Every finding on record at Grover C Dils Medical Center SNF

Based on observations, record review, interview, and policy review, the facility failed to ensure a person-centered comprehensive care plan was developed for one of four residents (Resident (R) 2) reviewed for oxygen therapy in the sample of 10 residents. By not having or implementing a comprehensive care plan could potentially place the residents at risk for unmet care needs.Findings include:R2 was admitted on [DATE] with diagnoses including acute chronic right side heart failure, and atrial fibrillation.On 03/23/2026 at 10:55 AM, R2 was lying in bed and wearing oxygen via a nasal cannula at 1 liter/minute. R2 acknowledged the use of oxygen. R2 stated, They put it on me for a while then took the dosage down from two to one liter.On 03/24/2026 at 11:50 AM, R2 was observed lying in bed with the oxygen on via nasal cannula set at 2 liters/minutes.R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/2025 revealed R2 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated she was cognitively intact. The MDS indicated R2 was receiving oxygen therapy.Physician Orders dated 02/25/2026 documented oxygen 1-2 liters per nasal cannula every shift for wheezing.R2's electronic medical record (EMR) revealed there was no care plan developed for the use of oxygen therapy.On 03/24/2026 at 12:30 PM, the Administrator stated, We would expect there to be a comprehensive care plan for oxygen administration.On 03/24/2026 at 12:48 PM, after reviewing R2's EMR, the Director of Nursing (DON) stated R2 had orders to be on 1-2 liters of oxygen via nasal cannula for wheezing and it was a routine order. After reviewing R2's care plan, the DON explained the admission MDS completed on 12/23/2025 indicated R2 was receiving oxygen and that a physician order was present. The DON also stated that R2 did not have a care plan addressing the oxygen.The facility's policy titled Care Plan, dated 08/10/2025, documented the purpose of a care plan, was to ensure individuals received personalized, consistent, and effective care tailored to their specific needs and preferences. Care plans addressed unique health, and social care needs to ensure appropriate and effective support. The policy required the creation of a comprehensive, person-centered care plan that addressed the residents' medical, psychological, and social needs. This plan was to be developed within 14 days of the completion of the resident's admission assessment.

Based on observations, interviews, record review, and policy review, the facility failed to ensure an oxygen (02) concentrator filter was free of dust and heavy buildup of lint for one of one sampled resident (Resident (R) 2) oxygen tubing was dated/labeled and changed for two of ten sampled residents (R2 and R7). This failure had the potential for the residents to have an increased chance of unnecessary respiratory treatments and/or infection.Findings include:R2's was admitted on [DATE] with diagnoses including acute chronic right heart failure, and atrial fibrillation. Physician Orders dated 02/25/2026 documented oxygen 1-2 liters per nasal cannula every shift for wheezing. 1. On 03/23/2026 at 10:55 AM, R2 was lying in bed and wearing oxygen via a nasal cannula. R2's oxygen tubing was connected to the oxygen concentrator which was set at liters/minute (l/min). There was no date/label as to when the oxygen tubing was changed. The black oxygen cabinet filter located on the left side of the concentrator was observed to be full of a thick buildup of white lint. R2 was asked if they had ever seen staff changed out the filter on the oxygen concentrator, R2 stated, No. On 03/24/2026 at 11:50 AM, R2 was lying in bed with oxygen tubing connected to the oxygen concentrator not dated/labeled. The same black filter located on the left side of the oxygen concentrator as the day before was still full of white lint. On 03/24/2026 at 12:30 PM, the Administrator explained the oxygen tubing was changed monthly. The night shift Certified Nursing Assistants (CNAs) were supposed to change the tubing monthly and date it, and there should have been a sticker on the tubing indicating when it was changed. The Administrator stated that the Plant Operations Director was responsible for the oxygen concentrator filters and conducted monthly rounds. On 03/24/2026 at 12:48 PM, the Director of Nursing (DON) was shown the oxygen concentrator and the dirty filter located on the side. The DON removed the black filter and acknowledged it needed to be cleaned, noting it appeared to have accumulated a few weeks' worth of dust. The DON was unsure when the filter had last been cleaned or changed. The DON indicated no date, or label was present and the expectation was for CNAs to place a sticker on the tubing when it was changed. 2. R7 was admitted on [DATE] with diagnoses including pulmonary fibrosis and pneumonia. Observation on 03/23/2026 at 11:37AM and on 03/24/2026 at 9:45AM in R7's room revealed the oxygen tubing was not dated or initialed. On 3/24/2026 at 9:51AM, Registered Nurse (RN)1 verified the R7's O2 tubing was not dated or initialed. RN1 explained the tubing was changed on the first of each month by night shift staff. CNAs should label the tubing with date/initial of who changed it and when. The facility's policy titled, Oxygen concentrator cleaning, inspection, and maintenance dated 08/08/2022 documented to ensure all oxygen concentrators used within the facility were maintained, safe, clean and proper working condition. The facility maintained all oxygen concentrators.Routine inspection, cleaning, and preventative maintenance would be performed by maintenance personnel. The facility's policy titled, Oxygen Administration per Nasal Cannula dated 05/12/2025 documented to supply low flow supplemental oxygen to the resident. Humidifier and nasal cannula should be changed every month. Oxygen tubing must be changed every month.the tubing labeled with date and initials of the staff that changed the tubing.

