**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview, staff interviews, and policy review, the facility failed to ensure a resident who experienced an unwitnessed fall with injury was provided timely treatment including notifying the physician of complaints of pain, inability to fully move extended leg and obtaining an x-ray. Actual harm occurred on 05/31/25, when Resident #30 experienced an unwitnessed fall from the bed with an injury. Following the incident, the resident continually complained of pain in his hip and had limited mobility with his leg. The facility did not obtain an x-ray of the hip until nine (9) days after the fall. Subsequently, Resident #30 was transferred to the hospital for surgical repair of a broken hip from the fall. This affected one (#30) of three residents reviewed for change in condition. The facility census was 28.Findings include:Review of the medical record for Resident #30 revealed an admission date of 02/24/24 and a discharge date of 06/13/25. admission diagnoses for Resident #30 included parkinsonism, malnutrition, atrial fibrillation, congestive heart failure, hypertension, type two diabetes mellitus, cardiomegaly, gastroesophageal reflux disease, benign prostatic hyperplasia, chronic pain, anxiety, depression, syncope and collapse, and history of transient ischemic attack. Resident #30 was admitted to Hospice on 12/29/24 for Parkinson's Dyskinesia.Review of the most recent quarterly Minimum Data Set (MDS) Assessment for Resident #30, dated 05/16/25, revealed a Brief Interview of Mental Status (BIMS) Score of 00, indicating Resident #30 had severely impaired cognition. Further review of the MDS Assessment revealed Resident #30 required substantial to maximum assistance for all functional abilities. Review of the Facility Fall Investigation for Resident #30 revealed he experienced an unwitnessed fall on 05/31/25 at 9:30 P.M. The facility investigation revealed the nurse heard a loud thud and went into Resident #30's room and observed the resident to be lying on the floor on his right side. ROM (range of motion) was performed and the resident (#30) complained of right hip pain. Morphine was given for pain, and hospice was notified and the hospice nurse stated she was going to contact the hospice NP (nurse practitioner) for further treatment. The facility investigation concluded Resident #30 attempted to get up, unassisted, and fell to the floor. Review of the hospice visit note dated 05/31/25 revealed Resident #30 had sustained an unwitnessed fall and was complaining of right hip pain. The hospice progress notes stated it was difficult to assess for leg length discrepancy as Resident #30 was either unwilling or unable to fully straighten his right leg. Review of the facility progress note dated 06/01/25 at 3:35 A.M. revealed Resident #30 stated he was in pain and Morphine was given. No other injuries were noted from previous fall. Review of the hospice visit note dated 06/01/25 revealed Resident #30 reports pain in right hip and it was difficult to assess for leg length discrepancy as Resident #30 was either unwilling or unable to fully straighten his right leg. The hospice progress note indicated Resident #30 had a slight grimace while his right leg was examined. The hospice nurse consulted the hospice physician who decided against sending Resident #30 to the emergency room (ER) on 06/01/25. Resident #30 continued to complain of right hip pain and requested a Lidocaine patch to his right hip. Hospice NP #202 declined ordering an x-ray at this time and a new order was placed for 4% Lidocaine topical patch to the right hip for five days.Review of the facility progress note dated 06/01/25 at 9:56 P.M. revealed Resident #30 received a new order for Lidocaine patch 4% to be applied to right hip x 5 days d/t (due to) fall. Resident #30's POA (power of attorney) aware.Review of the hospice visit note dated 06/02/25 revealed Resident #30 continued to report right hip pain.Review of the facility progress note dated 06/02/25 at 1:45 P.M. revealed Resident #30 stated he could not stand up. Review of the facility progress note dated 06/03/25 at 12:59 P.M. revealed Resident #30 complained of pain on his right side where he fell. Review of the hospice visit note dated 06/05/25 revealed Resident #30 was lying in bed with his right leg bent and when asked to straighten his leg, he tried but was unable to straighten it. The hospice nurse contacted NP #202, and an x-ray was ordered of Resident #30's right hip. Review of the facility progress note dated 06/05/25 at 9:15 P.M. revealed Resident #30 received a new order for an x-ray of the right hip/pelvis and lower spine. Review of the facility progress note dated 06/09/25 at 9:00 A.M. revealed the facility called the external imaging provider regarding the x-ray that was ordered on 06/05/25 and they stated Resident #30 was