**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to revise one resident's care plan with updated interventions status post fall for one of two residents reviewed for falls (Resident R25). Findings Include: Review of facility policy Care Plan Process, revised October 2017, revealed the plan of care is continually reviewed and updated by members of the interdisciplinary team to reflect the current needs of the resident. Review of facility policy Fall management Guideline, revised December 2022, revealed to reduce the risk of falls or fall related injuries the facility will implement appropriate person-centered interventions and the resident's plan of care will be updated accordingly. Resident specific interventions are put in place initially and ongoing, and the interdisciplinary team will review current falls and fall interventions. Review of Resident R25's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 9, 2023, revealed the resident was admitted to the facility on [DATE], and had diagnoses of muscle weakness, lack of coordination, unsteadiness on feet, and difficulty in walking. Continued review of the MDS revealed the resident required one-person physical assistance for transfers, ambulation, and toilet use. Review of Resident R25's fall risk assessment dated [DATE], revealed the resident was at high risk for falling. Review of Resident R25's care plan dated May 24, 2023, revealed the resident had a decline in his ability to perform independent bed mobility, transfers, and walking with rolling walker safely without falls. Continued review of Resident R25's care plan revised July 18, 2023, revealed the resident was at risk for falls related to his decline in mobility and balance impairment and had unwitnessed falls on June 30, 2023, July 8, 2023, and July 18, 2023. Review of facility incident report dated June 30, 2023, revealed Resident R25 rang call bell to report that he had fallen after coming from the bathroom. Resident R25 did not ring call bell for assistance to and from bathroom. Continued review of the incident report and review of Resident R25's comprehensive care plan revealed no documented evidence new interventions were implemented status post fall. Review of facility incident report dated July 8, 2023, revealed the nurse heard a loud noise coming from Resident R25's room and the resident yelling out. Resident R25 was subsequently found laying on the bathroom floor. Continued review of the incident report and review of Resident R25's comprehensive care plan revealed no documented evidence new interventions were implemented status post fall. Review of Resident R25's clinical record revealed a nursing note dated July 18, 2023, that the resident again had an unwitnessed fall and was observed kneeling on the floor in his bathroom holding onto his walker. Per Resident R25's comprehensive care plan revised July 18, 2023, revealed the resident was attempting to initiate morning care. Resident R25's care plan was subsequently updated on July 18, 2023, with new interventions to offer and encourage early morning get-up per the resident preference and that the resident would be assisted by the 11:00 p.m. to 7:00 a.m. nursing shift. Interview on July 19, 2023, at 12:15 p.m. with Director of Nursing, E1, confirmed Resident R25's care plan was not updated with new interventions status post falls on June 30, 2023, and July 8, 2023. Continued interview on July 19, 2023, at 1:00 p.m. with the Director of Nursing, Employee E1, revealed all three falls happened during the morning hours. 28 Pa. Code 211.10 (c) Resident Care Policies. 28 Pa. Code 211.10 (d) Resident Care Policies. 28 Pa. Code 211.12 (d)(5) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, resident and staff interviews, it was determined that the facility failed to monitor meal and nutritional supplement consumption for one of one resident reviewed for nutritional status. (Resident R20) Findings include: Review of facility policy Nutrition Risk Guidelines revealed that an undesired significant weight loss qualifies a resident for nutrition risk monitoring. Review of Resident R20's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated April 11, 2023, revealed that the resident was admitted to the facility on [DATE], and had the diagnoses of Alzheimer's Dementia (a disease that destroys memory and other important mental functions), anxiety disorder, and depression. A review of Resident R20's BIMS (Brief Interview of Mental Status) revealed a score of nine, which indicated that the resident had moderately impaired cognition. Review of R20's clinical records revealed Resident R20 had a documented weight of 153 pounds on April 11, 2023, and a weight of 144.2 on July 18, 2023; indicating a significant weight loss of 5.8% weight loss in three months. Further review revealed a documented weight of 174.8 pounds on January 15, 2023, and a documented weight of 144.2 on July 11, 2023; indicating a significant weight loss of 17.5% in six months. Review of physician orders revealed an order dated February 16, 2023, for a dietary supplement, Ensure Clear, two times a day for significant weight loss. This supplement order would provide 480 calories and 16 grams of protein total per day for resident to prevent further weight loss. Review of Resident R20's Medication Administration Records for February, March, April, May, June, and July of 2023 revealed documented evidence that the nutritional supplement had been provided to resident and that it was occasionally refused, but no documented evidence of supplement daily percent intakes by resident. Further review of progress notes revealed no documented evidence regarding an alternative supplement option choice offered to resident when resident had refused the Ensure Clear nutritional supplement. Interview with the Registered Dietitian, Employee E3, on July 18, 2023, at 1:08 p.m. revealed Resident R20 had a history of refusing meals and prefers to eat in her room. Further interview confirmed there was no documented evidence of supplement daily percent intakes by resident to be able to evaluate the effectiveness of this nutrition intervention. Observation of the resident room on July 19, 2023, at 11:03 a.m. revealed an ensure clear with a straw placed on Resident R20's stand. During an interview with Resident R20 this surveyor asked, do you drink all of the ensure? Resident stated, no. Follow-up interview with Resident R20's nurse, Employee E6, on July 19, 2023, revealed Resident R20 can make her needs known by using the call bell, passing it on to the nurse aids, and answering yes and no questions. During interview on July 19, 2023, at 3:05 p.m. with the Director of Nursing, Employee E1, and Administrator, Employee E2, it was confirmed that there was no daily monitoring evidence for Resident R20's nutrition supplement daily percent intakes. 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.6 (d) Dietary services 28 Pa. Code 211.12 (c)(5) Nursing Services