**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 of 3 sampled residents (R2) was free from significant medication errors. * R2 received a medication, Morphine, on 05/26/2024, which is not on R2's Medication Administration Record (MAR) and is not prescribed to R2. After administration, this medication required close monitoring of R2's physiological status. *R2 had orders for Clonazepam, oral tablet, 0.5mg to be given two times per day (AM and PM) for Anxiety. On 05/21/2024, R2 received 1 mg of Clonazepam during the PM medication pass instead of 0.5mg as prescribed. Findings include: The facility policy titled, Medication Administration with a last revision date of 05/10/2023, documents, in part: Policy: medications will be administered to residents as prescribed by persons lawfully authorized to do so in a manner consistent with the infection prevention and standards of practice. Personnel authorized to administer medications do so only after they familiarized themselves with the medication. The facility has sufficient staff to allow the administering of medications without unnecessary interruptions. Procedure: 3. Prior to administration, the medication and dosage schedule on the MAR is compared with the medication label. If the label and the MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physicians orders are checked for correct dosage schedule. Administration: 2. Medications are administered in accordance with written orders of the attending physician or physician extender. Medications are administered at the time they are prepared. Medications are not pre-poured. 5. Medications are administered without unnecessary interruptions. 7. Residents are identified before medication is administered. Methods of identification include: a. Checking identification band b. Tracking photograph attached to medical record. c. Asking resident to say and/or spell his/ her name d. If necessary, verify resident identification with other facility personnel. 11. Medications supplied for one resident are never administered to another resident. The facility policy, titled Medication Errors, with a last revision date of 05/10/2023, documents in part, Policy: it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Procedure: 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders. b. Per manufacturer specifications regarding the preparation and administration of the drug or biological. c. In accordance with accepted standards and principles which apply to professionals providing services. 2. The facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events. 3. Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines: a. Resident's Condition: if the resident's condition requires rigid control, such as strict intake and output measurement, daily weights, or monitoring of lab values. c. Frequency of Error: if an error is occurring repeatedly such as an omission of a resident's medication several times. 7. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration; b. Right resident and right documentation. 8. If a medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible. b. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. c. Document actions taken in the medical record. Per The National Institute of Health (NIH), National Library of Medicine (NLM), National Center for Biotechnology Information (NCBI), titled Morphine, with a last update of 05/22/2023, documents in part, Respiratory depression is among the more serious adverse reactions of Morphine and can also affect the cardiovascular system. Morphine can also affect the cardiovascular system and reportedly can cause flushing, bradycardia, hypotension, and syncope. Monitoring . Other essential parameters requiring monitoring include mental status, blood pressure, respiratory drive, and misuse/overuse. Although it may seem intuitive, it is also important to monitor what other medications a patient is taking. This list includes but is not limited to prescription medications. All patients taking morphine should understand the need to avoid any other substances that could lead to respiratory depression. These medications include but are not limited to alcohol, additional opioids, benzodiazepines, and barbiturates. Patients can become apneic at lower doses if combining morphine with any of these substances. Morphine (an opioid medication) is a Schedule II controlled substance, regulated by The Drug Enforcement Administration (DEA). Each category, of the five schedules of controlled substances, includes the substances' ability to cause harm. The schedules range from Schedule I (high) to Schedule V (low). The Food and Drug Administration (FDA) document, titled, Drug Safety Communications, dated 08/31/2016, documents in part, FDA warns about serious risks and death when combining opioid pain or cough medicines with benzodiazepines; requires its strongest warning. The FDA label for Morphine, titled, Highlights of prescribing information, MORPHINE SULFATE tablets, for oral use CII Initial U.S. Approval: 1941, documents in part, Contraindications- Significant respiratory depression. DRUG INTERACTIONS- Serotonergic Drugs: Concomitant use may result in serotonin syndrome. 1.) R2 was admitted to the facility on [DATE] with a diagnoses that includes heart failure, depression, schizoaffective disorder, anxiety, and respiratory failure. R2's most recent annual Minimum Data Set (MDS), dated [DATE], documents R2 requires oxygen therapy. R2 had the following medication orders in place for May of 2024: Celexa, Clonazepam, Ergocalciferol, Gabapentin, Lasix, Melatonin, Primidone, Risperdal, Seroquel, Tylenol, Depakote Sprinkles, and Acidophilus. Surveyor noted that R2's medications, Celexa, is a Selective Serotonin Reuptake Inhibitor (SSRI) and R2's Clonazepam is a benzodiazepines. First medication error: Surveyor reviewed R2's electronic health record (EHR) and noted a progress note for a medication error on 05/21/2024. The progress note documents that on 05/21/2024, R2 received a double dose of her ordered Clonazepam. R2's EHR, administration record for May 2024, documents R2 had an order for Clonazepam 0.5mg two times per day (AM and PM). Surveyor reviewed the document provided by NHA (Nursing Home Administrator)-A, titled, Drug Error Report, with no date that documents: R2 was given Clonazepam 1 mg instead of Clonazepam 0.5mg at 04:34 PM by LPN (Licensed Practical Nurse)-G. Notifications on 05/21/2024 were made to Supervisor at 08:30 PM, Physician notified at 09:30 PM and family notified at 09:40 PM. Explanation of event documented, checked dosage in MAR but pulled from wrong card. Both cards next to each other. Corrective action taken, Clonazepam 1 mg card will be marked HS ONLY. No new orders. Surveyor noted that after the medication error that was no documentation that R2's vitals were monitored. On 08/22/2024 at 08:44 AM, Surveyor interviewed UM (Unit Manager)-D. UM-D informed surveyor that she recalls the medication error on 05/21/2024 and stated LPN-C made a medication error with R2's Clonazepam at 04:34 PM and that she was notified of this error at 08:30 PM. UM-D stated she went and preformed a full assessment of R2 at that time she was notified. UM-D was unable to find documentation in the chart of UM-D full assessment. UM-D presented surveyor with the first set of full vitals obtained following the medication error. The full set of vitals that were obtained on 05/21/2024, at 09:55 PM were: temperature 97.5 degrees Fahrenheit (F), heart rate 75 beats per minute (bpm), respirations 18, oxygen saturation (sp02) 93% on nasal cannula and blood pressure (b/p) 120/69. UM-D informed Surveyor that R2 was then monitored for 3 days every shift. UM-D stated she performed verbal training with LPN-C as to paying better attention to the medication cards being pulled. UM-D stated yearly training is preformed to all nursing staff on medication administration and reporting of medication errors. Surveyor noted that R2 had no specific orders for monitoring of R2 and no orders to obtain vital signs, to monitor R2 were documented in R2's Medication Administration Record (MAR)/ Treatment Administration Record (TAR) or progress notes after this medication error occurred. Second medication error: Surveyor reviewed a progress noted, dated 05/27/2024, at 06:11 AM, that documents, Resident is alert and orient but drowsy. New order from [Nurse Practitioner] from Optum noted. Vital signs every hour X12 hours then q shift X 24 hours. Check neuro status at time of vital sign check. Resident noted to have decreased Bp and Spo2 R/T med error. [NAME] called 2 times this shift to check on resident's VS. verbal order to increase resident's oxygen via concentrator to 4 lpm d/t Spo2 @ 90% on 2L. O2 increased, and Pox increased to 94% via nasal cannula. Resident remained alert and responsive to verbal and tactile stimuli. Bp and Spo2 is within normal range at this time. Denies any pain or discomfort at this time. Surveyor reviewed the document provided by NHA-A, titled, Drug Error Report, with no date that documents in part: Date error occurred 05/26/2024 at 08:14 PM by Agency LPN-C. Supervisor notified on 05/26/2024 at 10:50 PM, Physician notified on 05/26/2024 at 11:30 PM and family notified on 05/27/2024 at 08:00 AM. Brief explanation or error- gave Morphine 30 mg instead of Clonazepam 1 mg in error. Explanation/statement of nurse making error- was pulling medications for another resident and needed to go to the restroom, then stopped and pulled medication for R2 and gave wrong medication. At the same time an ambulance was picking up another resident. Physician orders related to error: give 480 ml of fluid now, recheck vitals 30 mins and call Optum, vitals every hour for 12 hours then every shift for 24 hours. Corrective action documents see above. Date of counseling to nurse 05/31/2024 at 10:49 PM. Indicate how this error could have been prevented: complete one task at a time. Surveyor noted on R2's MAR/TAR the following order, 480 ml of fluid now. Recheck vital signs 30 min after and call Optum on call at [PHONE NUMBER] with update one time only for 1 Day -Start Date- 05/26/2024 2330 and documents, given at 03:16 AM b/p 94/59, temperature 97.3, pulse 80, respirations 18 and O2 90%. Surveyor noted the order was documented on R2's MAR/Tar as completed at 0316 hours. No documentation of Optum update, and no further new orders were located. Surveyor noted on R2's MAR/TAR the following order, Vital signs every hour X12 hours then q shift X 24 hours. Check neuro status at time of vital sign check every hour for 12 Administrations -Start Date- 05/27/2024 0000 and documents the following on 05/27/2024: 0000- b/p 79/50, temperature 97.4, pulse 76, respirations 19 and O2 92% 0100- b/p 88/42, temperature 97.1, pulse 85, respirations 19, and O2 93% 0200- b/p 85/51, temperature 96.9, pulse 90, respirations 18, and O2 91% 0300- b/p 94/59, temperature 97.3, pulse 80, respirations 18, and O2 90% 0400- b/p 98/63, temperature 97, pulse 75, respirations 18, and O2 91% 0500- b/p 98/58, temperature 97.6, pulse 77, respirations 19, and O2 94% 0600- b/p 108/69, temperature 97.7, pulse 75, respirations 19, and O2 95% 0700- b/p 112/64, temperature 98.3, pulse 82, respirations 18, and O2 92% 0800- b/p 126/69, temperature 98, pulse 85, respirations 20, and O2 92% 0900- b/p 130/74, temperature 98.1, pulse 83, respirations 18, and O2 92% 1000- b/p 119/64, temperature 98, pulse 82, respirations 18, and O2 91% 1100- b/p 122/62, temperature 98, pulse 82, respirations 18, and O2 92% Surveyor calculated the Mean Arterial Pressure (MAP) for R2, using the formula MAP= 2(DBP) + SBP/3, for the first 4 documented blood pressures. At 0000 hours, R2's MAP was 59 mmHg, 0100 was 57 mmHg, 0200 was 62 mmHg and at 0300 R2's MAP was 70 mmHg. According to The National Institute of Health (NIH), National Library of Medicine (NLM), National Center for Biotechnology Information (NCBI) document, titled Low Blood Pressure, documents low blood pressure is defined as a blood pressure reading less then 90/60 millimeters of mercury (mmHg). According to The National Institute of Health (NIH), National Library of Medicine (NLM), National Center for Biotechnology Information (NCBI) document, titled Physiology, Mean Arterial Pressure, documents, To perfuse vital organs requires the maintenance of a minimum MAP of 60 mmHg. Surveyor noted a progress note, dated 05/27/2024, at 10:19 PM, documents Resident being monitored for medication error. VSS. Very lethargic this shift. No c/o pain or discomfort. Appetite good. Will monitor. Surveyor noted a change in condition progress note, dated 05/28/2024, which documents in part. Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Fever At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 104/49 - 5/28/2024 20:20 Position: Sitting r/arm - Pulse: P 92 - 5/28/2024 20:20 Pulse Type: Regular - RR: R 22.0 - 5/28/2024 20:20 - Temp: T 99.3 - 5/28/2024 20:20 Route: Forehead (non-contact) - Weight: W 256.0 lb - 5/3/2024 13:34 Scale: Standing - Pulse Oximetry: O2 94.0 % - 5/28/2024 20:20 Method: Oxygen via Nasal Cannula . Nursing observations, evaluation, and recommendations are:Upon taking resident's vitals at dinner time, writer noticed that resident was febrile. After informing supervisor, writer was informed to remove resident from dinner table and to give her Tylenol after supper. An hour after Tylenol was administered, resident's temporal temperature decreased to 98.3. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: B. New Testing Orders: C. New Intervention Orders: - Other - Tylenol Surveyor noted a change in condition progress note dated 05/29/2024, at 11:55 AM, documents, Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change)Seems different than usual Tired, Weak, Confused, or Drowsy At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 86/58 - 5/29/2024 10:21 Position: Sitting l/arm - Pulse: P 103 - 5/29/2024 10:21 Pulse Type: Regular - RR: R 20.0 - 5/29/2024 10:21 - Temp: T 98.0 - 5/29/2024 10:21 Route: Forehead (non-contact) - Weight: W 256.0 lb - 5/3/2024 13:34 Scale: Standing - Pulse Oximetry: O2 86.0 % - 5/29/2024 10:20 Method: Oxygen via Nasal Cannula - Blood Glucose: BS 22.0 - 9/24/2022 08:14 . Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Increased confusion(e.g. disorientation) - Functional Status Evaluation: General weakness - Behavioral Status Evaluation: - Respiratory Status Evaluation: Other respiratory changes - Cardiovascular Status Evaluation: Resting pulse greater than 100 or less than 50 - Abdominal/GI Status Evaluation: - GU/Urine Status Evaluation: - Skin Status Evaluation: - Pain Status Evaluation: Does the resident/patient have pain? No - Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are:after breakfast, res. noted to have increased lethargy, weakness. Leaning to R side of W/c, repositioned. Lungs clear. Abd. soft round with + BS. Res. denies pain. HR elevated, B/P decreased, POX decreased. Oxygen increased to 2.5 L/min. Ate fair for bkft. [NAME], NP updated. NOR. POA [NAME] updated. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: CXR, labs, UA C&S per [NAME], NP B. New Testing Orders: - Blood Tests Urinalysis or culture X-ray Surveyor noted orders placed to rule out an infectious process, but no documented evidence of infection process causing R2's change in condition. Surveyor noted that per Drugs.com, Morphine and Celexa(citalopram) has a moderate drug to drug interaction and documents the following, Applies to: Morphine Sulfate SR (morphine), Celexa (citalopram) Using morphine together with citalopram can increase the risk of a rare but serious condition called the serotonin syndrome, which may include symptoms such as confusion, hallucinations, seizures, extreme changes in blood pressure, increased heart rate, fever, excessive sweating, shivering or shaking, blurred vision, muscle spasm or stiffness, tremor, incoordination, stomach cramp, nausea, vomiting, and diarrhea. Severe cases may result in coma and even death. Surveyor noted per Drugs.com, Clonazepam and Morphine have a major drug to drug interaction and documents the following, Applies to: Clonazepam, Morphine Sulfate SR (morphine) Using narcotic pain or cough medications together with other medications that also cause central nervous system depression can lead to serious side effects including profound sedation, respiratory distress, coma, and even death. Surveyor noted that per Drugs.com, morphine and Gabapentin have a major drug to drug interaction and documents, Applies to: Morphine Sulfate SR (morphine), Gabapentin Using narcotic pain or cough medications together with other medications that also cause central nervous system depression such as Gabapentin can lead to serious side effects including respiratory distress, coma, and even death. Surveyor noted that per Drugs.com, Morphine and risperidone have major drug to drug interactions and documents, Applies to: Morphine Sulfate SR (morphine), Risperdal (risperidone) Using narcotic pain or cough medications together with other medications that also cause central nervous system depression can lead to serious side effects including profound sedation, respiratory distress, coma, and even death. Surveyor noted that per Drugs.com, morphine and quetiapine have a major drug to drug interaction and documents, Applies to: Morphine Sulfate SR (morphine), Seroquel (quetiapine) Using narcotic pain or cough medications together with other medications that also cause central nervous system depression such as quetiapine can lead to serious side effects including respiratory distress, coma, and even death. On 08/21/2024 at 10:46 AM Surveyor interviewed UM-E. UM-E stated in the event of a medication error the resident will be monitored for signs and symptoms, put on the 24 hour board monitor vitals update physician and family. UM-E stated that for R2, her vitals were monitored for both medication errors, and for the second medication error, R2 was given water and felt fine. UM-E stated the form for medication error reporting was filled out on PM shift. On 08/21/2024 at 10:55 AM, Surveyor interviewed DON (Director of Nursing)-B who stated the unit manager will notify the physician and family once a medication error has been reported. DON-B stated the medication error reports are brought to QAPI (Quality Assurance and Performance Improvement) and it will be discussed whether teaching needs to be completed. DON-B stated the 5 rights are expected to be completed prior to medication administration, which include right patient, right route, right dose, right time and expiration dates. On 08/21/2024 at 01:30 PM, Surveyor interviewed RN-F who stated she is unsure of how agency nursing staff is trained on medication administration and medication error reporting. RN-F stated she has worked at the Facility for 7 years and does not recall the new employee orientation and states they are retrained annually. RN-F stated, the Facility did not provide training or education after the medication errors for R2, that she recalls. On 08/22/2024 at 07:42 AM, Surveyor interviewed NHA-A. NHA-A stated hired employees will receive annual training on medication administration and medication error reporting. NHA-A stated agency nursing staff are not provided the policy and/or procedure for medication administration or medication error reporting with orientation packet. NHA-A states training after both medication errors was provided to the nurses who made the medication errors, and no other staff were trained. NHA-A informed Surveyor that she could not locate Agency LPN-C's orientation check list at that time. NHA-A provided Surveyor with a document titled, Agency RN/LPN Orientation Check List. Surveyor noted, the policy and/or procedure for medication administration and medication error reporting was not listed on the document check list. On 08/22/2024 at 08:44 AM, Surveyor interviewed UM-D. UM-D who states she was notified on 05/26/2024 at 10:50 PM by the Agency LPN-C that a medication error occurred. UM-D states Agency LPN-C stated she think she gave R2 Morphine instead of Clonazepam. UM-D states Agency LPN-C then went and checked the medication cards and confirmed she gave R2 the wrong medication. UM-D states Agency LPN-C then notified the physician and family while UM-D went to assess R2. UM-D states she preformed an assessment on R2 at 11:00 PM on 05/26/2024 and states orders were put in for R2 to receive 480 ml of oral fluids, which UM-D gave before she left her shift, between 10:30 PM and 11:00 PM. UM-D states orders were also to perform neuro checks, vitals every hour and R2 was put on the board for 72 hours. On 08/26/2024 at 01:08 PM, NHA-A sent an email to Surveyor with the following documentation, titled, Medication Error, dated 05/21/2024 at 09:15 PM. Surveyor noted Mental Status Assessment was not completed on the form. NHA-A also sent a document, titled, Skilled Charting, dated 05/21/2024 at 09:55 PM, surveyor noted the vital sign documented for most recent blood sugar is from 09/24/2022, and the respiratory assessment section documents WDL but with no indication R2 was on oxygen. On 08/26/2024 at 01:08 PM, NHA-A sent an email to Surveyor with the following documentation, titled, Medication Error, dated 05/26/2024, at 10:49 PM. Surveyor noted Mental Status Assessment was not completed on the form. NHA-A also sent a document, titled, Skilled Charting, dated 05/26/2024 at 10:50 with a lock date of 05/27/2024 at 10:23 PM. Surveyor noted under the respirations vital sign, documents O2 of 95% and respirations 18 on 05/27/2024 at 06:49 PM, blood glucose 22 on 09/04/2022. All other vital signs documented with a date of 05/26/2024 at 11:41 PM. Surveyor noted under Medicare Summary of report, documents R2 was given a wrong medication at 2014. Nurse noted at 2250 when doing shift count with night nurse. R2 easily arousable denied nausea and lightheadedness. Vitals stable. No additional information was provided as to why the facility did not administer medications in accordance with prescribers orders, manufactures specifications and professional standards which resulted in R2 requiring rigid control and monitoring of R2's level of consciousness, oxygen saturation, blood pressure, temperature, and lab values.