Based on interview, record review, and document review, the facility failed to ensure Minimum Data Set (MDS) assessments and/or care plans were timely completed and/or transmitted for 8 of 11 months since the last recertification survey on 05/03/2024. The failed practice had the potential to delay care interventions and provide inadequate care and services to residents. A Medicare Recertification Survey was completed for the facility on 05/03/2024. An MDS Submission Report dated 03/27/2025, revised 04/29/2025, documented the following: June 2024: 44.4% of assessments were completed late (4 of 9) 11.1% of care area assessments were completed late (1 of 9) July 2024: 40.0% of assessments were completed late (2 of 5) August 2024: 10.0% of admission assessments were completed late (1 of 10) 10.0% of admission care plans were completed late October 2024: 33.3% of assessments were completed late (2 of 6) 16.7% of care area assessments were completed late (1 of 6) [DATE] 12.5% of assessments were completed late (1 of 8) 12.5% of care area assessments were completed late January 2025: 25.5% of assessments were completed late (2 of 8) February 2025 33.3% of assessments were completed late (1 of 3) March 2025 11.1% of assessments completed late (1 of 9) 11.1% of admission assessments completed late 11.1% of admission care plans completed late On 04/24/2025 at 11:11 AM, the Chief Nursing Officer (CNO), confirmed care plans had been completed and or transmitted late. The CNO explained was involved in the preparation of the care plans. The CNO acknowledged after other specialties completed their corresponding parts of the care plans, the CNO had been late signing off the care plans as completed for submission. The CNO acknowledged needed to work on completing care plans timely and needed to create a system to alert and help prevent late completion of care plans. The CNO explained the importance of care plans being completed timely due to care plans dictated the necessary personalized care to be given to residents. On 04/25/2025 at 9:05 AM, the Administrator, acknowledged was made aware care plans were submitted late. The Administrator reported the concern with late submissions of care plans had been addressed and had become a focus for the facility. On 04/25/2025 at 09:10 AM, the Chief Nursing Officer (CNO), confirmed assessments were transmitted late. The CNO stated had been catching up due to numerous responsibilities since transitioned into the position and was responsible for the completion and transmission of the assessments. On 04/29/2025 at 12:10 PM, the Resident Assessment Instrument (RAI) Education Coordinator, confirmed the information contained in the MDS Submission Report dated 03/27/2025, revised 04/29/2025, was an accurate account of data submitted by the facility. A facility policy titled Care Plan revised 03/22/2023 documented, the purpose of a care plan was to ensure individuals received personalized, consistent, and effective care tailored to their specific needs and preferences. Care plans were to be updated regularly to reflect changes in the resident's condition, preferences, and goals. Reassessment and modification of the care plan at least quarterly or whenever there was a significant change in the resident's status.

Based on interview, record review, and document review, the facility failed to ensure care plans and/or comprehensive assessments, were completed within the required timeframe for 6 of 10 residents (Resident 2, 3, 6, 7, 10, and 11). The failed practice had the potential to delay care interventions and provide inadequate care and services to residents. Findings include: Resident 2 (R2) R2 was admitted on [DATE], with diagnosis including epilepsy, unspecified not intractable without status epilepticus, unspecified symptoms and signs involving cognitive functions and awareness, and low back pain. R2's medical record documented a care plan was completed on 01/11/2024. R2's medical record documented the next care plan due had a target completion date of 04/11/2025, and an actual completion date of 04/23/2025. R2's care plan was completed late. Resident 3 (R3) R3 was admitted on [DATE], with diagnosis including dementia, unspecified severity with other behavioral disturbance, major depressive disorder recurrent, and degenerative disease of the nervous system. R3's medical record documented a care plan was completed on 12/11/2024. R3's medical record documented the next care plan due had a target completion date of 03/10/2025, and an actual completion date of 03/20/2025. R3's care plan was completed late. Resident 6 (R6) R6 was admitted on [DATE], with diagnosis including dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, need for assistance with personal care, and major depressive disorder recurrent. R6's medical record documented a care plan was completed on 12/11/2024. R6's medical record documented the next care plan due had a target completion date of 03/14/2025, and an actual completion date of 03/20/2025. R6's care plan was completed late. Resident 7 (R7) R7 was admitted on [DATE], with diagnosis including dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, low back pain, and polyosteoarthritis. R7's medical record documented a care plan was completed on 12/11/2024. R7's medical record documented the next care plan due had a target completion date of 03/14/2025, and an actual completion date of 04/23/2025. R6's care plan was completed late. On 04/24/2025 at 11:11 AM, the Chief Nursing Officer (CNO), confirmed care plans had been completed and or transmitted late including care plans for R2, R3, R6, and R7. The CNO explained was involved in the preparation of the care plans. The CNO acknowledged after other specialties completed their corresponding parts of the care plans, the CNO had been late signing off the care plans as completed for submission. The CNO acknowledged needed to work on completing care plans timely and needed to create a system to alert and help prevent late completion of care plans. The CNO explained the importance of care plans being completed timely due to care plans dictated the necessary personalized care to be given to residents. On 04/25/2025 at 9:05 AM, the Administrator, acknowledged was made aware care plans were submitted late. The Administrator reported the concern with late submissions of care plans had been addressed and had become a focus for the facility. A facility policy titled Care Plan revised 03/22/2023 documented, the purpose of a care plan was to ensure individuals received personalized, consistent, and effective care tailored to their specific needs and preferences. Care plans were to be updated regularly to reflect changes in the resident's condition, preferences, and goals. Reassessment and modification of the care plan at least quarterly or whenever there was a significant change in the resident's status. 40131 Resident 10 (R10) R10 was admitted on [DATE] and readmitted on [DATE], with diagnoses including sepsis, polyarthritis, cellulitis of left lower limb, left and right toe. A review of R10's medical records lacked documented evidence a comprehensive person-centered care plan was developed within 14 days following R10's admission. Resident 11 (R11) R11 was admitted on [DATE], with diagnoses including acute and chronic respiratory failure and chronic congestive heart failure. A review of R11's medical records lacked documented evidence a comprehensive person-centered care plan was developed within 14 days following R10's admission. On 04/25/2025 at 09:10 AM, the CNO confirmed a comprehensive person-centered care plan, or assessment had not been completed for R10 and R11 within 14 days of admission. The CNO indicated being responsible for completing the care plans but had been overwhelmed with numerous tasks during the transition period. A facility policy titled Comprehensive Care Plan, revised 03/22/2023, indicated a comprehensive, person-centered care plan was to be developed to address the resident's medical, psychological, and social needs. The plan was to be completed within 14 days following the completion of the resident's admission assessment.

