risk assessments completed on 03/29/23 and 07/22/23 indicated the resident was at moderate risk for the development of pressure ulcers. A weekly skin assessment on 07/17/23 indicated the resident's skin was clear and without pressure ulcers. On 07/22/23 a pressure ulcer tracking tool documented the resident developed a one centimeter by one centimeter (no depth documented) Stage II pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) on the sacrum. It stated it was a ruptured blister noted during morning care. Review of physician's orders revealed a treatm[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview, and policy review, the facility failed to ensure Resident #3, who had limited range of motion received the appropriate treatment and services to prevent further decrease in range of motion. Actual harm occurred on 06/13/22 when Licensed Practical Nurse (LPN) #196 identified Resident #3's left dominant hand had a decline in range of motion, the hand was more contracted and the nurse was unable to use an existing carrot splint as it caused the resident increased pain. The splint was subsequently discontinued. Prior to the decline there was no evidence staff were routinely providing passive range of motion for the resident. Following the identified decline, there was no evidence of a timely referral to therapy and no evidence any other interventions were implemented to attempt to prevent further decline of the left hand contracture. This affected one resident (#3) of one resident reviewed for range of motion. The facility census was 75. Findings include: Review of the medical record for Resident #3 revealed an admission date of 10/23/18 and diagnoses including dementia and cerebral vascular accident with left sided weakness. Review of an occupational therapy evaluation dated 12/21/21 revealed Resident #3 was referred for evaluation of left hand contracture due to poor staff carryover of passive range of motion and applying splint. Per staff, resident no longer fits in palmar guard splint and is experiencing decreased skin integrity of palm due to flexion contracture/rubbing of nails into palm. The plan was for therapy to provide passive range of motion to the left hand to decrease the contracture and to identify the most appropriate type of hand splint with a trial of a carrot splint. The goal was improved range of motion in the left hand and to tolerate a splint for greater than eight hours. Review of an occupational therapy Discharge summary dated [DATE] revealed the resident had good participation with passive range of motion, was utilizing the carrot splint with good success and comfort, and was able to tolerate the splint for greater than eight hours. It was recommended for the splint to continue with staff applying. However, review of range of motion restorative program documentation revealed range of motion services were discontinued on 01/06/22 (two days prior to occupational therapy being discontinued) due to resident not participating in programs on a routine basis, even though occupational therapy documented the resident had good participation in passive range of motion on 01/08/22. There was no evidence of any further range of motion services provided. A physician's order was obtained on 02/09/22 to encourage the resident to utilize the carrot splint to left hand daily (one month after occupational therapy was discontinued with recommendation for splint use). Review of the treatment administration records and nurses notes for May and June 2022 revealed no evidence of refusal of the carrot splint with it being documented as applied daily. However, review of a nurses progress note on 06/13/22 at 2:58 P.M. by Licensed Practical Nurse (LPN) #196 revealed resident's left hand is more contracted and trying to use the carrot splint causes the resident more pain. Splint will be discontinued at this time. There was no evidence of a referral to therapy due to the decline and no evidence that any other interventions were put in place to attempt to prevent further decline of the left hand contracture. The plan of care was silent to any range of motion services. A Minimum Data Set (MDS) 3.0 assessment completed 05/28/23 documented a Brief Interview for Mental Status score of 2, indicating severe cognitive impairment. The assessment identified the resident had upper extremity impairment on one side and required extensive assistance from two staff with bed mobility and toileting. Review of an occupational therapy evaluation dated 07/25/23 revealed Resident #3 was noted with a significant left hand contracture currently not appropriate for splint option due to severity, will require intensive passive range of motion prior to splinting. Resident was at risk for losing ability to feed self (left hand dominant). The strength of the left hand was unable to be determined due to severe pain. Occupational therapy was to begin 07/25/23 five times per week for four weeks. Observations on 07/25/23 at 10:10 A.M. revealed Resident #3 to be in bed. Her left hand was contracted with all of her fingers bent inward towards the palm in a fist. No padding or splinting of the hand was observed. Observations on 07/26/23 at 7:13 A.M. revealed Resident #3 (who was left hand dominant) to be feeding herself in bed with her right hand. Her left hand remained contracted with all of her fingers bent inward towards the palm in a fist. No padding or splinting of the hand was observed. Interview with Rehab Director #205 on 07/26/23 at 1:25 P.M. confirmed Resident #3 was re-evaluated by occupational therapy on 07/25/23 due to her left hand contracture. She confirmed Resident #3 was last seen by occupational therapy 01/08/22 after being provided with therapy due to poor staff carry over of passive range of motion and splint use from the last time she had received therapy. She confirmed Resident #3 was discharged [DATE] with good participation in passive range of motion and use of carrot splint. She stated after the resident was discharged from occupational therapy, she would have expected the nursing staff to continue with passive range of motion and use of the carrot splint as she was able to tolerate it for eight hours. She stated she did not know why the restorative program was discontinued 01/06/22 when therapy documented good participation on 01/08/22. She confirmed a referral was not made to therapy after the splint was discontinued in June 2022. She confirmed the resident's left hand contracture had declined and staff would have to start out with a rolled towel until passive range of motion was provided and the resident was able to utilize a splint again. Interview with LPN #196 on 07/26/23 at 2:00 P.M. confirmed she discontinued the carrot splint on 06/13/22. She stated that she felt like she was told by someone to discontinue it as she would not have done it on her own but does not remember the details of why it was discontinued. She stated she did not know why the resident was not referred back to therapy when the splint was discontinued since the resident's hand was more contracted, at that time. Observations on 07/26/23 at 2:15 