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents and evaluate and analyze the risks and eliminate them for 1 of 4 (R61) residents reviewed for accidents. * R61 sustained 2 falls in which the facility identified toileting or need for toileting as the root cause. A thorough investigation of the falls was not completed as to when R61 was last seen or toileted and there was no evidence the facility completed a B&B (bowel and bladder) assessment to determine R61's toileting needs, or possible pattern of toileting needs. R61 sustained a 3rd fall resulting in rib fractures and a head injury requiring staples. Findings include: The facility policy titled Continence Management dated 2/24/20 documents (in part) . .B. Bladder management 1. Complete an initial interdisciplinary bladder assessment upon admission and with each comprehensive MDS (Minimum Data Set) assessment thereafter. a) interview the resident and/or family, significant other. b) complete a 3-day bladder diary. d) Complete a patterning summary to determine continence. e) develop a toileting plan based on the resident elimination pattern/type of incontinence *prompted *scheduled *check and change. f) Determine if eligible for bladder retraining The facility policy titled Fall Reduction Program revised 8/4/23 documents (in part) . .Post Fall 1. The charge nurse/designee will assess the resident and provide necessary first aid. 2. In the event of an unwitnessed fall, the nurse will initiate neurological checks as per protocol and document on the neurological flowsheet. 3. Appropriate unit staff will be provided with fall investigation statements to be completed immediately. 4. The charge nurse/designee will determine the root cause analysis of the fall and implement interventions to be placed. 5. The nurse will review and utilize the Interact Fall Care Path to ensure a complete clinical assessment. R61 admitted to the facility on [DATE] and has diagnoses that include dementia, anxiety, Congestive Heart Failure, Atherosclerotic Heart Disease and Glaucoma. R61's fall risk assessment Morse Fall Scale dated 2/22/23 documented a score of 65, indicating a high risk for falls. R61's Quarterly BIMS (Brief Interview for Mental Status) dated 5/2/23 documented a score of 0, indicating severe cognitive impairment. R61's BIMS score dated 7/26/23 documented a score of 2 indicating severe cognitive impairment. R61's Quarterly MDS dated [DATE] documented R61 as occasionally incontinent of bowel and bladder. Subsequent Quarterly MDS' dated 5/2/23 and 7/26/23 documented R61 as occasionally incontinent of bowel and bladder. Each of R61's above Quarterly MDS' documented: Section H0200 Urinary Toileting Program: Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? NO. R61's Care Plan Focus area dated revised 1/26/23 documents: (R61) has an ADL (Activity of Daily Living) self-care performance deficit Activity Intolerance, Confusion, Fatigue, Impaired balance - Interventions include Toilet use: The resident requires extensive assistance by (1) staff for toileting - dated 1/21/22. Transfer: The resident requires extensive assistance by (1) staff to move between surfaces - dated 1/21/22. R61's Care Plan Focus area dated revised 1/26/23 documents: (R61) is at risk for falls r/t (related to) Confusion, Deconditioning, Gait/balance problems, Unaware of safety needs. Interventions include PT (Physical Therapy) evaluate and treat as ordered or PRN (as needed) - initiated 11/21/22. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: PT and OT (Occupational Therapy) exercises - initiated 11/21/22. Soft touch call light - initiated 1/20/23. Use pillows to elevate feet while in recliner. Do not use wedge in recliner, only when in bed - initiated 1/25/23. Weighted blanket to use throughout the day - initiated 2/15/23. R61's Care Plan Focus area dated revised 1/26/23 documents: (R61) has had an actual fall with pain to right hip. Poor Balance, Poor communication/comprehension, Unsteady gait. Interventions include: 15 minutes safety checks - initiated 7/03/23. Continue interventions on the at-risk plan - dated 11/9/22. Discussed with POA (Power of Attorney) that staff will put (resident) to bed at night - initiated 4/27/23. Dycem on wheelchair cushion - revised 1/30/23. Gripper socks at bedtime - initiated 11/17/22. NOCs (Night shift) will toilet (resident) at midnight and 5 AM - initiated 5/30/23. Use pillows to elevate feet while in recliner. Do not use wedge in recliner, only when in bed - revised 1/27/23. R61's CNA (Certified Nursing Assistant) care card dated 10/25/23 documents: Fall risk. Transfer 1p (person)/with pivot and cueing. Ambulates with RNA (Restorative Nursing Ambulation) and family. Offer toileting every 2-3 hours during waking hours. NOC (night) - toilet at 12 midnoc (midnight) and 5 AM. No incontinence products at this time/only regular panty. To wear gripper socks at HS (hour of sleep). Dycem on wheelchair cushion. Surveyor reviewed the facility fall investigations for R61's falls: Date/time of incident: 4/25/23 at 10:45 PM. Fall response checklist - Immediate intervention placed: Cares and back to bed. Fall investigation statement: FSI (Fall scene investigation report): Found on the floor (unwitnessed) in bathroom. Toilet contains urine/feces, floor. Gripper socks. Time last toileted: Blank (no documentation entered). Continence at above time - wet. Re-creation of last 3 hours before fall: The primary nursing assistant who observed and/or assisted the resident during the three hours prior to the fall will write a description to recreate the life of the resident before the fall. Surveyor noted this section was blank/no documentation entered. What appears to be the root cause of the fall? (R61) needed to go to the bathroom. CNA-N statement: Prior to fall when was last time you saw the resident? 10:50 PM. What was the resident doing when you saw them last? Sleeping. (Surveyor noted the time R61 was last seen that CNA-N indicated was after the time the fall occurred). When was the last time the resident was toileted? I'm not sure. IDT (Interdisciplinary Team) review dated 5/2/23 documents: Review of unwitnessed fall from 4/25/23 at 10:45 PM. (R61) found on the floor in the bathroom. Incontinent of urine. Was previously put to bed by daughter around 7:00 PM. Intervention is for staff to assist resident to bed at a later time. The facility identified the root cause of the R61's fall was the need for toileting. A thorough investigation of when R61 was last seen or toileted was not completed. The CNA statement of when R61 was last seen was after the fall occurred. There was no bowel and bladder assessment completed to determine R61's toileting needs or pattern for toileting completed. Date and time of incident: 5/30/23 at 6:50 AM. Fall response checklist - Immediate intervention placed: Toilet times during night shift. FSI - Found on the floor (unwitnessed). Urine on floor. Bare feet, gripper socks laying on floor next to bed. Time last toileted: 2:30 AM. Continence at above time: Wet. What appears to be the root cause of the fall? Resident attempting to self-transfer to toilet. Lost balance, slipped on urine on floor - incontinence. Recreation of last 3 hours before fall (completed and signed by Registered Nurse (RN)-H who worked 1st shift): 6:50 AM - shift started at 6:30 AM. Resident found sitting on floor doorway to bathroom. Urine on floor. Resident incontinent of urine. Statement of Rehab Tech-J (who worked 1st shift and found R61): During morning rounds saw resident sitting in the doorway of the bathroom. Prior to the fall when was the last time you saw the resident? 