**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not, for 2 of 26 sampled residents, ensure that the environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistance device to prevent accident. Resident identifiers: 35 and 56. Findings include: 1. Resident 56 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction due to thrombosis, type 2 diabetes mellitus, squamous cell carcinoma, protein-calorie malnutrition, atrial fibrillation, need for assistance with personal care, history of falling, mood disorder, pressure ulcer of sacral region, dementia, generalized edema, anemia, hypertension, hyperlipidemia, and renal osteodystrophy. On 4/1/24 at 9:18 AM an observation of resident 56 was made. Resident 56 was sitting in a wheelchair close to the nurses' station. Resident 56 was observed to have a bandage on her head dated 4/1. Resident 56 was unable to explain why she had a bandage on her head. Resident 56's electronic medical record was reviewed. Resident 56's Minimum Data Set (MDS) from 12/20/23 documented that resident 56 required a two-person extensive assist with bed mobility, transfers, and toilet use. The MDS documented that the resident scored a 5 on the Brief Interview for Mental Status (BIMS). In accordance with the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument Manual (RAI) Version 3.0 Manual, a score of 5 represents severe cognitive impairment. Resident 56's care plan was reviewed. Resident 56 had a care plan initiated on 9/20/23 with a focus that stated, [resident 56] is at risk for falls related to dementia with Confusion and decreased safety awareness, deconditioning, weakness. The goal stated, [resident 56] will be free of minor injury through the review date. The interventions stated, Allow resident to sleep in upright position as she prefers. , initiated 12/1/23. Anticipate and meet the resident's needs., initiated 9/20/23. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance., initiated 9/20/23. Bolster mattress to bed., initiated 2/16/24. Ensure commonly used items (ice water, glasses if applicable, call light, phone, remote) are within reach of resident prior to leaving room., initiated 9/20/23. Ensure resident bed remote is clipped near resident on bedsheet., initiated 10/13/23. Ensure that the resident is wearing appropriate footwear (non-skid shoes, non-skid socks, etc.) prior to any transfers or ambulating., initiated 9/20/23. An incident report from 10/12/23 documented, resident found sitting on the floor, by bathroom door, with lower extremities under the bed. Resident wearing non skid socks when found. Bed found not in low position. Bed was in low position before fall. CNA [Certified Nursing Assistant] states resident plays with a bed remote. The resident's description on the incident report documented, Resident stated, I don't think I fell resident denies hitting head. The immediate action taken on the incident report stated, head to toe assessment done. Redness to R [right] hip noted. Skin intact. No deformities noted. ROM [range of motion] at baseline. Resident assisted back into bed. The care plan was reviewed, and it revealed that an intervention was added to the residents fall care plan. The intervention was added on 10/13/23 and stated, Ensure resident bed remote is clipped near resident on bedsheet. An incident report from 11/26/23 documented, During rounds @ 0120 [at 1:20 AM], CNA observed resident on the floor in her room next to the bed, resident bleeding from the forehead, . resident assessed for injury and assisted onto the bed, resident stated her head hurt when assessed for pain, no other pain noted. The resident states she doesn't know what happened but states that it has not been a great day for her. The incident report did not document any new interventions. An Emergency Department (ER) documented dated 11/26/23 documented that resident 56 was seen at the ER on [DATE] at 5:25 AM and was given 6 sutures on her forehead. On 4/4/24 at 11:45 AM an interview with the Director of Nursing (DON) was conducted. The DON stated that that the intervention after the fall on 11/26/23 was to send her out to the hospital, and on 12/1/23 the care place was updated that stated, Allow resident to sleep in upright position as she prefers. An incident report from 1/20/24 documented, When giving res [resident] her morning meds this RN [registered nurse] observed a bruise to resident's L [left] forehead and swelling down to L eye. When asked res stated she fell, but is unable to give any details regarding what happened. The incident report did not document any new interventions. The care plan was reviewed and there were no updated interventions for the residents fall care plan. On 4/4/24 at 11:46 AM an interview with the DON was conducted. The DON stated that the intervention for the call on 1/20/24 was to ensure that pillows were placed between her bed and her dresser. The DON stated that she could not find the intervention in her fall care plan and that the fall care plan should have been longer than what it currently was. The DON stated that she found the intervention regarding the pillow placement in the resident's skin care plan and that it was added on 1/22/23. On 2/15/24 an incident report from 2/15/24 documented, Nurse heard noise coming from the residents room approx [approximately] at 3:20 [AM]. Responded to noise. Observed resident laying face down between beds with head towards wall. Bed in low position and call light within reach. Assessed resident noted large laceration to forehead. Called the west nurse over for assistance. Pressure applied to laceration. Head to toe assessment completed. Swelling to R [right] ring finger. Laceration to bridge of nose. Bilateral knee discoloration . Resident c/o [complained of] pain to right ring finger, bilateral knees and head. Neuro checks initiated resident A&O [alert and oriented] x 1 . Received orders to send resident out to hospital. 911 called. EMS arrived. Resident sent out to [name redacted] hospital. Resident unable to give a description. An ER documented dated 2/15/24 documented that resident 56 was seen at the ER on [DATE] at 4:12 AM for a 10 centimeter (cm) head laceration and was give 20 sutures and 2 staples. An x-ray was preformed on the residents finger and the ER document reported, no acute abnormality of the right hand. A Nurses Note from 2/15/24 at 9:31 AM documented, Resident returned from [name redacted] hospital at approx. 