Based on observation, interview, and document review, the facility failed to ensure hot water was available in the kitchen sinks for food preparation, handwashing, and sanitation. The failed practice had the potential to increase the risk of cross contamination, inadequate handwashing, and food borne illness. Findings include: On 04/22/2025 at 10:35 AM, hot water was not available in the kitchen at the hand/eye wash sink, the pot washing sink, and the adjacent food preparation sink. The water was allowed to run for an extended time and the faucets failed to produce hot water. The hot water faucet's temperature was approximately 66 degrees. On 04/22/2025 at 10:44 AM, the Dietary Manager confirmed there was no hot water in the kitchen sinks. The Dietary Manager explained one water heater was down in the main building. There were times during the day the kitchen was without hot water in the sinks due to the laundry, which was located next to the kitchen, running the washer and the hot water would then not reach the kitchen sinks. The Dietary Manager explained the automatic dishwasher in the kitchen had its own dedicated water heater in working order. The Dietary Manager reported during the times when there was no hot water in the kitchen, the pot washing sink was used only for rinsing items prior to placing all items such as pots, pans, and utensils in the high temperature dishwasher. The Dietary Manager demonstrated how the kitchen was boiling water in a stovetop kettle to use for refilling hot water in two small towel soaking containers. The Dietary Manager acknowledged hot water was necessary in the kitchen for handwashing, cleaning, and sanitation. On 04/22/2025 at 2:12 PM, the Plant Operations Director, reported was in the process of waiting for an electrician to visit to install new water heaters. The Plant Operations Director explained had two 100-gallon heaters in the general storage room pending installation. The Plant Operations Director confirmed the kitchen had one small, dedicated water heater for the dishwasher only and reported most of the time the hot water was adequate in the sinks unless the laundry room was running the washer, then the hot water would not reach the kitchen sinks. The Plant Operations Director reported the north and south resident rooms had their own water heaters, and the day room closet had another water heater. The Plant Operations Director confirmed the kitchen was the only area impacted by the one water heater down. The Plant Operations Director acknowledged received report hot water was not heating up in the kitchen sinks a couple of months prior. The Plant Operations Director explained needed the electrician to do their part first and then would work on the plumbing and install the new water heater. The Plant Operations Director reported did not have an appointment scheduled with the electrician and would set up the appointment as soon as possible. On 04/24/2025 at 6:05 AM, hot water was available at the kitchen sinks. The cook reported there was hot water in the kitchen sinks most days, except when laundry was working, then there would be no hot water in the kitchen sinks. The [NAME] explained once laundry left for the day, hot water would return to the kitchen usually at around 1:30 PM. The [NAME] explained kitchen staff were boiling water and used bleach and cleaners to sanitize surfaces. The [NAME] acknowledged not having hot water could have led to food and kitchen surfaces contamination, and hot water was necessary for hand hygiene. The [NAME] acknowledge there should have been hot water in the sinks at all times. On 04/24/2025 at 11:11 AM, the Chief Nursing Officer (CNO), acknowledged was aware pending plumber work was needed for water heaters. The CNO denied was aware there was no hot water in the kitchen sinks. The CNO acknowledged facility policy stated a lavatory with hot and cold running water was to have been available in the Dietary Department. The CNO confirmed a lack of hot water in the kitchen could have led to improper cleaning of items in the kitchen that needed to be washed or cleaned with hot water, an increased risk of contamination of surfaces, and unsanitary conditions in the kitchen. On 04/25/2025 at 7:50 AM, hot water was available in all sinks including the hand/eye wash sink, as well as pot washing, and food preparation sink. This surveyor confirmed the laundry room washing machine was on. On 04/25/2025 at 8:12 AM, the Plant Operations Director, confirmed the lack of hot water in the kitchen sinks occurred randomly and not every time the laundry washing machine was running, as was the case observed at 7:50 AM. On 04/25/2025 at 8:12 AM, the Administrator, acknowledged was aware the kitchen had issues with no hot water in the hand/eye wash sink only. The Administrator denied was aware also the pot washing and food preparation sinks were affected. The Administrator denied was aware the kitchen staff had to boil water stovetop in a kettle and was not aware the kitchen had implemented alternatives such as boiling water and running all items through the dishwasher in the absence of hot water from the sinks. The Administrator acknowledged hot water should have been available in the kitchen at all times. Facility policy titled Infection Control Policies and Procedures Policy: Dietary - Infection Control Guidelines, revised 11/07/2025, documented the dietary personnel would adhere to the guidelines established to assist in providing a high level of patient care by reducing the ever-present risk of nosocomial infection of patients and staff members. The hand washing section documented a lavatory with hot and cold running water was to be available in the Dietary Department.