5/29/23 (day before the fall). When was the last time the resident was toileted? I don't know. IDT review dated 6/6/23 documents: Review of unwitnessed fall from 5/30/23. (R61) was found sitting on the floor in the doorway of her bathroom. Noted to be barefoot and incontinent of urine at time of fall. Previously toileted around 5 AM. Intervention is to toilet resident at midnight and 5 AM. The facility identified the root cause of R61's fall was R61 attempting to self-transfer to toilet, lost balance, slipped on urine on floor/ incontinence. A thorough investigation of the fall to include when R61 was seen or last toileted was not completed. The fall investigation did not include statements from the night shift staff to determine when R61 was last seen or toileted. The documentation of 2:30 AM was completed by RN-H who did not work the previous shift. There was no evidence R61 was toileted at 2:30 AM as per the fall report, or at 5:00 AM as indicated on the IDT review. There was no bowel and bladder assessment completed to determine R61's toileting needs or pattern for toileting completed. Date and time of incident: 7/1/23 at 3:15 PM. Fall response checklist -immediate intervention placed: Sent to ER (emergency room). FSI: Wheelchair/bed brakes unlocked. Resident was found lying on right side with right hand holding head. Blood noted from right side of head. Found on floor (unwitnessed) at nurses' station. Prior to fall: Sitting in recliner sleeping. Socks/shoes on. Time last toileted: Perhaps AM. Wet, soiled, dry: Not noted. Recreation of last 3 hours before fall (completed by CNA-T) documented: Wasn't here three hours prior to fall. She was sitting in her recliner with feet up. I clocked in, put my things up and my lights were ringing. I went to toilet (resident room number) when I came out, she (R61) was on the floor at nurses' station. What appears to be the root cause of the fall? (R61) attempted to stand up from recliner and fell. Surveyor noted the fall investigation does not indicate R61's continence at the time of fall or when the resident was last toileted. CNA-E statement (worked 1st and 2nd shift) documented: Last seen sleeping in recliner at the nurse's station (no time indicated). Last time resident was toileted? N/A Licensed Practical Nurse (LPN)-U statement (worked 2nd shift) documents: When last time seen resident: About 2:30 ish at the nurses' station. She was being fed ice cream by a CNA. Last time resident was toileted? I do not know. LPN statement (name not on facility staff list/worked 2nd shift) documented: Last time seen resident: 1 minute before the fall, sleeping in recliner. Last time toileted? If she was toileted, it must be during AM shift. CNA-T statement (worked 2nd shift) documented: I clocked in at 3:09 PM, she (R61) was at the nurse's station sitting in her recliner, laying back with feet up. When was the last time toileted? Unsure. Agency staff-V statement (worked 2nd shift) documented: Last time saw resident: at 2:30-2:40 when I clocked in. Sitting in nurse's station with nurses and CNA's getting fed ice cream by me, until the CNA on the shift came to show me around. Last toileted? N/A IDT review dated 7/5/23 documents: Prior to fall resident had been in recliner in nurses' station and had appeared to be sleeping with blanket covering her. Resident had been toileted 45 minutes prior to fall. Two nurses were back and forth through the nurses' station within the 15 minutes prior to the fall and observed resident with eyes closed and relaxed posture in reclining chair. Nurse went to medication cart located in hallway in front of nurses' station. While at the medication cart, nurse had her back to resident. Prior to fall nurse indicates resident did not make any sounds or call out for help. Immediate interventions upon return from hospital included 15 min checks and PT/OT (Physical and Occupational Therapy) eval. The facility did not complete a thorough investigation as to when R61 was last toileted. The only statement from 1st shift staff prior to the fall documented the time R61 was last toileted as N/A. All other statements were from the 2nd shift. There was no evidence R61 was toileted 45 minutes prior to the fall as indicated in the IDT review. The facility did not complete a bowel and bladder assessment to determine R61's toileting needs or pattern for toileting. R61 was sent to the ER following the fall. The hospital Discharge summary dated [DATE] documents (in part) .s/p (status post) fall on 7/1/23. Pt (patient) normally A&O (alert and oriented) x 1 only at baseline. Imaging showed right sided rib fractures. Scalp wound was closed at bedside. Major diagnostic studies: CT (Computerized Tomography) Trauma chest/abdomen/pelvis with spine result date 7/1/23 - acute nondisplaced or minimally displaced fractures of the right posterolateral fourth-seventh ribs. At the time of discharge the patient had: Abnormal physical findings: Scalp contusion/injury to superior aspect of scalp with one staple in place, tenderness to right chest wall. Surveyor observations while on survey: On 10/24/23 at 8:10 AM Surveyor observed R61 lying in bed on her back, slightly to right side. Pillow was under her head and on her right side and a bolster was on her left side. The bed was positioned next to the wall on her right side, in the lowest position. Call light in bed within reach. Surveyor observed a Roho type cushion in the wheelchair. No dycem on top or below the wheelchair cushion as per care plan intervention dated 1/30/23. On 10/25/23 at 10:48 AM Surveyor observed R61 sitting in her wheelchair at the nurses' station, asleep. R61 was wearing socks and shoes. Surveyor observed no dycem on top or below the wheelchair cushion. On 10/26/23 at 8:45 AM Surveyor observed R61 lying in bed on her back, slightly to the right side. Bolster was in place and call light within reach. Surveyor observed no dycem on top or below the wheelchair cushion. On 10/25/23 at 11:09 AM Surveyor spoke with Director of Nursing (DON)-B and Quality Improvement (QI) Coordinator-I about R61's falls. Surveyor advised R61 was identified to be incontinent with each fall. Surveyor asked where the IDT information regarding toileting times came from, as it did not match the fall investigation at the time of the fall. DON-B stated: I'm not sure, it must have been said at the IDT meeting. Surveyor advised DON-B the fall investigations document different times. Surveyor asked if the facility completed a root cause analysis related to R61's toileting needs and incontinence. DON-B stated: We have tried to put her on a toileting plan, it absolutely does not work. She will not go to the bathroom when we ask, she will only go when she wants. I want to say we've done 3-day B&B. Surveyor asked for evidence of a 3-day B&B assessment to assess for patterning - none was provided. DON-B reported after the 4/25/23 fall the facility thought because her daughter put her to bed so early, an intervention would be to put her to bed later. On 10/25/23 at 3:20 PM Nursing Home Administrator (NHA)-A and DON-B were advised of Surveyor concerns the facility identified the need for toileting and incontinence as the root cause of R61's two previous falls (4/25 and 5/30/23). A thorough investigation of when R61 was last toileted was not completed and a B&B assessment to determine toileting needs or patterning was not completed to prevent further falls. R61 sustained another fall on 7/1/23 which resulted in injuries requiring staples to her head and rib fractures. The facility did not complete a thorough investigation as to when R61 was last toileted or if she was continent or incontinent at the time of the fall. A B&B was not