0730 [7:30 AM] with a dx [diagnosis] of laceration without foreign body of scalp. Resident returned with 2 staples and 20 sutures to laceration on forehead. Splint noted to R ring finger . No neurological deficits noted. H-T [head to toe] completed by this nurse. New discoloration/swelling noted to L eye, resident unable to open eye due to swelling. Small laceration also noted above left eyebrow. Site cleansed and steri strip applied. During assessment resident observed picking at both lacerations. Slight bleeding noted to both sites, site cleansed . Staff attempted to ice residents face, but resident refused. NP [Nurse Practitioner] notified . The care plan was reviewed, and it revealed that an intervention to resident 56's care plan on 2/16/24 and it stated, Bolster Mattress to bed. On 4/3/24 at 4:53 PM an interview with RN 3 was conducted. RN 3 stated that she was the nurse for resident 56 when resident 56 fell on 2/15/24. RN 3 stated, I was at the nurses' station when I heard a loud noise. I began checking rooms, I opened her door and saw that she wasn't on her bed. I walked in and saw her laying face down and she [resident 56] was saying, oh god it's dripping. [resident 56] wasn't able to tell me what happened. [Resident 56] does often try to get up. I called the doctor right away, and reported it to the family and the on call manager. I believe resident 56 got a bolster mattress after that fall. RN 3 stated that the fall happened during the night shift and there were three CNA's and 2 nurses working at the time. 2. Resident 35 was admitted to the facility on [DATE] with diagnoses which included dementia, abnormalities of gait and mobility, type 2 Diabetes Mellitus, mild protein-calorie malnutrition, cognitive communication deficit, dysphagia, nondisplaced fracture of lateral malleolus of right fibula, mood disorder, major depressive disorder, and hypothyroidism. On 4/4/24 at 1:29 PM an observation of resident 35's room was made. Resident 35 was observed in her bed. A bolster mattress was on resident 35's bed, the bed was in the low position, the room was free of clutter, the call light was within reach, and there was not a fall mat observed next to the bed. Resident 35 was unable to be interviewed due to low cognition. Resident 35's electronic medical record was reviewed. A quarterly MDS from 3/19/24 documented that a BIMS questionnaire could not be conducted do the resident being rarely or never understood. Resident 35's care plan was reviewed. A care plan initiated on 10/13/23 stated, [Resident 35] is at risk for falls related to dementia with decreased safety awareness and poor impulse control, gait imbalance, weakness, psychotropic medication use. The goal stated, [Resident 35] will be free of minor injury through the review date. The interventions stated, Anticipate and meet the resident's needs., initiated 10/13/23. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance., initiated 10/13/23. Bolstered mattress in place while resident is in bed., initiated 10/23/23. Educate staff to allow resident to stay up after meals as she seems to prefer to stay out of bed., initiated 1/12/24. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility., initiated 10/13/23. Ensure commonly used items (ice water, glasses if applicable, call light, phone, remote) are within reach of resident prior to leaving room., initiated 10/13/23. Ensure that the resident is wearing appropriate footwear (non-skid shoes, non-skid socks, etc.) prior to any transfers or ambulating., initiated 10/13/23. [Resident 35] has a custom wheelchair. Ensure that resident is positioned correctly while up in wheelchair., initiated 3/1/24. Offer resident her strips of fabric she enjoys fiddling with., initiated 2/9/24. Offer sensory blanket when awake., initiated 2/19/24. Resident moved to a room closer to the nurses' station., initiated 10/20/23. The resident needs a night light., initiated 12/4/23. The resident needs activities that minimize the potential for restlessness/falls while providing diversion and distraction., initiated 12/4/23. The resident uses fall prevention device: Floor ma. Ensure the device is in place as ordered., initiated 2/2/24. An Alert Note from 8/11/23 at 10:26 AM documented, CNA witnessed the patient fall on her buttocks with no head injury. She reported that she saw the patient get up from the chair, stumbled back and fell on her buttocks. It should be noted that the resident's fall care plan was initiated on 10/13/23. On 4/4/24 at 11:52 AM an interview with the DON was conducted. The DON stated, With her fall on 8/11/23, we were concerned that she wasn't getting enough sleep. The fall happened right after lunch. A staff member saw her stand up and fall down on her bum. I think that's when we put in charting of hours of sleep for her as an intervention. A Nurses Note from 9/23/23 at 7:28 AM documented, Resident was found on the floor in front of the bathroom door by the CNA. The floor was clear of clutter and debris. Residents right ankle was perpendicular to her leg. Notified provider and sent to [hospital name redacted]. Notified on-call . notified family [name redacted] who requested [name redacted] hospital. EMS administered Morphine, sent facesheet, POLST, medication list with EMS. A Nurses Note from 9/23/23 at 11:50 PM documented, .Res [resident] received morphine just before leaving hospital. Res with medial/lateral Malleolor fracture. Reduction was performed in the ER. NWB [non-weight bearing] and will need surgery. 1150 [11:50PM] resident returned from hospital. Resident has splint on right foot . Resident responds when the foot is touched by being startled . Resident with facial grimace and frowning, tense musclesand [sic] moaning . Resident is restless, crying, attempting to get out of bed. Stayed with resident until a 1 to 1 staff arrived. Neuro checks in place. Will continue to monitor. A Progress Note from 9/28/23 at 5:37 PM documented, Resident arrived from orthopedic surgery appointment at approx. 1600 [4:00 PM] . Orders from [Doctors name redacted] X-ray show non-displaced fibula Malleolus fx [fracture]; surgery not needed. No weight bearing for 2-3 weeks. Keep splint for now, [Doctors name redacted] will change in two weeks. Return to clinic 10/12 or 10/16 to get x rays . Resident currently resting in bed eating dinner. A Nursing Note from 10/19/23 at 10:48 AM documented, Resident observed sitting on the floor next to her bed. Residents [sic] was leaning towards her left side and was using her left hand to support herself. The bed was at the lowest position. Head to toe completed-assessed for injury prior to getting her back in bed. No new skin injury noted . The care plan was updated on 10/20/23 and stated, Resident moved to a room closer to the nurses' station. A Nurses Note from 10/22/23 at 5:47 AM documented, Resident found lying face down on the floor next to the bed. Head to toe assessment completed. No lacerations, skin tears, bruising, or deformities noted. No new injuries noted . The care plan was updated on 10/23/23 and stated, Bolstered mattress in place while resident is in bed. An Alert Note from 12/1/23 at 3:58 AM documented, Resident was found sitting on the floor in front of her w/c [wheelchair] with her feet forward towards her bed in her bedroom doorway. The UWF [unwitnessed fall] happened on 12/1/23 at 1815 [6:15 PM]. Resident unable to tell nurse what happened. Looks like she slipped out of her w/c . Resident has black boot to her R foot for fracture from a previous fall on 9/23. Circulation on R foot is good and boot is in place. She had a sock and shoe on the other foot. She was helped up into w/c and taken to her bed and placed in her bed where she has spent the rest of the evening relaxing . The care plan was updated on 12/4/23 after the residents next fall on 12/3/23. A Nurses Note from 12/3/23 at 5:47 AM documented, Resident was found sitting on floor next to bed. Assessed by nurse. No new injuries or areas of redness or bruising found. Started on neuros . The care plan was updated on 12/4/23 and stated, The resident needs a night light. And The resident needs activities that minimize the potential for restlessness/falls while providing diversion and distraction. An Alert Note from 12/10/23 