P.M. revealed LPN #196 to attempt to put a wash cloth, which was folded over once, into Resident #3's left hand. LPN #196 tried to open the resident's fingers enough to put the folded washcloth in between her fingers and the palm of her hand. The resident verbalized oh, as if in pain. LPN #196 stated she did not feel any type of range of motion was provided after the splint was discontinued in June 2022. Interview with the Director of Nursing on 07/27/23 at 9:40 A.M. confirmed the plan of care was silent to range of motion services and there was no evidence of any range of motion services provided once the splint was discontinued in June 2022. Review of the facility policy titled Functional Range of Motion, dated 11/2011 revealed the functional range of motion assessment would be used to identify the residents active or passive range of motion and/or limitations of each body part, allowing for intervention when appropriate to maintain or improve present level of functioning and to prevent decline in functional status. Referrals would be made to therapy or restorative nursing when clinically indicated and based upon physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of fall investigations, interview, and policy review, the facility failed to ensure Resident #48 was properly positioned in bed when unattended resulting in an avoidable fall with major injury (hip fracture). Actual Harm occurred on 04/04/23 following a fall at 10:40 P.M. when the facility failed to ensure the resident was properly positioned in bed and left unattended resulting in the resident rolling out of bed and sustaining a hip fracture. This affected one resident (#48) of two residents reviewed for accidents. Findings include: Record review revealed Resident #48 was admitted to the facility on [DATE] with hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, tremors, left foot drop, bilateral hearing loss, diabetes, Foley catheter due to neuromuscular dysfunction of the bladder and chronic kidney disease. Review of Resident #48's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/22/23 revealed the resident required extensive assistance of two person for bed mobility and toileting, and total dependence for transfers. The resident had limited range of motion on one side of the upper and lower extremity. Review of Resident #48's plan of care revealed the resident was at risk for falls related to cerebrovascular accident (CVA). There was no evidence to place something in front of the resident or stand in front of her when providing peri care and two assists if needed per the interdisciplinary team (IDT) note dated 04/21/23. Review of Resident #48's nursing note dated 04/04/23 revealed an aide reported to the nurse while changing the resident she rolled out of bed. The resident stated she just kept right on rolling that she couldn't stop herself. The resident complained of right hip pain and stated she did hit her head. The resident was transported to a local hospital; however, it was full, and she was being moved to another local hospital due to a right hip fracture. The note indicated she would more than likely not need surgery and the fracture would heal on its own. Review of Resident #48's hospital note dated 04/04/23 revealed the resident had non-displaced right femoral neck fracture. Review of the facility fall investigation dated 04/04/23 revealed State Tested Nursing Assistant (STNA) #169's statement indicted she had rolled Resident #48 to her side and hit the call light to get the nurse to apply Zinc on the resident. The statement revealed the STNA waited five to ten minutes and then asked if she could go get her really quick. When the STNA returned the resident was on the floor. The STNA did not see or hear the resident hit the floor. The STNA reported the root cause of the fall was she should have had the resident roll back on to the bed fully. There was no evidence of a second staff member assisting in the resident's care at the time of the incident. Review of a late entry IDT note dated 04/21/23 revealed IDT review of 04/04/23 incident: State Tested Nursing Assistant (STNA) had just completed peri care while the resident was lying on her left side holding to grab bar with right hand to steady herself in position. The STNA stepped to door to summon nurse for treatment and when she turned the resident was lying on floor on her back. The resident stated she rolled forward and couldn't stop and that she bumped her head and right hip hurt. Nurse was summoned, resident stabilized in place, assessed and physician was notified with orders to send to emergency room (ER) for evaluation. X-ray showed non-displaced right femur fracture, however, ortho felt surgery was not needed and to treat conservatively. At present the resident was weight bearing as tolerated. The resident has not been able to ambulate for a very long time as she is afraid, she may fall, is transferred in Hoyer and uses wheelchair for mobility with staff assist. Resident has diagnoses of left hemiplegia from CVA/muscle spasms and uses right arm and hand for activities of daily living (ADL's) and holding herself over on side for peri care. Air mattress to bed for comfort with bolsters for her comfort and states she feels secure with the bolsters. Staff educated to place something in front of her or stand in front of her when providing peri care and two assists if needed. Review of Resident #48's care guide revealed no evidence to place something in front of her or stand in front of her when providing peri care and two assists if needed per the IDT note dated 04/21/23. The care guide indicated the resident required extensive assist to total assist with bed mobility and toileting. Bilateral grab bars on bed to assist with bed mobility. Position with pillows if needed due to tendency to lean to the left. Use two assists with all transfers with floor staff. Interview on 07/24/23 at 10:26 A.M. and 07/27/23 at 2:10 P.M., with Resident #48 confirmed she doesn't have much control of her left side due to a stroke and was not able to control her body and rolled out of bed fracturing her hip. The resident could not recall many details of the incident, but staff was providing care and left her on her side, and she rolled out of bed and could not stop herself. Interview on 07/27/23 at 2:16 P.M. with the Director of Nursing (DON) confirmed the STNA had left Resident #48 on her side in the bed, which was not a safe position, resulting in the resident rolling out of bed and fracturing her hip. The STNA should have waited for staff to answer the call light or rolled the resident back on her back in bed. The plan of care was not updated to reflect the new intervention to have place something in front of her or stand in front of her when providing peri care and two staff assist if needed per the IDT note dated 04/21/23. Review of the facility policy titled Fall Management (dated 01/14/14 and revised 08/18/22) revealed safety was a priority. The facility's effort was to focus on minimizing fall risk and fall related injuries. New intervention would be implemented by the unit staff as soon as possible.