completed to determine R61's toileting needs or pattern for toileting. On 10/26/23 at 8:40 AM Surveyor spoke with Licensed Practical Nurse (LPN)-W who reported if R61 is not in bed or in activities, they like to keep her near the nurses station, maybe in the recliner so she's within view of people because she has had falls. On 10/26/23 at 10:06 AM Surveyor spoke with Staffing Coordinator-X who confirmed RN-H only works 1st shift and does not work night shift. Surveyor reviewed schedule for 5/29/23 - 5/20/23. RN-H was not on schedule for night shift. Surveyor reviewed the schedule for 5/30/2023 1st shift. RN-H and Rehab Tech-J were on the schedule for 1st shift. Surveyor verified CNA hours are 6:30 AM -2:30 PM and Nurse hours are 6:30 AM - 3:00 PM. On 10/26/23 at 8:49 AM Surveyor spoke with QI Coordinator-I who reported R61 is a busy person and likes to talk to everyone, that's why we keep her in view and interactive. Surveyor advised of concern related to toileting identified as root cause of falls and incontinence at time of falls prior to 7/1/23. She reported R61 isn't really incontinent, she doesn't even wear a brief, only underwear. I think she was incontinent at the time of the fall because she couldn't get to the bathroom in time. Surveyor advised of concern the facility did not complete a thorough investigation as to when she was last toileted and there was no B&B assessment to determine toileting needs or pattern of toileting need to prevent further falls. No additional information was provided. On 10/26/23 at 10:38 AM QI Coordinator-I asked to speak to Surveyor. She reported the facility did a continence evaluation in July when R61 came back from the hospital. Surveyor advised again of concern the facility identified toileting as root cause of 2 prior falls, there was no assessment to determine R61's toileting needs or pattern for toileting and R61 sustained another fall on 7/1/23 resulting in injuries. QI Coordinator-I stated: But she was seen literally minutes before she fell. Surveyor advised the investigation does not document if she was dry, incontinent or when she was last toileted. The investigation documented the fall occurred at 3:15 PM and the last time R61 was toileted documents perhaps AM. QI Coordinator-I reported she believed the facility did a B&B in May and would look to see what she could find. On 10/26/23 at 11:50 AM QI Coordinator-I returned to speak with Surveyor. She stated: Unfortunately I don't have much more information to be honest. We did a continence evaluation in July after her fall. She was at one time being toileted at 2 AM and 5 AM, but back in January her daughter asked that she not be woken at this time. We re-implemented the night toileting after the May fall. I'm not able to find anything regarding a B&B assessment to determine patterning related to her toileting needs following her falls. No additional information was provided. Surveyor reviewed R61's Quarterly Continence Evaluation dated 5/2/23 which documented: Continence history: Are you or have you ever been incontinent of bowel or bladder? Bladder Incontinence Onset: Gradual Duration of bladder incontinence: 6 months - 1 year Voiding patterns while awake - How frequently do you go to the toilet on average each day? 5-6 Symptoms of stress/urge incontinence: Unknown/unable to answer. Are you aware of the urge to void: Yes Surveyor review of R61's medical record revealed no documentation in progress notes and no care plan or interventions regarding R61's refusal or resistance to toileting as DON-B reported. No additional information was provided

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 (R55) of 4 residents reviewed for nutrition and hydration had their nutritional care needs recognized, evaluated, and addressed to provide adequate parameters of nutritional status. * R55 was admitted to the facility on [DATE] weighing 122.5 lbs. R55 was put on weekly weights on 8/6/23 and weighed 118.0 lbs. on 8/14/23. The week of 8/20/23, R55's weight was not taken. Next weight taken was on 8/28/23 and was 111.0 lbs. noting a 11.5 lbs. or 9.4% loss in 3 months. Assistant Dietician (AD)-R assessed resident on 8/30/23 and used the previous weight of 118.0 lbs. and did not note the significant weight loss. The week of 9/5/23, R55's weight was not taken. Next weight taken was on 9/11/23 and was 105.0 lbs. noting a 16.5 lbs. or 13.5% loss in 3.5 months. R55 had been refusing food and fluids and no interventions were put in place or reassessments were completed by AD-R or Registered Dietician (RD)-Q. When R55 was reweighed on 9/11/23 at 105.0 lbs., she was also dehydrated needing a total of 4L of IV fluids and she had to be sent out to hospital to reinsert IV that could not be done at the facility. During survey, Surveyor had multiple observations of R55's meal card and meal assistance needs not being followed resulting in minimal intake of food and fluids. The intake was not charted correctly and thus falsely interpreted by RD-Q. R55 was also observed with minimal fluid intake which did not meet the daily intake basic needs calculated by RD-Q. Findings include: R55 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Dysphagia and Gastro-Esophageal, Reflux Disorder without Esophagitis. Surveyor reviewed R55's weights. Documented weight on 5/23/23 was 122.5 lbs. Surveyor reviewed R55's admission Minimum Data Set (MDS) with an assessment reference date of 5/30/23. Documented under Staff Assessment for Mental Status was an assessment of severely impaired. Documented under Eating - how resident eats or drinks regardless of skill was 3/2 indicating Extensive assistance - resident involved in activity, staff provide weight-bearing support; One person physical assist. Surveyor reviewed R55's Comprehensive Care Plan with an initiation date of 5/31/23. Focus: Inadequate oral food/beverage intake related to decreased appetite as evidenced by: fluctuating oral intake; undesirable weight loss. Goal: 1) 50% or greater oral intake per most meals. 2) Weight maintenance, desirable weight gain. Interventions: 8oz Ensure/Ensure Plus [three times daily (tid)] Continue no added salt, dysphagia 3 diet. Modifications to diet consistency per Speech Therapist. Likes yogurt and ice cream Offer resident a bedtime snack daily. Weigh resident weekly, and document weight in the Electronic Medical Record (EMR). Notify MD of significant weight changes. Surveyor reviewed Nutrition/Dietary Note with an assessment date of 5/31/23 documented by AD-R. Documented was, Resident admitted following hospitalization due to cerebral infarction. Medical history includes CHF, COPD, [peripheral vascular disease (PVD)]. Resident is on a no added salt, dysphagia 2 diet, thin liquids, and uses a straw while drinking. Resident is eating 50% or less per most meals. Spoke with resident's daughter, who is the activated [power of attorney (POA)]. She agreed with supplementing diet with 4oz Ensure/Ensure Plus with each medication pass. Daughter stated that resident would sometimes drink the supplements at home. Medications: Ferrous gluconate; Apixaban; Folic acid; Multivitamin/mineral; Spironolactone; Lansoprazole; Vitamin B1; Carvedilol; Atorvastatin; Polyethylene glycol; Docusate sodium HT: 61 WT: 121# BMI: 22.9 Calculated daily energy needs: 1375-1650 kcals (25-30 kcals/kg) Calculated daily protein needs: 55-66 grams (1.0-1.2 grams/kg) Calculated daily fluid needs: 1375-1650ml (1ml/kcal) Nutrition Diagnosis: Inadequate oral food/beverage intake related to medical diagnosis/decreased appetite as evidenced by: oral intake of 50% or less per most meals; need for nutritional supplementation. Nutrition Interventions: 1) Continue no added salt, dysphagia 2 diet. 2) Will obtain order for 4oz Ensure/Ensure Plus with each medication pass. 3) Weigh resident weekly, and document weight in EMR. 4) Offer resident a bedtime snack daily. Nutrition Goals: 1) Oral intake trends 75% or greater per most meals. 