at 4:00 AM documented, Resident was found by nurse sitting on floor next to bed on opposite side of her bedside mat. Bed in lowest position. Resident had removed boot from RLE [right lower extremity]. Head to toe assessment complete. No new injuries noted. The care plan was not updated. An Alert Note from 1/11/24 at 6:45 PM documented, At approximately 1845 [6:45 PM] nurse was notified that resident had slid of [sic] her bed. Nurse went into room and observed resident sitting on the floor next to her bed. Her back was against the bed and she was sitting upright on her bottom. Bed was at lowest position. Resident had been put into bed 10 min prior. Resident did not hit her head. H-T [head-to-toe] assessment completed. No new injuries upon assessment . The care plan was updated on 1/12/24 and documented, Educate staff to allow resident to stay up after meals as she seems to prefer to stay out of bed. An Alert Note from 2/1/24 at 8:30 PM documented, Resident found on floor beside bed. Bed at lowest setting. Brief was undone, but still on. Head to toe assessment done. No injuries seen, but she did have some fresh BM [bowel movement] on finger tips and a few scratches on bottom. Brief did have BM. Helped back intobed [sic] at lowest setting . The care plan was updated on 2/2/24 and stated, the resident uses fall prevention device: Floor mat. Ensure the device is in place as ordered. An Alert Note from 2/5/24 at 2:35 AM documented, [Resident 35] had a new unwitnessed fall this evening. She was found on the floor next to her bed. Small abrasion to L knee found. Wound cleaned with wound spray and covered with bandaid. No further injuries . She was unable to tell nurse how the fall occurred . The fall care plan was updated on 2/9/24 and documented, Offer resident her strips of fabric she enjoys fiddling with. A Nursing Note from 2/17/24 at 2:32 PM documented, Resident slid herself off the bed onto her buttocks. The bed is on the lowest setting. This nurse was watching from the nursing station. No injuries/deformities noted . The fall care plan was updated on 2/19/24 and documented, Offer sensory blanket when awake. An Alert Note from 2/23/24 at 4:25 PM documented, Resident slipped out of her wheelchair onto the floor in the main dining room during the activity at 1620 [4:20 PM]. Fall was witnessed by CNA. Resident did not hit her head or appear to have any pain. Nurse assessed. No injuries noted. Resident has been very anxious today attempting to stand up several times throughout the shift. Staff redirecting her with sensory activities . The fall care plan was not updated. A Nurses Note from 3/3/24 at 9:45 AM documented, The resident got up from her wheelchair and sat down on the floor. This nurse got up and walked out of the nursing station and around to the left of the hall. The resident fell back while sitting on her buttocks and hit the back of her head. A small bump on her posterior head noted. Resident has full range of motion in all extremities .Will continue to monitor. The fall care plan was not updated. On 4/4/24 at 9:05 AM an interview with CNA 4 was conducted. CNA 4 stated that if a resident had an unwitnessed fall, CNA's were instructed to make sure the resident was safe, and immediately tell a nurse. CNA 4 stated that vitals were started and staff were supposed to try and find out if anyone saw the fall or try to identify the cause of the fall. CNA 4 stated that neuros were filled out and once the neuros were completed the sheet was given to the nurses station. CNA 4 stated that there were general fall preventions for all of the residents. CNA 4 that staff were typically educated on new fall prevention interventions during rounds. On 4/4/24 at 9:47 AM an interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that if a resident had an unwitnessed fall, the nurses are expected to initiate neurological checks, assess for injuries, check range of motion, ask the resident about pain, assess the residents baseline, complete a skin check, and identify any immediate injuries. LPN 1 stated that staff are expected to inform the DON, complete an incident report, and try to identify the cause of the fall. On 4/4/24 at 11:40 AM an interview with the DON was conducted. The DON stated that the facility conducts a fall committee meeting weekly. The DON stated that the fall committee members included herself, the unit managers, sometimes social services, and the activities members. The DON stated that recent falls, trends and new interventions were discussed in the fall committee meetings. The DON stated that all new interventions were placed in the care plan. The DON stated that new interventions were implemented after each fall. The DON stated that after a resident fell, an incident report was completed, and the fall was discussed in the interdisciplinary team meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 3 out of 26 sampled residents, residents that had multiple falls with injuries were not provided interventions or adequate supervision to prevent falls from occurring. A resident had a fall that resulted in a left hip fracture and the resident was hospitalized . In addition, a resident had a fall resulting in a hematoma to the forehead. Resident identifiers: 32, 48, and 53. Findings included: 1. Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, psychosis not due to a substance or known physiological condition, dementia, need for assistance with personal care, muscle weakness, unsteadiness on feet, dysphagia, major depressive disorder, presence of left artificial hip joint, presence of left artificial ankle joint, chronic obstructive pulmonary disease, persistent affective mood disorder, essential hypertension, and convulsions. On 5/2/22 at 8:35 AM, an interview was conducted with resident 48. Resident 48 stated that he had been hospitalized on ce since his admission to the facility. Resident 48 stated that he was unable to recall the details of the hospitalization or when it happened. During the interview Resident 48's call light was observed on the floor near the head of the bed. On 5/2/22 at 12:39 PM, an observation was conducted of resident 48's room. A fall mat was not present in resident 48's room. Resident 48 stated that he did not have a fall mat. Resident 48's medical record was reviewed on 5/3/22. A care plan Focus initiated on 11/17/19, documented [Name of resident 48 removed] is at risk for falls psychosis, intracranial injury, convulsions, repeated falls, abnormal posture, need for assistance with personal care, abnormality of gait and mobility, lack of coordination, dementia. A care plan Goal initiated on 11/17/19, documented [Name of resident 48 removed] will not sustain serious injury through the review date. The interventions included, but not limited to: a. Be sure resident 48's call light is within reach and encourage him to use it for assistance as needed, resident 48 needs prompt response to all requests for assistance. Initiated on 11/18/19. b. Ensure commonly used items were within reach prior to leaving the room. Initiated on 11/18/19. A Fall Risk Evaluation dated 6/15/20, documented resident 48 Not at Risk for falls. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 48 had a Brief Interview for Mental Status (BIMS) score of 6. A BIMS score of 0 to 7 indicates severely impaired cognition. In addition, resident 48 was documented as requiring extensive assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Resident 48 required supervision of one person for walk in room and corridor. Resident 48 was not steady moving from a seated to standing position and surface to surface transfers between bed and chair or wheelchair. Resident 48 was only able to stabilize with human assistance. On 8/2/20 at 4:27 AM, an Alert Note documented Around 0400 (4:00 AM), pt (patient) was seen getting up from the floor of his room. Pt had his nasal cannula wrapped around his R (right) shoe. Pt appeared to have tripped and fallen because of that. Pt stated, 'I fell but I am okay.' Pt was assessed for any injuries. No apparent injuries. V/s (vital signs) WNLs (within normal limits). Neuro (neurological) checks started. Pt denies any pain. MD (Medical Director) notified. [Note: No new interventions were implemented to prevent falls.] On 8/4/20 at 8:15 AM, a Nursing Note documented At approximately 0815 (8:15 AM) [name of resident 48 removed] was standing at the nurses station just hanging out. Night nurse [name of nurse removed] and I were in the process of counting narcotics when we heard [name of resident 48 removed] saying 'whoa' 'whoa' so we both quickly turned around to find [name of resident 48 removed] on the floor. I asked [name of resident 48 removed] what happened when he said 'I slipped on my socks' 'I am fine honey' Upon assessment I did NOT find as (sic) injuries, bruises, or markings. A care plan Focus initiated on 8/4/20, documented The resident has had an actual fall with injury A care plan Goal initiated on 8/4/20, documented The resident broke his left hip and had surgery. Will resume usual activities without further incident through the review date. The interventions included: a. Ensure that resident 48 was wearing shoes while ambulating. Initiated on 8/4/20. b. Physical Therapy (PT) consultation for strength and mobility. Initiated on 8/4/20. c. A second pair of shoes was ordered for resident 48. Initiated on 8/4/20. d. Pharmacy consultation to evaluate medications. Initiated on 8/4/20. [Note: A pharmacy consultation to evaluate resident 48's medications related to the fall on 8/4/20, was unable to be located.] e. Neuro checks per facility protocol. Initiated on 8/4/20. [Note: Intervention was a medical intervention and not an intervention to prevent falls.] On 8/7/20 at 7:47 AM, an Alert Note documented CNA (Certified Nursing Assistant) witnessed fall. Resident fell and hit his head on back of chair. Assessed for any injuries. Resident denies any pain, says 'I feel fine.' CNA and Nurse helped him up on either side and helped him back to his room and bed. Neuro checks started. Resident denied any weakness or pain. Both CNA and Nurse helped him up and ambulating to room with one on each side. His gait felt weak to nurse as we were helping him. When spoke with sister she was concerned, and asked about awareness of numerous brain surgeries he has had in past. A care plan intervention initiated on 8/7/20, documented Nurse Practitioner to asses resident [Note: No new interventions to prevent falls were identified within the Nurse Practitioner (NP) assessment.] A care plan intervention initiated on 8/10/20. documented CBC (complete blood count) and CMP (comprehensive metabolic panel) for increase in falls. [Note: No new interventions to prevent falls were identified from the laboratory blood draw.] On 8/11/20 at 4:10 AM, an Alert Note documented Heard groaning sounds coming from residents room. Nurse and CNA went to check on resident and was found on the floor laying on his right side by they (sic) door. Resident stated 'I just fell hard' when asked if he could describe what happened.Immediate (sic) head to toe assessment. No bruising, skin tears or red spots noted, pupils PERRlA (pupil, equal, round, reactive to light and accommodation) no bumps or bruising on head. Resident stated 'I hurt everywhere'. No visual signs of pain when moving Lower extremities, Resident was able to stand with assist and transfer into wheelchair and then transfer back to bed. Non-skid socks place on resident. Care plan interventions initiated on 8/11/20, documented Non-skid socks when in bed. and COVID-19 (Coronavirus disease) testing as needed. [Note: The COVID-19 testing intervention was a medical intervention and not an intervention to prevent falls.] A Fall Risk assessment dated [DATE], documented resident 48 At Risk for falls. A quarterly MDS assessment dated [DATE], documented that resident 48 required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident 48 required limited assistance of one person for walk in room and corridor and locomotion on and off the unit. Resident 48 was not steady moving from a seated to standing position and surface to surface transfers between bed and chair or wheelchair. Resident 48 was only able to stabilize with human assistance. On 10/16/20 at 6:48 PM, a Nursing Note documented On assessment Resident noted to be guarding his left leg and grimacing & saying 'ouch ouch' post fall incident, unwitnessed dated 10/16/20, 1814pm (6:14 PM). No skin breakdown noted, no redness. Limited ROM (range of motion) to left leg noted. Assisted Resident to bed, Oxygen on, bed in low position. Call light in reach. NP ordered xray of hip, called in for STAT (immediately) tonight, . [Note: No new interventions were implemented to prevent falls.] On 10/16/20 at 7:32 PM, a Nursing Note documented Sent patient to [name of hospital removed] ED (emergency department) for further evaluation of left hip post unwitnessed fall incident tonight. Resident is verbalizing intense pain even on light palpation and unable to perform any ROM over left leg. Requested STAT-Xray earlier but has not been performed at this time prior to transfer. The Hospital History and Physical dated 10/16/20, documented a chief complaint of left hip pain. presents to the emergency room after a ground level fall from his wheelchair. He landed on his left hip. Workup in the emergency room showed a left hip fracture. I was consulted. Orthopedics was called by the emergency room physician. On 10/17/20 at 9:12 AM, a Nursing Note documented Spoke with [name of Power of Attorney (POA) removed] in regard to [name of resident 48 removed] fall and transfer to hospital last night. Surgery is scheduled for sometime today, [name of POA removed] calling for update and will call back to give information. A reentry Fall Risk assessment dated [DATE], documented resident 48 At Risk for falls. On 10/21/20 at 3:45 AM, an Alert Note documented . Resident doing well with readmission. Resident denies pain at the moment, but will say 'ouch' during brief changes. Resident is following hip precautions and is compliant with medications. A significant change MDS assessment dated [DATE], documented that resident 48 had a BIMS score of 4. A BIMS score of 0 to 7 indicates severely impaired cognition. In addition, resident 48 was documented as requiring extensive assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Resident 48 was not steady with surface to surface transfers between bed and chair or wheelchair and was only able to stabilize with human assistance. A quarterly MDS assessment dated [DATE], documented that resident 48 required extensive assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Resident 