Based on observation, interview, record review, and document review, the facility failed to develop and implement a baseline care plan within 48 hours of admission to address pain for 1 of 10 sampled residents (Resident 10) and Oxygen (O2) therapy for 1 of 10 sampled residents (Resident 11). This deficient practice could have led to unmanaged pain, ineffective symptom control, and compromised respiratory status during the early stages of admission. Findings include: Resident 10 (R10) R10 was admitted on [DATE] and readmitted on [DATE], with diagnoses including sepsis, polyarthritis (inflammation of multiple joints), cellulitis of the left lower limb (a person's leg), and toe wounds. The Pain Interview, dated 03/05/2025, documented the interview was conducted with a pain frequency of frequently over the last five days and had limited the day-to-day activities because of pain. The pain interview was incompletely filled out with the indicators and frequency. The Admission Minimum Data Set, dated dated dated [DATE], documented a brief interview of mental status with a score of 15/15, which indicated intact cognitive status, and R10 was in frequent pain. A Physician Order dated 01/09/2025, documented Oxycodone Hydrochloride oral tablet 10 milligrams (mg) to give 10 mg three times a day at 9:00 AM, 2:00 PM, and 9:00 PM for polyarthritis. A Physician Order dated 08/07/2025, documented Tylenol oral tablets to be given 500 mg by mouth three times a day for pain at 8:00 AM, 2:00 PM, and 9:00 PM. The Medication Administration Record from 04/01/2025 to 04/24/2025, documented the Oxycodone 10 mg and Tylenol 500 mg were administered three times a day. R10 ' s medical record lacked documented evidence a baseline care plan had been formulated to provide direction for the management of pain. On 04/22/2025, R10 reported persistent toe pain related to hammertoes, with ongoing discomfort rated at 3 to 4 out of 10, despite scheduled administration of Oxycodone 10 mg and Tylenol 500 mg three times daily. R10 indicated most of the time, the pain level remained at 3 to 4 following administrations. R10 reported some relief was achieved, but the pain was not completely resolved. On 04/25/2025 at 8:25 AM, R10 was seated in bed and reported a pain level of 4 out of 10 following the administration of pain medication. R10 indicated the Oxycodone helped reduce the pain but did not completely relieve it, and the effectiveness was not sustained. R10 reported the pain was affecting activities of daily living (ADLs) and mood and desired the possibility of receiving additional pain relief or alternative comfort measures. R10 indicated the non-pharmacological interventions had not occurred, but when pain medication was due, staff were prompt in administering it. R10 expressed a satisfactory pain level would be complete relief from pain. On 04/23/2025 at 12:31 PM, a Licensed Practical Nurse (LPN) confirmed the absence of a baseline care plan for R10's pain. The LPN indicated R10 was admitted with pain, and a baseline care plan should have been completed by the licensed nurse following R10's admission. On 04/25/2025 at 9:10 AM, the Chief Nursing Officer (CNO) acknowledged the baseline care plan had not been developed within 48 hours following R10's admission. The CNO indicated the care plan was a very important tool to direct the care of the resident and should have been in place. Resident 11 (R11) R11 was admitted on [DATE], with diagnoses including chronic respiratory failure and congestive heart failure. A physician order dated 10/04/2023 documented continuous Oxygen (O2) therapy at 2-3 liters per minute (LPM) via nasal cannula. On 04/22/2025 at 12:05 PM, R11 observed with O2 flowing at 4 LPM via nasal cannula. Later in the day at 3:29 PM, R11 was observed with a nasal cannula in place but the concentrator turned off. On 04/23/2025 at 1:40 PM, O2 was observed flowing at 3.5 LPM. The LPN confirmed licensed nurses were responsible for ensuring appropriate O2 use. The LPN indicated a cannula change schedule and monitoring should have been indicated in the baseline care plan when a resident was admitted with it. The LPN indicated R11 was dependent on O2. R11's medical record lacked documented evidence of a baseline care plan addressing oxygen therapy to guide staff in monitoring oxygen use, ensuring safe delivery, and addressing oxygen-related needs. On 04/24/2025 at 11:11 AM, the CNO confirmed failure to develop a baseline care plan within 48 hours following R11's admission and acknowledged there should have been a person-centered care plan to direct the care of the O2 use. A facility policy titled Oxygen Administration, revised January 2019, indicated a physician order was required for oxygen use, nasal cannula and humidifier were to be changed monthly, and a care plan was to be developed. A facility policy titled Baseline Care Plan, revised 03/22/2023, indicated the facility was to develop and implement a baseline care plan for each resident within 48 hours of admission. The plan was to include initial goals based on admission orders, physician orders, dietary orders, therapy services, and other recommendations. The policy directed the facility to respect and incorporate residents' rights and preferences into the care plan, ensuring residents had input in their care and treatment.

Based on observation, interview, record review, and document review, the facility failed to ensure the signs and symptoms of bleeding or adverse effects for a resident on Warfarin (anticoagulant medication) were consistently monitored, documented, and reported to the physician for 1 of 10 sampled residents (Resident 9). The deficient practice had the potential to result in adverse outcomes, including an increased risk of bleeding or clotting complications and potential harm due to inadequate monitoring, delayed medical intervention, increased hospitalization s, or even life-threatening hemorrhages. Findings include: Resident 9 (R9) Resident 9 (R9) was admitted on [DATE], with diagnoses including persistent atrial fibrillation and thrombophilia (blood clotting disorder). On 04/22/2025 at 12:23 PM, R9 was seated in a wheelchair in the room, verbally alert and oriented, with multiple bruises or skin discoloration on bilateral upper extremities. R9 verbalized taking an anticoagulant, and the assigned licensed nurse indicated R9 was taking a Warfarin anticoagulant medication. A Physician order dated 01/24/2023, documented Warfarin Sodium 2.5 milligrams (mg) to give 2.5 mg by mouth daily in the afternoon for hypercoagulability/longstanding atrial fibrillation. A Care Plan dated 01/13/2023, documented R9 was on anticoagulant therapy (Warfarin) related to atrial fibrillation. The interventions included administering anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness as needed and as ordered. Daily skin inspection, laboratory as ordered, and monitor/document, report adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle point pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant changes in vital signs. A Physician order dated 02/16/2023, documented to draw INR level on the 16th of each month. The PT-INR (Prothrombin time-international normalized ratio, (a blood test measuring how long it took for blood to clot) dated 04/16/2025, documented the result of 3.0, which was a high value. The INR therapeutic range related to oral anticoagulants is 2.0-3.0. The Quarterly Minimum Data Set, dated dated dated [DATE], documented the brief interview of mental status, a score of 11/15 indicating mild cognitive impairment, and was taking anticoagulant. On 04/24/2025 at 6:01 AM, the night shift Registered Nurse (RN) indicated residents on anticoagulants should have been monitored daily for bruising and bleeding, and observations should have been documented daily and reported. The RN indicated R9 had persistent bruising on both arms, which was inconsistently and inaccurately documented. The RN indicated during the administration of Warfarin, the system prompted staff to report whether there