2) Weight maintenance of 121# +/-5#. Surveyor reviewed Swallow Precautions/Guidelines for R55 documented by Speech Language Pathologist (SLP)-S. Documented with an updated date of 6/1/23 was: Diet Texture: Level 3 and soft foods Liquid Consistency: Thin [with] straw PRECAUTIONS AND ASSISTANCE REQUIRED: Upright for all meals and 30 minutes after Eat in supervised Set up tray (cut food, open containers and condiments) and position within reach of resident Small single sips Alternate solids and liquids every 2-4 bites Additional comments/guidelines: Patient likes bananas and can bite off [independently] You can offer if meal intake at meals is poor. Surveyor reviewed R55's MD orders. Documented with a start date of 6/1/23 and no end date was [No Added Salt (NAS)] diet, Dysphagia 3 texture, Thin consistency, STRAW WITH ALL LIQUIDS for Nutrition. Documented with a start date of 8/9/23 and no end date was Weight Monitoring: obtain weight WEEKLY. Update MD with significant changes. Surveyor reviewed R55's weights. Documented on 8/14/23 was 118.0 lbs. There was no weight taken the week of 8/20/23. Documented on 8/28/23 was 111.0 lbs. noting a 11.5 lbs. or 9.4% loss in 2 months. Surveyor noted (AD)-R assessed resident on 8/30/23 for a Quarterly Nutrition Assessment and used the previous weight of 118.0 lbs. and did not note the significant weight loss. Documented under Summary/Plan was, .Resident is aphasic. She is tolerating a NAS dysphagia level 3 diet and [oral intake (PO)]/Fluid intake at most meals: 51-75% (appetite and intake improved since admission). She needs total assist at meals and requires a straw for all beverages. [current body weight (CBW)] 118lbs w/ no significant weight changes x90 [days]. She receives Ensure 4oz w/each med pass with good acceptance per documentation. Will continue w/current diet order and regimen will weigh weekly to monitor for any weight loss. Nutrition Goals: Weight maintenance, (no weight loss) her BMI is currently 22.3 (normal) Intake at most meals 75% or greater. Skin will be intact, and lab will be [within normal limits (wnl)]. AD-R did not use the most current weight of 111.0 lbs. and did not address the significant weight loss. The week of 9/5/23 R55's weight was not taken. Surveyor reviewed Progress Notes for R55 and noted R55 was regularly refusing food and fluids. Documented on 9/1/23 at 11:30 AM was Refusing cares, crying episodes, refusing meals/Meds . Documented on 9/6/23 at 1:27 PM was Refusing meals/meds. Documented on 9/9/23 at 2:50 PM was Refused to eat even with encouragement but did accept fluids. Becomes angry when staff intervenes to assist with meal. Pushes food away. There were no reassessments of R55's weight, fluid or food intake or other interventions added by AD-R or RD-Q until 9/6/23 at 6:17 PM when RD-Q documented, Will decrease Ensure to 4oz bid to promote increased oral food/beverage intake at meals. Surveyor noted this did not address the significant weight loss. Surveyor reviewed R55's MD orders. On 9/10/23, an order of Mirtazapine Oral Tablet 7.5 MG (Mirtazapine) Give 1 tablet by mouth in the evening for appetite was added to stimulate appetite and a urinalysis (UA) was ordered to rule out a urinary tract infection. RD-Q and AD-R had yet to reassess R55 and address the weight loss and decreased intake. Next weight taken was on 9/11/23 and was 105.0 lbs. noting a 16.5 lbs. or 13.5% loss in 2.5 months. Documented in Progress Notes on 9/11/23 at 1:27 PM was, Results from UA negative. Res. oral intake [continue] to be poor as she refuses meals. Did accept small amts. of juice/ensure clear. POA in to visit and assist with meal but intake still poor. [Nurse Practitioner (NP)] also in and updated on [change in condition], wt. loss, appetite and UA result and behavior. [new order (NOR)] for IV hydration x 2 L and repeat labs on 9/13/23 . Documented in Progress Notes on 9/12/23 at 1:05 AM was, At approx. [11:10 PM] this Nurse assessed that resident's IV was leaking at site of insertion, and noted it was not positional. IV [discharge] L forearm and pressure dressing applied . send to [Hospital] for IV placement/hydration. [Ambulance] notified and returned immediately and transferred resident to [Hospital] . Documented in Progress Notes on 9/12/23 at 1:48 PM was, NOR to give [additional] L of IV hydration for total of 3 L and re-draw labs tomorrow per [NP]. Documented on 9/13/23 at 6:03 PM was, NOR to continue IV D5.45 for one more liter. Surveyor reviewed total fluid intake for days leading up to dehydration incident and IV fluids. Documented was: 9/1/23: 720 mL 9/2/23: 100 mL 9/3/23: 400 mL 9/4/23: 360 mL 9/5/23: 230 mL 9/6/23: 960 mL 9/7/23: 1020 mL 9/8/23: 600 mL 9/9/23: 700 mL 9/10/23: 1200 mL 9/11/23: 640 mL Surveyor noted RD-Q calculated total fluids needed daily was 1375 to 1650 mL per day. R55 did not receive close to that amount to the days leading up to becoming dehydrated. Surveyor reviewed R55's meal ticket which instructed staff under alerts. Documented was: > STRAW W/ALL DRINKS > TOTAL ASSIST WITH FEEDING During survey, Surveyor observed R55 at lunch on 10/24/23 and breakfast on 10/24/23 and 10/25/23. The following observations were made: On 10/24/23, R55 was in the dining area between 8:25 AM when resident was brought breakfast until 9:15 AM when she was assisted from the table in her wheelchair out of the dining area. At 8:37 AM, a staff member walked by and encouraged R55 to eat but does not assist her, all staff were assisting other residents. At 8:53 AM, R55 had eaten half of a cup of yogurt and drank half an 8 ounce glass of milk. The cream of wheat and water remained untouched. No other food or drink was consumed. At 9:11 AM, R55 fell asleep at table and at 9:15 AM staff took R55 out of dining area. At no point did R55 have total assist with feeding per her meal ticket and swallowing plan. R55 did not have straws in either of her beverages per order, and per 8/30/23 quarterly nutritional assessment and meal ticket. R55 took in 120 mL of fluids and 10% of her meal. On 10/24/23, R55 was in the dining area between 12:05 PM when resident was brought to dining area until 1:55 PM when she was assisted from the table in her wheelchair out of the dining area. At 12:30 PM, R55 was given a brown piece of bread, she picked at it with her fingers and took a couple very small bites. R55 also had an 8 oz. glass of cranberry juice and water. R55 drank half the glass of cranberry juice. At 12:35 PM, staff set soup in front of R55 and attempted to bring a spoon to her mouth. R55 put her hands up 3 times to block and the staff member walked away. R55 did not eat her soup. At 1:00 PM, staff brought a plate with mashed potatoes and gravy and a slice of enchilada that is not cut up. At 1:04 PM, R55 tried to pick the cheese off the enchilada with her fingers. At 1:15 PM, staff assisted to cut the enchilada into smaller pieces. At 1:35 PM, R55 had eaten 2 pieces and had gone back to picking at the brown bread. At 1:47 PM, staff put a fork in her hand and told R55 to eat the potatoes. R55 ate 3 bites. Staff returned to try to assist