48 required limited assistance of one person for walk in room and corridor. An admission Fall Risk assessment dated [DATE], documented resident 48 Not at Risk for falls. On 2/15/22 at 10:49 PM, a Nursing Note documented Resident was heard calling out from room at 2155 (9:55 PM). When staff entered to check on him he was found lying on his back on the floor. Resident stated, 'I fell on my back.' Resident was assessed. No injuries noted to head. Denied hitting his head. Redness and some minor scratches were found to the right side of his back. Area cleaned. Also has redness to the front of left thigh. Originally stated his back hurt but quickly said it was feeling better while nurse was assessing. Denies pain at this time. Neuro checks initiated and WNL. A Fall Risk assessment dated [DATE], documented resident 48 Not at Risk for falls. A care plan Focus initiated on 3/5/19, documented [Name of resident 48 removed] has limited physical mobility r/t (related to) r/t (sic) dementia, lack of coordination, abnormalities of gait and mobility, need for assistance with personal care, intracranial injury, convulsions. He is at risk for falls. [Name of resident 48 removed] had an actual fall 2/15/2022. The interventions included, but not limited to: a. Fall mat placed at bedside. Initiated on 1/18/22. b. Non-skid socks to prevent further incident of fall (2/15/22). Initiated on 2/16/22. [Note: A care plan intervention Non-skid socks when in bed. Was initiated on 8/11/20.] c. Provide supportive care, assistance with mobility as needed. Document assistance as needed. Initiated on 2/16/22. On 5/3/22 at 12:49 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that falls were discussed in the morning meeting with the team and the team would try to find the cause of the fall. UM 1 stated that interventions were implemented to prevent another fall from happening and interventions were based on the previous fall. UM 1 stated that fall interventions were on the resident care plan. UM 1 stated that each resident had a Kardex in the Kardex book that staff were expected to review and sign. UM 1 stated the Kardex were updated weekly and as needed. [Note: The resident Kardex book was reviewed and five staff had signed the book.] On 5/3/22 at 1:04 PM, an interview was conducted with CNA 9. CNA 9 stated that she would check the Kardex book for resident fall interventions or she would check with the nurse in the morning. CNA 9 stated that she would check with the nurse in the morning to make sure no one fell the day before. CNA 9 stated the fall interventions in place for resident 48 were to check on him and offer a drink, check to see if he was wet, and ensure resident 48's bed was in a low position. CNA 9 stated that resident 48 did not eat much but resident 48 would eat ice cream. CNA 9 stated that resident 48 did not have a fall mat. [Note: CNA 9 had not signed the Kardex book.] On 5/3/22 at 1:23 PM, an interview was conducted with CNA 10. CNA 10 stated that she would have to ask the charge nurse and check the resident's care plan for fall interventions. CNA 10 stated that resident 48 was an extensive one person assistance. CNA 10 stated that she would have to ask someone regarding fall interventions for resident 48. CNA 10 stated that she did not know off the top her head if resident 48 had a low bed or a fall mat in place. [Note: CNA 10 had not signed the Kardex book.] On 5/3/22 at 1:43 PM, an interview was conducted with CNA 2. CNA 2 stated if a resident had a fall she would report to the nurse immediately, she would check the resident, and take the resident's vital signs. CNA 2 stated that resident 48 had never fallen in the bed but he would get unsteady on his feet when he walked. CNA 2 stated that resident 48 did not have a fall mat. [Note: CNA 2 had not signed the Kardex book.] On 5/4/22 at 9:03 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 48 was noncompliant at every aspect. LPN 1 stated that resident 48 was on hospice and required assistance with everything and resident 48 refused to get out of bed and walk. LPN 1 stated that several interventions for falls have been implemented at different times. LPN 1 stated that resident 48 had been more compliant and very verbal lately. LPN 1 stated resident 48 did have a fall mat at one time. LPN 1 stated that interventions in place to keep resident 48 safe from falls were supervision while in the wheelchair and a one to two person assistance with transferring. LPN 1 stated that resident 48 was able to reposition himself and preferred to do that on his own but LPN 1 would check resident 48 every hour and a half to check on his positioning. LPN 1 stated that resident 48 had not fallen recently but in the past resident 48 would fall because he did not want help. LPN 1 stated staff had tried many interventions prior to get resident 48 where he was at. LPN 1 stated if the fall intervention was something she could put into place immediately she would. LPN 1 stated if the falls were a trend they would be discussed in the morning meeting every day with the team. LPN 1 stated that fall interventions were on the resident Kardex and the staff must check the Kardex book daily. LPN 1 stated that interventions were also discussed through report with the nurses every morning. LPN 1 stated the Kardex book was updated weekly and the UM's would tell the staff if the book was updated prior to the weekly update. LPN 1 stated if a resident had a fall the nurse would assess the resident and the immediate concerns would be addressed by the MD. On 5/4/22 at 10:01 AM, an observation was conducted of resident 48's room. A floor mat was not present in resident 48's room. 2. Resident 53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, Alzheimer's disease, muscle weakness, cognitive communication deficit, difficulty in walking, mood disorder due to known physiological condition, major depressive disorder, spondylosis, and chronic pain. Resident 53's medical record was reviewed on 5/5/22. A care plan Focus initiated on 8/31/21, documented [Name of resident 53 removed] has limited physical mobility. [Name of resident 53 removed] has an actual fall without injury 3/18/22. [Name of resident 53 removed] had an actual fall without injury 4/11/22. [Name of resident 53 removed] had an actual fall with injury, (R forehead hematoma) 5/4/2022. A care plan Goal initiated on 8/31/21, documented [Name of resident 53 removed] will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. The interventions included, but not limited to: a. Ambulation: Resident 53 requires up to extensive assistance of one staff to walk. Initiated on 8/31/21. b. PT and Occupational Therapy (OT) referrals as ordered, and as needed. Initiated on 8/31/21. A reentry Fall Risk Evaluation dated 1/28/22, documented resident 53 Not at Risk for falls. A quarterly MDS assessment dated [DATE], documented that resident 53 had a BIMS score of 3. A BIMS score of 0 to 7 indicates severely impaired cognition. In addition, resident 53 was documented as requiring extensive assistance of two persons for bed mobility, transfers, walk in room, locomotion on the unit, and dressing. Resident 53 required extensive assistance of one person for walk in corridor, locomotion off unit, toileting, and personal hygiene. Resident 53 was not steady moving from a seated to standing