were signs or symptoms (s/s) of bleeding or bruising-option '1' for no signs and symptoms and option '2' if signs and symptoms were present. The RN confirmed the documentation was inconsistent as it was documented as '1,' indicating no s/s when bruises were evident and persistent. The RN confirmed there was no documentation the bruising was reported to the physician. On 04/24/2025 in the morning, the Chief Nursing Officer (CNO) indicated licensed nurses were expected to consistently monitor residents receiving Warfarin, document daily, and report signs and symptoms such as persistent bruising or skin discolorations. A facility policy titled Anticoagulant Management Program, revised 03/03/2023 documented, the facility ensured all residents receiving anticoagulant therapy were monitored and followed to reduce the likelihood of resident harm associated with the use of anticoagulant therapy. Residents on Warfarin therapy had continuous INR monitoring, with documentation in the medical record. Process improvement was monitored for effectiveness.Based on observation, interview, record review, and document review, the facility failed to ensure the signs and symptoms of bleeding or adverse effects for a resident on Warfarin (anticoagulant medication) were consistently monitored, documented, and reported to the physician for 1 of 10 sampled residents (Resident 9). The deficient practice had the potential to result in adverse outcomes, including an increased risk of bleeding or clotting complications and potential harm due to inadequate monitoring, delayed medical intervention, increased hospitalization s, or even life-threatening hemorrhages. Findings include: Resident 9 (R9) Resident 9 (R9) was admitted on [DATE], with diagnoses including persistent atrial fibrillation and thrombophilia (blood clotting disorder). On 04/22/2025 at 12:23 PM, R9 was seated in a wheelchair in the room, verbally alert and oriented, with multiple bruises or skin discoloration on bilateral upper extremities. R9 verbalized taking an anticoagulant, and the assigned licensed nurse indicated R9 was taking a Warfarin anticoagulant medication. A Physician order dated 01/24/2023, documented Warfarin Sodium 2.5 milligrams (mg) to give 2.5 mg by mouth daily in the afternoon for hypercoagulability/longstanding atrial fibrillation. A Care Plan dated 01/13/2023, documented R9 was on anticoagulant therapy (Warfarin) related to atrial fibrillation. The interventions included administering anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness as needed and as ordered. Daily skin inspection, laboratory as ordered, and monitor/document, report adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle point pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant changes in vital signs. A Physician order dated 02/16/2023, documented to draw INR level on the 16th of each month. The PT-INR (Prothrombin time-international normalized ratio, (a blood test measuring how long it took for blood to clot) dated 04/16/2025, documented the result of 3.0, which was a high value. The INR therapeutic range related to oral anticoagulants is 2.0-3.0. The Quarterly Minimum Data Set, dated dated dated [DATE], documented the brief interview of mental status, a score of 11/15 indicating mild cognitive impairment, and was taking anticoagulant. On 04/24/2025 at 6:01 AM, the night shift Registered Nurse (RN) indicated residents on anticoagulants should have been monitored daily for bruising and bleeding, and observations should have been documented daily and reported. The RN indicated R9 had persistent bruising on both arms, which was inconsistently and inaccurately documented. The RN indicated during the administration of Warfarin, the system prompted staff to report whether there were signs or symptoms (s/s) of bleeding or bruising-option '1' for no signs and symptoms and option '2' if signs and symptoms were present. The RN confirmed the documentation was inconsistent as it was documented as '1,' indicating no s/s when bruises were evident and persistent. The RN confirmed there was no documentation the bruising was reported to the physician. On 04/24/2025 in the morning, the Chief Nursing Officer (CNO) indicated licensed nurses were expected to consistently monitor residents receiving Warfarin, document daily, and report signs and symptoms such as persistent bruising or skin discolorations. A facility policy titled Anticoagulant Management Program, revised 03/03/2023 documented, the facility ensured all residents receiving anticoagulant therapy were monitored and followed to reduce the likelihood of resident harm associated with the use of anticoagulant therapy. Residents on Warfarin therapy had continuous INR monitoring, with documentation in the medical record. Process improvement was monitored for effectiveness.

Based on observation, interview, record review, and document review, the facility failed to ensure a physician order for the use, care management, and monitoring of a protective seizure helmet were obtained for 1 of 10 sampled residents. The failed practice had the potential to increase risk of injury from falls and delay identification of skin conditions or concerns. Findings include: Resident 2 (R2) R2 was admitted on [DATE], with diagnosis including epilepsy, unspecified not intractable without status epilepticus, symptoms and signs involving cognitive functions and awareness, and low back pain. A physician order dated 06/27/2024, documented seizure precautions. On 04/22/2025 at 11:55 AM, R2 was observed walking in room independently, R2 was wearing a helmet. On 04/23/2025 at 3:25 PM, R2 was observed walking in room, helmet was not on. On 04/25/2025 at 7:58 AM, R2 was observed sitting on right side of bed with feet touching the floor, speaking to an LPN. R2's helmet was not on. R2 was crying and reported had a rough night. The LPN confirmed R2 did not have helmet on, and explained the LPN would put helmet on when R2 would stand up. R2's medical record lacked documented evidence of a physician order for the use of a protective seizure helmet. R2's medical record lacked documented evidence of a physician order for care management for a protective seizure helmet. R2's medical record lacked documented evidence of monitoring for the use of a protective seizure helmet. A care plan initiated 06/19/2024, documented R2 was high risk for falls related to R2's seizure disorder and occasional poor safety awareness. Fall risk interventions included R2 was to wear helmet while ambulating even in the room. A Long-Term Care Progress Note dated 12/05/2024, documented for seizures instructions to continue to have R2 wear helmet while was up and awake. On 04/24/2025 at 9:32 AM, a Licensed Practical Nurse (LPN) reported R2's seizures usually happened in the morning while R2 was sitting on the bed or chair. The LPN ensured R2 had helmet on during the LPN's whole shift. The LPN reported R2 would at times take off helmet when sat on the chair or bed and R2 would forget to put the helmet back on. The LPN acknowledged R2 at times did not have the helmet on. The LPN confirmed there was not a physician order for the use of the helmet in R2's medical record. The LPN acknowledged having a physician order could have given clarification for when the physician wanted the helmet on, and it would have set up a standard procedure for all staff to follow, to ensured consistency with the use of the helmet. On 04/24/2025 at 11:11 AM, the Chief Nursing Officer, reported R2 had seizures regularly, and the seizures seemed to happen in the mornings. The CNO explained the helmet was to be worn for safety to prevent injury from falls. The CNO reported the staff was aware R2 was to wear the helmet for safety due to the small number of residents in the facility. The CNO confirmed no physician orders were in place for the use and care management of the helmet. The CNO acknowledged a physician order should have been obtained for consistency with use of the helmet and care management including skin assessments and checks.