combative and refused the x-ray. Review of the facility progress note dated 06/09/25 at 9:01 A.M. revealed a STAT (urgent or rushed) x-ray was ordered for Resident #30. Review of the hospice visit note dated 06/09/25 revealed Resident #30 continued to have complaints of right hip pain.Review of the hospice progress notes dated 06/09/25 revealed the x-ray results dated 06/09/25 for Resident #30 revealed he had a mild displaced comminuted intertrochanteric fracture of right hip with varus angulation. Resident #30 wished to go to the hospital to see if they could fix it. Review of the hospital records for Resident #30 revealed he was admitted to the hospital on [DATE] with a diagnosis of acute comminuted intertrochanteric fracture of the proximal right femur with a plan to have surgery to repair the broken hip.Review of electronic mail (e-mail) communication on 06/18/25 at 11:02 A.M. between Unit Manager #131 and an external imaging provider, revealed an order had been received for an x-ray for Resident #30's right hip on 06/05/25, but the resident refused. Further review of the e-mail communication revealed the x-ray technician states she reported Resident #30's refusal to an unidentified staff member on 06/05/25 at 4:38 P.M. Interview on 08/26/25 at 10:49 A.M. with Resident #30's family member revealed Resident #30 had an unwitnessed fall on 05/31/25 and did not have an x-ray performed until 06/09/25). She stated after the x-ray was obtained, Resident #30 wanted to be transferred to a hospital to see about having his broken hip repaired.Interview on 08/27/25 at 7:06 A.M. with Unit Manager #131 revealed Resident #30 fell on [DATE] and imaging was not completed until 06/09/25. Unit Manager #131 stated an initial imaging order was placed on 06/05/25 but was not completed due to resident refusal. Unit Manager #131 stated the delay in care was due to waiting on orders from the hospice provider. Interview on 08/27/25 at 8:55 A.M. with Unit Manager #131 revealed if the facility does not get answers regarding resident care from the hospice provider, the facility should seek directions from the facility provider regarding resident care. She stated the floor nurse communicates with hospice nurses and providers, but the Unit Manager will assist in following up and following through with resident care issues that are relayed to her from a floor nurse. She stated if the Unit Manager does not receive follow-up from hospice, the issue should be escalated to the Director of Nursing (DON) to determine what the next steps would be. Interview on 08/27/25 at 1:13 P.M. with Licensed Practical Nurse (LPN) #111 revealed she was the hospice nurse who initially assessed Resident #30 after his fall, but she works for the facility now. She stated when she initially saw Resident #30 after his fall, he was complaining of pain in his right hip, but there was no swelling, bruising, or redness noted upon her initial assessment. Interview on 08/27/25 at 2:24 P.M. with hospice NP #202 revealed the hospice nurse initially assessed Resident #30 and reported to her Resident #30 did not have reproducible pain and she could not assess a difference in the lengths of his legs. Review of the policy titled, Change of Condition: Observing, Recording and Reporting, dated 08/07/24, revealed the facility will record and report any change in condition to the nurse in charge and attending physician so proper treatment will be implemented. This deficiency represents non-compliance investigated under Complaint Numbers 2566353 and 1358032.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure physician orders for a nutritional supplement were followed and the physician and dietician were notified regarding a significant weight loss. This resulted in actual harm when Resident #3's ordered nutritional supplement was not available from the supplier for the facility to administer, the facility did not reach out to the physician or the dietician for an alternate supplement or different interventions, and the resident had a significant weight loss of 15.2 pounds/ 8.5 percent weight loss. Additionally, when the significant weight loss occurred the facility failed to notify the physician and dietician of the occurrence. This affected one (#3) of three residents reviewed for weight loss. The facility census was 28. Findings include: Review of Resident #3's medical record revealed an admission date of 06/10/23. Diagnoses included Parkinson, cognitive communication deficit, dysphagia, and Lewy body dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/18/23, revealed Resident #3 had severe cognitive impairment and required extensive assistance with activities of daily living, including eating. Review of a plan of care for Resident #3 initiated on 09/25/23, and revised on 10/26/23, revealed the resident was care planned for malnutrition related to decreased