position, walking, turning around and facing the other direction while walking, moving on and off the toilet, and surface to surface transfers between bed and chair or wheelchair. Resident 53 was only able to stabilize with human assistance. On 3/18/22 at 5:58 PM, a Nursing Note documented resident was found on the floor beside the window, she states that she hit her head, CNA to take vitals, lung sounds clear with dim (diminished) to bases, no pain with movement reported, no skin tears noted. Neuro checks to start. A care plan intervention initiated on 3/18/22, documented Provide supportive care, assistance with mobility as needed. Document assistance as needed. [Note: The care plan intervention was initiated on 8/31/21. No new interventions were implemented to prevent falls.] A care plan intervention initiated on 3/22/22, documented PT referral and medication changes (3/18/22) [Note: A review of the March 2022 Medication Administration Record (MAR) revealed that haloperidol was decreased from 2 milligrams (mg) three times a day to 1 mg two times a day. Resident 53 was not referred to PT until 4/11/22.] A Fall Risk Evaluation dated 4/1/22, documented resident 53 At Risk for falls. On 4/11/22 at 3:07 AM, an Incident Report documented Resident was found by CNA at 0240 (2:40 AM) on her floor. Resident was previously sleeping. Nurse assisted resident back to bed and checked for injuries. No injuries noted. Resident requires a 1 to 1 for safety due to resident's constant pacing and instability on her feet. Soft C (cervical)-Collar ordered. A care plan intervention initiated on 4/11/22, documented Staff will attempt to place soft C-Collar when [name of resident 53 removed] is out of bed (4/11/22). [Note: Intervention was a medical intervention and not an intervention to prevent falls.] On 4/22/22 at 11:00 PM, an Alert Note documented 2045 (8:45 PM) Resident was on neuro checks for an unwitnessed fall in her room from previous shift. Resident was found on the floor in her room. Head to toe assessment [NAME] (sic), did not find any injury. helped into bed. She continually is moving her legs back and forth. CNA stayed with her until she went to sleep. Meds (medications) also given including scheduled lorazepam, tolerated well. Daughter was understanding and even saying she would give her permission for her mother to sleep on the floor if it would help. I assured her we didn't want to do that. We want her to be safe and comfortable. [Note: No new interventions were implemented to prevent falls.] On 5/3/22, an observation was conducted of resident 53 ambulating in the hall with staff. Resident 53 was observed without the C-Collar each time resident 53 was in the hall ambulating with staff. On 5/4/22 at 11:35 PM, a Nursing Note documented 2135 (9:35 PM) CNA called out that resident was on floor. Resident was lying on back when assessed, but CNA reported when she first saw her on floor her feet were under her bed. Resident seems in constant motion most of the time. However the fall occurred she must have hit her head as there was a large hematoma on the R side of her forehead with swelling and bruising, a little larger than a fifty cent piece. On full head to toe assessment no other injuries were found. helped back to bed, she is resistant as she continues to move and makes effort to get up out of bed. Taking 2 people to hold her still to obtain VS (vital signs) . Hand grasp strong and equal on both hands. When asked resident what had happened she did not respond. When she was placed in bed nurse emphasized to her it was important that she stay in bed to not get hurt. Resident responded, 'okay' while moving to bring self out of bed. CNA at bedside. daughter [name of resident 53's daughter removed] asked if she would be ok if we were to get a protective helmet for her to wear on her head. She was ok with that. A helmet was found, but was unable to get on her head with the current swelling. No new orders. OK to use ice on forehead. On 5/5/22 at 12:21 PM, an interview was conducted with CNA 9. CNA 9 stated that a staff member was with resident 53 all the time. CNA 9 stated that resident 53 was sleeping right now and CNA 9 tired to watch her. CNA 9 stated that resident 53 would go to the bathroom every two to three hours. CNA 9 stated that she would walk with resident 53, offer her water, and be with her to prevent falls. CNA 9 stated that resident 53 was not on a toileting program for every one to two hours. A care plan intervention initiated on 5/5/22, documented AMBULATION:The resident requires (SPECIFY: assistance) by (X) staff to walk (SPECIFY FREQ (frequency)) and as necessary. [Note: The care plan interventions was initiated on 8/31/21. No new interventions were implemented to prevent falls.] On 5/5/22 at 12:29 PM, an interview was conducted with LPN 1. LPN 1 stated that resident 53 was a one to one when out of bed. LPN 1 stated that resident 53's feet were always moving even when resident 53 was sleeping. LPN 1 stated that resident 53 was started on a scheduled dose of Ativan. LPN 1 stated that resident 53 would sleep for two hours versus 20 minutes prior to the Ativan. LPN 1 stated if resident 53 had someone with her she did not fall. LPN 1 stated that resident 53 was extremely active that morning and it took two people to take her vital signs. On 5/5/22 at 1:23 PM, an interview was conducted with UM 1. UM 1 stated that resident 53 had a change in January 2022. UM 1 stated that resident 53 was ambulatory and very aggressive. UM 1 stated that resident 53 had broken a window and would push people. UM 1 stated that resident 53 had been transferred at that time to a Behavioral Health Hospital and the hospital put resident 53 on high doses of Haldol. UM 1 stated that resident 53's decline was before the taper of the Haldol because resident 53 was snowed. UM 1 stated that when the Haldol was decreased she did not have behaviors but she was extremely weak. UM 1 stated resident 53's Haldol was discontinued on 3/18/22. UM 1 stated that resident 53 was now active again since the Haldol was discontinued. UM 1 stated that resident 53 was eating when she was readmitted but resident 53 was not moving at all and would barley wake up. 3. Resident 32 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, dementia without behavioral disturbance, muscle weakness, need for assistance with personal care, malignant neoplasm of breast, anxiety disorder, chronic pain, restless legs syndrome, history of falling, and depression. Resident 32's medical record was reviewed on 5/4/22. An admission Fall Risk Evaluation dated 12/8/21, documented resident 32 At Risk for falls. An admission MDS assessment dated [DATE], documented that resident 32 had a BIMS score of 11. A BIMS score of 8 to 12 indicates moderately impaired cognition. In addition, resident 32 was documented as requiring extensive assistance of one person for bed mobility, transfers, walk in room and corridor, locomotion on the unit, dressing, toilet use, and personal hygiene. Resident 48 required supervision of one person for locomotion off unit. The Care Area Assessment Summary documented that Falls triggered for a new care plan. A care plan for falls was unable to be located. On 1/9/22 at 6:45 AM, an Incident Report documented Patient fell next to her bed. Fell forward from the foot of her bed, toward the head