Based on observation, interview, record review, and document review, the facility failed to ensure the resident's Oxygen (O2) was monitored and care orders were obtained per policy for 1 of 10 sampled residents (Resident 11). The deficient practice could have the potential to result in inadequate oxygen administration, unrecognized respiratory decline, delayed medical intervention, and compromised resident safety. Findings include: Resident 11 (R11) R11 was admitted on [DATE], with diagnoses including acute and chronic respiratory failure and chronic congestive heart failure. A Physician Order dated 10/04/2023, documented O2 via nasal cannula (NC) 2-3 liters continuous for congestive heart failure/dyspnea and shortness of breath. The History and Physical dated 10/04/2023, documented R11 had chronic shortness of breath, was on supplemental O2 and the plan was to continue with O2 use. The Minimum Data Set, dated dated dated [DATE], documented the brief interview of mental status with a score of 12/12, indicating intact cognitive status. The active diagnosis was respiratory failure with O2 use. The Monthly assessment dated [DATE], documented R11 utilized O2 at 2 LPM via nasal cannula. R11's medical records lacked documented evidence the care orders for O2 use were obtained. On 04/22/2025 at 12:05 PM, R11 was in the dining room eating lunch, and O2 was flowing at 4 liters per minute (LPM) via nasal cannula. The O2 cannula was dated 04/07/2025. On 04/22/2025 03:29 PM, R11 was in the chair, awake and verbally responsive. The O2 nasal cannula was connected to R11's nostrils, but the concentrator was not turned on. There were no signs and symptoms of respiratory distress. R11 indicated it was unnoticed the O2 was not turned on. R12 indicated was continuously dependent on O2 at 2 LPM. R11 indicated the staff missed turning it on upon return to the room. On 04/23/25 at 1:40 PM, R11 was seated in a chair with O2 flowing at 3.5 LPM via nasal cannula. A Licensed Practical Nurse (LPN) indicated the licensed nurses were responsible for ensuring R11 received O2 continuously at 2-3 LPM as ordered, and the nasal cannula was changed monthly. The LPN verified and confirmed R11's O2 was flowing at 3.5 LPM. The LPN acknowledged the O2 liters flow was not followed, and there were no care orders in place for the cannula change schedule. The LPN explained care orders for O2 use were not deemed necessary, as the tubing was labeled with the last change date 04/07/2025 and was routinely replaced monthly. The LPN indicated there was a binder for the monthly schedule of the resident's O2 but was unable to locate it. A facility policy titled Oxygen Administration required a physician order for administering Oxygen, the humidifier and nasal cannula should have been changed every month and when needed. To verify the order in the resident's medical record.

Based on observation, interview, record review, and document review, the facility failed to ensure non-pharmacological interventions were consistently implemented, the effectiveness of pain management was monitored and documented, including location, frequency, severity, and duration, and opioid use adverse effects were monitored for 1 of 10 sampled residents (Resident 10). This deficient practice could have led to unresolved pain and diminished quality of life. Findings include: Resident 10 (R10) R10 was admitted on [DATE] and readmitted on [DATE], with diagnoses including sepsis, polyarthritis (inflammation of multiple joints), cellulitis of the left lower limb (a person's arm or leg), and toe wounds. The Admission Minimum Data Set, dated dated dated [DATE], documented a brief interview of mental status with a score of 15/15, which indicated intact cognitive status. R10 was in frequent pain. On 04/22/2025 in the morning, R10 indicated having hammertoes causing wounds on the second toe of the left foot. R10 expressed experiencing unrelieved pain even after receiving pain medication. Most of the time, the pain level remained at 3 to 4 following administrations. R10 reported receiving scheduled pain medication three times a day along with Tylenol. Some relief was achieved, but the pain was not completely resolved. A Physician Order dated 08/07/2024, documented Tylenol oral tablet to give 500 mg by mouth three times a day by mouth for pain at 8:00 AM, 2:00 PM and 9:00 PM. A Physician Order dated 01/09/2025, documented Oxycodone Hydrochloride oral tablet 10 milligrams (mg) to give 10 mg three times a day at 9:00 AM, 2:00 PM, and 9:00 PM for polyarthritis. The Medication Administration Record from 04/01/2025 to 04/24/2025, documented the Oxycodone 10 mg and Tylenol 500 mg were administered three times daily. A Care Plan dated 09/05/2024, documented R10 had chronic pain. Interventions included to anticipate R10's need for pain relief and respond immediately to any complaint of pain and observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care. The goal documented R10 would verbalize relief of pain or ability to cope with incompletely relieved pain through the review date. R10 would not have an interruption in normal activities due to pain through review date. A Care Plan dated 12/09/2024, documented R10 had acute pain/ chronic pain with interventions to administer pain medications per order, if non medication interventions were ineffective. To determine level of needed assistance based on activities of daily living. To determine R10's satisfactory pain level and monitor for factors/activities precipitate or aggravate pain. The goal was R10 would report satisfactory pain control. R10's Pain Interview dated 03/05/2025, documented the pain frequency was frequent over the last five days and limited the day-to-day activities because of pain. The pain interview was incompletely filled out with the pain indicators and frequency. R10's medical records lacked documented evidence non-pharmacological interventions were implemented and documented, the effectiveness of pain management was monitored and documented, including location, frequency, severity, and duration to determine whether pain management mechanisms were effective and opioid use adverse effects were monitored. On 04/23/2025 at 12:31 PM, a Licensed Practical Nurse (LPN) explained the procedure used to assess the resident's pain. The assessment included identifying a 0/10 pain level scale and