and R55 pushed the plate away. At 1:55 PM, staff assisted R55 out of the dining area. At no point did R55 have total assist with feeding per her meal ticket, and per 8/30/23 quarterly nutritional assessment and swallowing plan. R55 did not have straws in either of her beverages per order and meal ticket. R55 took in 120 mL of fluids and 15% of her meal. On 10/25/23, R55 was in the dining area between 8:21 AM when resident was at the dining table with food in front of her until 9:05 AM when she finished her meal. At 8:21 AM, R55 had taken a few bites of cream of wheat and drank half of the 8 oz. cranberry juice. At 8:30 AM, staff brought a glass of water to R55 who continued to sip on juice and pushed water away. At 8:40 AM, R55 finished her glass of juice. At 8:46 AM, staff brought a plate of food with French toast with syrup. R55 took bites of food with her fork and at times, using her hands. At 8:54 AM, staff encouraged resident to keep eating. Resident continued to eat the French toast. At 9:05, AM staff removed resident's plate. R55 ate all her French toast. At no point did R55 have total assist with feeding per her meal ticket, and per the quarterly nutritional assessment and swallowing plan. R55 did not have straws in either of her beverages per order and meal ticket. R55 took in 120 mL of fluids and 100% of her meal. Surveyor reviewed R55's Food and Fluid Intake charting. Documented under Nutrition - Amount eaten was: 10/24/23 Breakfast: 51-75% 10/24/23 Lunch: 51-75% 10/25/23 Breakfast: 51-75% Surveyor noted R55 only ate 10 to 15% for either breakfast or 100% of lunch noting mis- documentation. On 10/25/23 at 1:36 PM, Surveyor interviewed RD-Q. Surveyor asked if R55 should have assistance with eating. RD-Q stated Speech Therapy (SLP-S) could answer that. Surveyor asked if she has a change in assistance would she be aware. RD-Q stated yes. Therapy and Nursing would update her and she would update the Care Plan. Surveyor asked if there had been any recent changes in assistance. RD-Q stated not that she knew of. Surveyor asked about weekly weights and why there are weeks missing. RD-Q stated nursing should get the weights and if there is a discrepancy they will ask for a reweigh. Surveyor asked why there was no weight for the week of 8/20 and 9/4. RD-Q stated she will investigate that. Surveyor asked who required R55 to use straws. RD-Q stated that would have been SLP-S. On 10/26/23 at 10:13 AM, Surveyor interviewed SLP-S. Surveyor asked if R55 needs total assist with feeding. SLP stated she needs someone in the room. SLP-S stated from what she has noticed, R55 is feeding herself and picking at food, she does better with somebody there though. Surveyor asked what happens if there is a change in diet or eating. SLP-S stated she lets the dieticians know. She emails them, they change it on the care plan and meal tickets. SLP-S stated she does not have access to that. Surveyor asked what R55 is on now including any alerts or notes. SLP-S stated Dysphagia level 3, thin liquids, upright for all meals, constant supervision, (staff in the room around her), feeding assist as needed, set up tray, small bites, small single sips, alternate solids and liquids every 2-3 bites, check for pocketing and clear if necessary with liquid wash or finger sweep. If pocketing worsens downgrade to pureed. Surveyor noted the meal card stated total assist. SLP-S stated that is probably when she saw her the first time. Surveyor asked why is it not updated. Surveyor noted there is an order for total assist and an order that included straws with all beverages. SLP-S stated, Straws with all drinks? I am not sure about that. Maybe nursing? SLP-S asked Surveyor who put the order in. Surveyor stated, You did. Surveyor noted there was a revision done on 9/18 by AD-R. SLP-S stated she was totally unsure. Surveyor noted it was on the meal tickets too. SLP-S stated, I don't have access to meal tickets. I tell [AD-R] - she puts it in. Surveyor asked what the staff should be following. SLP-S stated the meal tickets, They get developed from the care plans, that is what they should be following. Surveyor reviewed R55's updated meal ticket provided by SLP-S on 10/26/23 which instructed staff under alerts to: > ASSIST W/FEEDING AS NEEDED > CUT UP FOOD INTO SMALL PIECES > FOLLOW SWALLOW GUIDELINES On 10/26/23 at 1:09PM and 2:15 PM, Surveyor interviewed RD-Q and AD-R. Surveyor asked AD-R why she did not use the 8/28/23 weight when she was doing her assessment on 8/30/23. AD-R stated, Not sure. Maybe I was waiting for a reweigh. Surveyor noted the next weight taken was not until 9/11/23 and a whole other week was missed and there was already a significant weight loss. Surveyor stated then there was an additional weight loss after that for a total of 17.5 lbs. or 14.3% weight loss. Surveyor asked how often residents at high risk for weight loss are assessed. RD-Q stated their weights are looked at weekly. Surveyor stated if they are looked at weekly why is there no weight for the week of 8/20/23 and 9/4/23 and no one addressed the significant weight loss found on 8/28/23. RD-Q and AD-R were unsure. Surveyor asked if they notice weight loss in a resident what is the process for assessment. RD-Q stated they look at how they are eating, assess the result of not eating, look for change in edema, involve nursing if needed, consider interventions, call Power of Attorney if needed. RD-Q stated, Really, you are looking for the cause. Surveyor asked if they look at hydration status and labs. RD-Q stated every time I see the resident I look at nutrition and I look at hydration. Surveyor asked how she calculated fluid intake. RD-Q stated it is a set of standards they follow and not necessarily calculated. RD-Q stated it is just a gauge. RD-Q stated if the resident is eating 75% it is common that they are drinking the same amount. Surveyor noted there are food and fluids documented for her and they are not accurate. RD-Q stated if there is a concern with fluid intake nursing will let me know. Surveyor stated R55 was dehydrated and was not even hitting the gauge. RD-Q stated that is why she was given fluids. Surveyor asked what interventions or other assessments were done prior to prevent the dehydration. RD-Q stated she had supplements and Ensure. Surveyor noted those were already in place. Surveyor also noted the Remeron for appetite was put in place by the NP. Surveyor asked if there were any other assessments of the weight loss or to prevent the dehydration. RD-Q stated, Just [AD-R's] on 8/30. Surveyor asked if they found a reason why that weight was used. AD-R stated, My best assumption is that we were waiting for a reweigh. On 10/26/23 at 1:46 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Licensed Practical Nurse (LPN)-I. Surveyor asked if staff chart every meal and fluid intake for each resident. LPN-I stated yes, every meal, fluids, and bedtime snacks. Surveyor asked who reviews this documentation to see if there are trends or low numbers. NHA-A stated the Dieticians and Unit Managers do a review and let us know if any are missed. Surveyor asked should the dieticians and unit managers have caught the 8/28/23 11 pound weight loss? NHA-A stated yes. Surveyor asked if AD-R should have used an old weight for her 8/30/23 assessment? Surveyor asked about the documentation of intake at the 3 meals observed and charting not being accurate. NHA-A stated we will fix that. Surveyor asked for any additional information, no additional documentation was provided.