of her bed. Overbed table moved slightly aside as she fell on bedside mat. Patient stated that she bumped her head on the overbed table as she fell. Attempts made through the rest of the night to keep her from walking without assist. Very forgetful and continuously getting up and walking around, with and without walker, gait very unsteady. On 1/24/22 at 7:21 PM, a Nursing Note documented Resident was walking near the nurses station and slipped and fell and was in a sitting position with her legs out and walker beside her resident was then assessed and no c/o (complains of) pain . [Note: No new interventions were implemented to prevent falls.] A Fall Risk Evaluation dated 1/24/22, documented resident 32 At Risk for falls. A care plan Focus initiated on 1/25/22, documented [Name of resident 32 removed] had had an actual fall on 1/9/2022, and 1/24/22 with (no injury) Poor Balance, Unsteady gait. A care plan Goal initiated on 1/25/22, documented [Name of resident 32 removed] will resume usual activities without further incident through the review date. The interventions included, but not limited to: a. Provide activities that promote exercise and strength building when resident 32 is getting up from bed to walk. Initiated on 2/10/22, for fall on 1/9/22. [Intervention was implemented a month after resident 32 fell.] b. Monitor, document, and report as needed for 72 hours to MD for signs and symptoms of pain, bruises, change in mental status, and new onset of confusion, sleepiness, inability to maintain posture, and agitation. Initiated on 1/25/22. [Note: Intervention was a medical intervention and not an intervention to prevent falls.] c. Neurological checks. Initiated on 1/25/22. [Note: Intervention was a medical intervention and not an intervention to prevent falls.] d. Reorient resident 32 and provide frequent education regarding use of wheelchair and walker. Initiated on 2/10/22, for fall on 1/24/22. [Intervention was implemented 17 days after resident 32 fell.] On 3/23/22 at 5:57 PM, an Alert Note documented Fall day 1. During shift at 5:30pm staff heard resident crying from her room. This nurse and staff went immediately into her room and observed resident sitting on her buttocks by the bathroom and next to bed A. As per resident, 'I was going back to bedand (sic) I fell.' 'My head hurts' As per assessment, resident able to follow commands. Able to move her upper and lower extremity well. Able to stand up with 1 assist. No skin tear. No bumps or bruise. Resident complained of pain on her head, but no rednessor (sic) bumps noted at this time. Received order to closely monitor neuro check and notify on call for any furtherchange (sic) of conditions. Endorse oncoming nurse to continue monitor. Educated resident to use of call light. Bed at thelowest (sic) position and call light in reach. Frequent check done to continue monitor neuro and resident's safety. Resident is up for dinner in dining room at this time. Care plan interventions initiated on 3/24/22, included Non-skid socks (3/23/22) and Toileting schedule in place (3/23/22). A Fall Risk Evaluation dated 3/23/22, documented resident 32 Not at Risk for falls. On 3/24/22 at 12:15 AM, an Incident Report documented 0015 (12:15 AM) Resident found on floor beside bed. Helped back into bed. Total body assessment done, no injuries found. no new orders. 0050 (12:50 AM) Resident c/o pain in R hip, can move it freely, Acetaminophen given. Resident seen from nursing desk sitting on side of bed, when nurse at bedside assisting her to lay back down asked her first what she was trying to do. she responded, 'She was going to see her father'. Staff to keep more frequent checks on her. Consider 1:1 (one to one) staffing for her. [Note: No new interventions were implemented to prevent falls.] A Fall Risk Evaluation dated 3/24/22, documented resident 32 At Risk for falls. On 4/2/22 at 4:18 PM, a Nursing Note documented patient was found in her room on the floor. She reported a fall and reported that she did fall. From the aids (CNAs) she is not a person who is normally oriented and she was only oriented to self and situation. She reported that she did not hit her head, it is unknown if she is a reliable historian at this time due to her diagnosis and being on hospice. Patient was then moved off of floor and put back into bed. She reported no pain except for her right arm . Patients is able to bear weight on both bilateral extremities and has adequate grip strength at this time. No other acute problems noted at this time. Patient will be monitored on the Neuro check protocol for any worsening signs of intracranial bleeding. A care plan intervention initiated on 4/2/22, documented PT / OT Referral (4/2/22). [Note: Resident 32 was discharged from PT services on 9/17/21. A PT and OT referral was unable to be located.] On 4/30/22 at 12:18 AM, a Nursing Note documented At 2300 (11:00 PM) on 4/29/2022 heard resident call out for help. She was found sitting[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 26 sampled residents, a resident who had experienced a significant weight loss did not have interventions put in place to prevent further significant weight loss. Resident identifier: 53. Findings included: Resident 53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, Alzheimer's disease, muscle weakness, cognitive communication deficit, difficulty in walking, mood disorder due to known physiological condition, major depressive disorder, spondylosis, and chronic pain. Resident 53's medical record was reviewed on 5/5/22. A care plan focus initiated on 5/2/22, documented [Name of resident 53 removed] has nutritional problem or potential nutritional problem r/t (related to) dx (diagnosis) depression, Hx (history) Covid 19 (Coronavirus disease) w/ (with) BMI (body mass index) 17.5 w/recent sign (significant), weight losses and need for supplements to meet needs. The care plan goals initiated on 12/1/21, documented No significant weight loss of 5% (percent) in 30 days or 10% in 180 days. and [Name of resident 53 removed] will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx (signs or symptoms) of malnutrition through review date. The care plan goal was revised on 4/24/22. The following care plan interventions included: a. Provide and serve diet as ordered. Initiated on 8/31/21. b. Provide, serve diet as ordered. Monitor intake and record every meal. Initiated on 9/7/21. c. Weigh per facility policy. Initiated on 9/7/21. d. Registered Dietitian (RD) to evaluate and make diet change recommendations as needed. Initiated on 9/7/21. Resolved on 9/14/21. e. Provide and serve supplements as ordered. Initiated on 5/2/22. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 53 had a Brief Interview for Mental Status (BIMS) score of 3. A BIMS score of 0 to 7 indicates severely impaired cognition. A Skin and Nutrition Review dated 2/22/22, documented that resident 53 had a recent significant weight loss of 3.2% since 2/15/22. Will recommend Med Pass 60 milliliters (ml) three times a day (TID) for recent significant weight loss. [Note: The Med Pass TID recommendation was not implemented until 4/13/22. This indicated a 50 day delay for the implementation of the Med Pass TID supplementation.] On 2/22/22, resident 53 had a documented weight of 152 pounds (lbs). On 4/13/22, resident 53 had a documented weight of 126.8 lbs. With these reference weights, resident 53 experienced a documented significant weight loss of 16.58 % during a two month interval. The Amount Eaten was reviewed for February 2022. Out of 84 opportunities resident 41 ate 76 to 100 % of the meal on 39 occasions, 51 to 75 % of the meal on 43 occasions, and 26 to 50 % of the meal on 3 occasions. On 3/4/22, resident 53 had a documented weight of 153.6 lbs. On 4/5/22, resident 53 had a documented weight of 134.4 lbs. With these reference weights, resident 53 experienced a documented significant weight loss of 12.50 % during a one month interval. The Amount Eaten was reviewed for March 2022. Out of 93 opportunities resident 53 ate 76 to 100 % of the meal on 16 occasions, 51 to 75 % of the meal on 31 occasions, 26 to 50 % of the meal on 27 occasions, and 0 to 25 % of the meal on 10 occasions. A Skin and Nutrition Review dated 4/13/22, documented that resident 53 had a recent significant weight loss on 4/13/22, of 17.4% since 3/4/22. A 19.9% weight loss since 1/28/22, and a 18.5% weight loss since 10/19/21. Will recommend Med Pass 90 ml four times a day (QID), fortified diet, and Magic cup every day. Resident 53 has had a slow decline since January 2022. Resident 53 had been eating less and has had a cognitive decline. Resident 53 had a gradual weight loss with her change of condition. [Note: The Med Pass QID recommendation was not implemented.] A physician's order dated 4/13/22, documented Med Pass 2.0 TID for weight management. [Note: This was the recommendation that was placed from documentation of the Skin and Nutrition Review on 2/22/22.] A Skin and Nutrition Review dated 4/20/22, documented that resident 53 had a recent significant weight loss of 3.5% since 4/13/22. A 22.7% weight loss since 1/28/22, and a 21% weight loss since 10/26/21. Resident 53 averages 25 to 50% of meal intake of a regular fortified diet. Resident 53's Magic cup intake was 50% 2 out of 6 days and refuses the other days. Resident 53's Med Pass intake was 25% TID. Recommend stopping the Magic cup due to poor acceptance, will recommend Med Pass 60 ml QID, and a Healthshake every day. May also consider an appetite stimulate related to recent weight losses. [Note: Recommendations were not implemented.] The Amount Eaten was reviewed for April 2022. Out of 90 opportunities resident 53 ate 76 to 100 % of the meal on 4 occasions, 51 to 75 % of the meal on 16 occasions, 26 to 50 % of the meal on 19 occasions, and 0 to 25 % of the meal on 36 occasions. On 10/26/21, resident 53 had a documented weight of 155.6 lbs. On 4/30/22, resident 53 experienced a documented weight of 118.8 lbs. With these reference weights, resident 53 experienced a documented significant weight loss of 23.65 % during a six month interval. On 4/5/22, resident 53 had a documented weight of 134.4 lbs. On 5/3/22, resident 53 had a documented weight of 115.4 lbs. With these reference weights, resident 53 experienced a documented significant weight loss of 14.14 % during a one month interval. A Skin and Nutrition Review dated 5/4/22, documented that resident 53 had a weight loss of 14.1% since 4/5/22, and a weight loss of 27.1% since 11/2/21. Resident 53 continues to decline and was on comfort cares per the unit manager (UM). Recommended the Med Pass 60 ml QID, and evaluate for appetite stimulant. [Note: These recommendations were recommended during the Skin and Nutrition Review dated 4/20/22. The recommendations were not implemented on 4/20/22. This indicated a 14 day delay in implementation of nutritional interventions, and during the time frame from 4/19/22 to 5/4/22, resident 53 had experience a 5.7 % further decline in weight.] The Amount Eaten was reviewed for May 2022. Out of 14 opportunities resident 53 ate 51 to 75 % of the meal on 1 occasion, 26 to 50 % of the meal on 2 occasions, and 0 to 25 % of the meal on 9 occasions. On 5/5/22 at 12:36 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 53 did not like to eat. LPN 1 stated that resident 53 would eat the softer foods but resident 53 had zero appetite. LPN 1 stated that it was hard to get resident 53 to drink the Med Pass. LPN 1 stated that she would try frequently to get resident 53 to drink the Med Pass. LPN 1 stated that resident 53 would drink water. LPN 1 stated that resident 53 was not able to feed herself. LPN 1 stated that resident 53 had a head droop and resident 53 would move her head away when she was finished eating. LPN 1 stated that resident 53's daughter would come to the facility and feed resident 53 either during breakfast or lunch. LPN 1 stated that a health shake was separate from the Med pass and they were not the same thing. LPN 1 stated a Magic cup or a high protein supplement would come on the snack tray from the kitchen. LPN 1 stated a health shake would come from the kitchen. LPN 1 stated items like Breeze, Boost, Med Pass, or Ensure came from the nurse and were documented on the Medication Administration Record or the Treatment Administration Record. LPN 1 stated that resident 53 did not like the Magic cup. LPN 1 stated that the RD recommendations went to the UM and the UM would communicate the recommendations to the floor nurse. LPN 1 stated that the Skin and Nutrition meetings were every Wednesday and the UM would let the nurses know about recommendations on Thursday mornings. On 5/5/22 at 1:23 PM, an interview was conducted with UM 1. UM 1 stated that resident 53 had a change in January 2022. UM 1 stated that resident 53 was ambulatory and very aggressive. UM 1 stated that resident 53 had broken a window and would push people. UM 1 stated that resident 53 had been transferred at that time to a Behavioral Health Hospital and the hospital put resident 53 on high doses of Haldol. UM 1 stated that resident 53's decline was before the taper of the Haldol because resident 53 was snowed. UM 1 stated that when the Haldol was decreased she did not have behaviors but she was extremely week. UM 1 stated that resident 53 would eat 100% of her meals but because she was snowed she was not eating much. UM 1 stated that resident 53 was on weekly weight for a month when she was readmitted from January 2022 to 2/23/22. UM 1 stated that resident 53 was eating during that time. UM 1 stated resident 53's Haldol was discontinued on 3/18/22. UM 1 stated that resident 53 was now active again since the Haldol was discontinued. UM 1 stated that resident 53 was eating when she was readmitted but resident 53 was not moving at all and would barley wake up. UM 1 stated that in April 2022 was when she noticed that resident 53 was not eating well. UM 1 stated that when a recommendation was received the UM would put in the orders. UM 1 stated if an appetite stimulant was recommended the UM would ask the doctor. UM 1 stated that Med Pass QID may have been an error. UM 1 stated the Med Pass was entered TID and the paper notes documented TID. UM 1 stated the physician and Doctor of Nursing Practice do not attend the Skin and Nutrition meetings. On 5/5/22 at 1:50 PM, an interview was conducted with UM 2. UM 2 stated that she had missed putting in the orders from the Skin and Nutrition meeting on 4/20/22. UM 2 stated that all of the notes from the Skin and Nutrition meeting were input into the evaluation, the recommendations were followed up on with the physician and orders would be documented.