appetite and significant weight loss in 09/23. Review of physician orders for 09/23 revealed Resident #3 was on a regular, mechanical soft diet with thin liquids and Muscle Milk supplement twice daily. Review of the Medication Administration Record (MAR) from 09/05/23 through 09/19/23 revealed Resident #3's Muscle Milk was not available for administration per physician orders. Documentation on the MAR revealed that despite the Muscle Milk not being available, an alternate was offered and accepted by Resident #3 on one occasion on 09/05/23. Review of weights for Resident #3 revealed on 09/11/23 a weight of 176 pounds (#), 09/12/23 of 171.2#, 09/13/23 of 170#, 09/14/23 of 176.3#, 09/15/23 of 178#; and 09/16/23 of 162.8#, which was a 15.2# or an 8.5 percent (%) weight loss. Resident #3's weight continued to decline on 09/17/23 to 160.8#, and 09/19/23 of 158#. On 09/19/23 Resident #3 was sent to the hospital for change of condition and a readmission weight on 09/26/23 was 169#. Review of State Tested Nurse Aide (STNA) documentation for meal intake revealed on 09/12/23 the only documented meal was dinner at 51-75% consumed. On 09/13/23 Resident #3 consumed 51-75% for breakfast and 0% for lunch and dinner was not documented. There was no documentation of oral intake for Resident #3 on 09/14/23 for any meals. On 09/15/23 Resident #3 consumed 1-25% of both breakfast and lunch and there was no documentation for dinner. On 09/16/23 Resident #3 consumed 51-75% of breakfast and only 1-25% for lunch and dinner. Review of the intake documentation for Resident #3 revealed a nutritional supplement was offered and accepted on 09/12/23 with 100% consumed, 09/13/23 with 25% consumed, none on 09/14/23, 09/15/23 with 50% consumed, and 09/16/23 with 100% consumed. Review of a readmission nutritional assessment, dated 09/28/23, for Resident #3 revealed a recent hospitalization for urinary tract infection (UTI), dehydration and acute kidney failure. Resident #3 had a readmission weight of 169.5 #, indicating a significant weight loss of 5.1% for 30 days. Resident #3's oral intakes are improving and are comparable to his previous nutritional assessment. He continues a pureed diet with thin liquids for dysphagia. He continues to receive Muscle Milk nutritional supplement twice daily. Interview on 10/26/23 at 9:15 A.M. with Licensed Practical Nurse (LPN) #103 stated Resident #3 gets Muscle Milk supplement that the family supplies and when they are waiting for more she will give the resident an Ensure supplement so he gets something. Interview on 10/26/23 at 10:10 A.M. with Registered Dietician (RD) #108 stated Resident #3 was not on her radar for significant weight loss. He had fluctuations since admission but nothing significant for her until his recent hospitalization. RD #108 stated upon admission she trialed Ensure nutritional supplement and he had a few refusals and the family suggested Muscle Milk as he was drinking this at home. RD #108 stated the family provided the supplement in the beginning and then the facility assumed responsibility for ordering the supplement of choice. RD #108 was aware the resident was being weighed daily but was not sure why he was a daily weight since he didn't trigger for monitoring daily for her. Interview on 10/31/23 at 11:19 A.M. with Central Supply Clerk (CSC) #107 stated the facility became responsible for ordering the Muscle Milk nutritional supplement for Resident #3 on 06/29/23. CSC #107 stated she began having a supplier issue with getting the supplement in the middle of the summer and she stated she alerted her supervisor of this problem. CSC #107 stated she began trying to find the supplement anywhere she could and was sometimes able to get it from Amazon. CSC #107 did not attempt to order anything different she is not able to make those decisions without direction from her supervisor. Interview on 10/31/23 at 11:08 A.M. with RD #108 stated she was not notified of a 15.2 # weight loss for Resident #3. RD #108 stated she would have identified the weight loss on her next monthly weight review. RD #108 also stated she was not notified of supplier issues with getting the Muscle Milk. Interview on 10/31/23 at 2:33 P.M. with Physician #120 she was not notified of a the significant weight loss for Resident #3 and was not notified that the supplement of choice, Muscle Milk, was not available from the supplier. Review of facility policy titled Resident with Weight Loss, dated 05/03, revealed the purpose is to monitor and assure that residents maintain acceptable nutritional parameters unless conditions exist that predetermine that a nutritional problem is unavoidable and to provide nutritional interventions to residents when indicated. If weight loss is identified the physician will be notified. This deficiency represents non-compliance investigated under Complaint Number OH00146963.