describing sharpness, onset, intensity, location, frequency, severity and duration. The LPN explained pain assessments occurred every shift for R10 as documented. R10 had been receiving scheduled opioid pain medication three times daily. The LPN indicated when scheduled pain medication was administered, did not require pain assessment. The LPN confirmed no monitoring system was in place to ensure effectiveness of pain management for R10. The LPN confirmed no documented evidence demonstrated consistent use of non-pharmacological interventions. The LPN confirmed the documented pain level after administrations remained unsatisfactorily. On 04/24/2025 at 6:00 AM, a night Registered Nurse (RN) indicated R10's pain had not been assessed before and after the administration of scheduled pain medication. The RN stated the Medication Administration Record (MAR) lacked a section to document the effectiveness of routine pain medication. The RN indicated non-pharmacological interventions were not consistently implemented or documented. The RN acknowledged reassessment and documentation of the resident's response were required to measure the effectiveness of pain medication but had not been completed. The RN indicated R10 had frequently experienced pain. On 04/25/2025 at 8:25 AM, R10 was seated in bed and reported a pain level of 4 out of 10 following the administration of pain medication. R10 indicated Oxycodone helped reduce the pain but did not completely relieve it, and the effectiveness was not sustained. R10 reported the pain affected activities of daily living (ADLs), and mood, and expressed a desire for additional pain relief or alternative comfort measures. R10 indicated non-pharmacological interventions had not been implemented but stated staff were prompt in administering pain medication when due. R10 expressed a satisfactory pain level would be complete relief from pain. On 04/25/2025 at 8:49 AM, the Licensed Practical Nurse (LPN) indicated R10 received a scheduled opioid three times a day. The LPN stated being uncertain of the facility ' s protocol for opioid toxicity. The LPN explained non-pharmacological interventions were not documented, pain was not reassessed to determine the effectiveness of pain management interventions, and adverse reactions were not monitored or addressed. On 04/23/2025 at 4:04 PM, the Chief Nursing Officer (CNO) acknowledged there was no documented evidence R10's pain level had been monitored before and after the administration of Oxycodone and Tylenol. The CNO acknowledged non-pharmacological interventions had not been implemented or documented. The CNO emphasized the importance of monitoring the effectiveness of pain medication and adverse reactions to ensure adequate pain management. A facility policy titled Opioid Program revised on 05/16/2024, indicated opioid prescriptions were not to be used as the first line of pain management for chronic pain. A multimodal approach was to be used, incorporating both pharmacological and non-pharmacological treatments. A facility policy titled Pain Assessment revised on 03/12/2023, indicated the facility was to respect and support the resident's right to optimal pain assessment and management. Residents were to be reassessed within one hour to determine the level of pain control or relief achieved. Pain was to be assessed and documented, including duration, characteristics, intensity, pain level, use of analgesics, pain interventions, vital signs, effectiveness of all interventions, and any side effects or adverse reactions.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% was obtained during medication pass. There were 31 opportunities observed, which revealed two errors. The medication error rate was 6.45%. Findings include: Resident 13 (R13) R13 was admitted on [DATE], with diagnoses including hypothyroidism and gastro-esophageal reflux disease (GERD). On 04/24/2025 at 7:30 AM, a Licensed Practical Nurse (LPN) prepared the medications, including Omeprazole 20 milligrams (mg) 1 capsule, and Levothyroxine Sodium 112 micrograms (mcg) 1 tablet. At 7:50 AM, the LPN administered the medications after breakfast. R13 confirmed having finished eating. A Physician Order dated 08/07/2024, documented Levothyroxine Sodium oral tablet to give 112 micrograms by mouth daily for hypothyroidism. The Medication Administration Record (MAR) from 04/01/2025 - 04/24/2025, documented Levothyroxine was administered at 8:00 AM A Physician Order dated 08/06/2024, documented Omeprazole oral tablet delayed release 20 milligram (mg) to give 20 mg by mouth two times a day related to GERD. The MAR from 04/01/2025 - 04/24/2025, documented Omeprazole was administered at 7:30 AM. The meal- times information documented the breakfast was scheduled at 7:15 AM. On 04/24/2025 at 10:50 AM, the LPN confirmed Omeprazole and Levothyroxine were administered after breakfast. The LPN explained the medications should have been given before breakfast for optimal absorption. The LPN indicated the physician would be notified of the medication administration error and a request would be made to revise the medication administration time to prevent future errors. On 04/24/2025 at 11:10 AM, the Chief Nursing Officer (CNO) acknowledged proton pump inhibitors such as Omeprazole should have been administered early in the morning to ensure acid suppression, and Levothyroxine should have been administered on an empty stomach for optimal absorption. The CNO confirmed breakfast had started at 7:15 AM. On 04/25/2025 at 11:45 AM, during a telephone interview, the Pharmacist explained consistency in the timing of Omeprazole and Levothyroxine administration was important. The Pharmacist indicated absorption may have been altered if taken with a meal and stated Omeprazole and Levothyroxine should have been administered prior to meals. The Pharmacist acknowledged it may have been missed during the medication review to request the provider to update the order for administration on an empty stomach. The manufacturer's instructions indicated Prilosec (Omeprazole) was a compound that inhibited gastric acid secretion and was to be swallowed with a glass of water before eating in the morning. The Full Prescribing Information, Reference ID: 5037921, indicated Levothyroxine was to be administered as a single dose on an empty stomach, one-half to one hour before breakfast.

Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure 7 of 10 sampled residents (Resident (R) 6, R14, R7, R1, R8, R11 and R12) had an accurate Minimum Data Set (MDS) assessment. The deficient practice had the potential for inaccurate assessment and care planning of the resident. Findings include: Review of the RAI Manual dated 10/23 indicated, .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT (Interdisciplinary Team) completing the assessment . 1. Resident 6 was admitted to the facility on [DATE]. Resident 6's Significant Change MDS with an Assessment Reference Date of (ARD) of 03/27/2024, revealed the resident was severely cognitively impaired. The assessment indicated the resident was dependent on caregiving staff to move the resident side-to-side while in bed, and staff did not transfer the resident out of bed due to safety concerns. The assessment revealed the facility coded the resident with the use of bi-lateral side rails as a restraint. 2. Resident 14 was admitted to the facility on [DATE]. Resident 14's Quarterly MDS with an ARD of 04/01/2024 indicated was moderately cognitively impaired. The assessment indicated was independent to move side to side while in bed. The assessment revealed the resident required substantial to maximum assistance from staff to transfer from the bed to her wheelchair. The assessment revealed the facility coded the resident with the use of bi-lateral side rails. During an interview on 05/02/2024 at 11:14 AM, the Administrator, Director of Nursing (DON), and the Chief Operating Officer (COO) all stated that the MDS was to be accurate. The DON stated a restraint was any device that would hinder someone's movement and for R6 and R14, the side rails did not hinder their movements. 3. Review of Resident 7's (R7) January 2024 Medication Administration Record (MAR) showed a facility admitted [DATE]. The MAR showed documentation that R7 received sertraline, an antidepressant selective serotonin reuptake inhibitor (SSRI) during the assessment period for the MDS with an ARD of 01/13/2024. The Quarterly MDS with an ARD of 01/13/2024 was coded that R7 received an antipsychotic on a regular basis and an indication for use was in the medical record. Review of R7's physician orders did not indicate that R7 had an order for an antipsychotic medication. In an interview on 05/02/2024 at 1:52 PM, the COO provided a printed copy of the January 2024 MAR and clarified that sertraline was an antidepressant. The COO indicated R7 was not receiving an antipsychotic and the MDS was not accurately coded. In an interview on 05/02/2024 at 2:41 PM, the DON was not sure if there were any policies regarding MDS accuracy, but if not, they would use the RAI manual. Review of the October 2023 RAI manual, page N-5, stated: .High-Risk Drug Classes: Use and Indication .Coding Instructions: Code all high-risk drug class medications according to their pharmacological classification, not how they are being used. 4. Resident 1 (R1) was admitted to the facility on [DATE] admitted on [DATE] with medical diagnoses that included dementia, polyosteoarthritis, lower back pain, pain due to orthopedic prosthetic device, and displaced intertrochanteric fracture. During an interview on 04/30/2024 at 9:35 AM, R1 used the side rail on the bed. The Electronic Medical Record (EMR) showed a Bed Rail Assessment completed on 02/07/2024. The assessment revealed, Side Rails/Assist Bar are indicated and serve as an enabler to promote independence. The Restraint Assessment Form completed on 02/02/2024 showed the type of restraint as bed rails. R1's Annual MDS with an ARD of 02/09/2024 showed the bed rails coded as physical restraints used daily. 5. Resident 8 (R8) was admitted to the facility on [DATE] with medical diagnoses that included dementia, anxiety, pseudobulbar affect, glaucoma, left hip pain, retinal break, and displaced fracture of the femoral neck. R8's Restraint Assessment Form, dated 03/04/2024 revealed the type of restraint as bed rails for mobility aid. R8's Quarterly MDS, with an ARD of 03/07/2024, showed R8 was coded for the restraint of bed rails used daily. 6. Resident 11 (R11) was admitted on [DATE] with medical diagnoses that included heart failure, atrial fibrillation, dementia, atherosclerotic heart disease, and hypertension. R11's Restraint Assessment Form completed 04/08/2024 revealed the type of restraint as bed rails x [times] 2. R11's Annual MDS, with an ARD of 01/08/2024, showed R11 had side rails as restraints that were used daily. 7. Resident 12 (R12) was admitted on [DATE], with medical diagnoses that included traumatic subdural hematoma, acute embolism and thrombosis of extremity deep veins, aphasia, osteoarthritis, epilepsy, anxiety, nocturia, restlessness and agitation. R12's Restraint Assessment Form dated 04/06/2024, revealed the type of restraint as bed alarm, and siderails r/t [related to] mobility aide. R12's Admission MDS, with an ARD of 01/11/2024, showed R12 had side rails as restraints that were used daily. Review of the facility's policy titled Restraint Use, reviewed 11/16/23, showed: Definitions: Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints include, but are not limited to, leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions, and lap trays the resident cannot remove easily. Also included as restraints are facility practices that meet the definition of a restraint, such as: Using siderails that keep a resident from voluntarily getting out of bed . During an interview on 05/02/2024 at 11:15 AM, the DON (who completed the MDS assessments), COO and the Administrator, all confirmed the side rails for R1, R8, R11, and R12 were not used as restraints to keep the residents in bed. They all stated that the MDSs were coded incorrectly.

Based on observation, interview, record review and policy review, the facility failed to attempt alternatives to the use of side rails for four of six residents (R) reviewed with side rails (R1, R8, R11, and R12). This failure had the potential to create a safety hazard for any resident using side rails in the facility. Findings include: 1. Review of R1's printed Admission Record showed a facility admitted [DATE], readmission on 03/14/2023, with medical diagnoses that included dementia, polyosteoarthritis, lower back pain, pain due to orthopedic prosthetic device, and displaced intertrochanteric fracture. On 04/30/2024 at 9:35 AM, R1 stated the side rail on the bed was used by the resident. The Bed Rail Assessments completed 02/07/2024 indicated no alternatives attempted prior to the use of the bed rails. Review of R1's printed care plan showed a bed mobility status of supervision/set up help only to independent/set up help only, and transfer performance of limited assist /one-person physical assist. 2. Review of R8's printed Admission Record showed a facility admitted [DATE] with medical diagnoses that included dementia, anxiety, pseudobulbar affect, glaucoma, left hip pain, retinal break, and displaced fracture of the femoral neck. Observation on 04/30/2024 at 9:15 AM showed R8 in bed on a low-air-loss air mattress with bilateral upper quarter side rails. Review of R8's printed Bedrail Assessment Form, dated 03/07/2024, showed no documented alternatives attempted prior to the use of the bed rails. Review of R8's printed Care Plan showed for bed mobility that the resident required extensive to total assist by two staff to turn and reposition in bed every two hours and as necessary; and the resident uses mobility bars/bed rails to maximize independence with turning and repositioning in bed. The Care Plan showed Side Rails: half rails up as per Dr's [Doctor's] order for safety during care provision, to assist with bed mobility. 3. Review of R11's printed Admission Record showed a facility admitted 12/28/2022 with medical diagnoses that included heart failure, atrial fibrillation, dementia, atherosclerotic heart disease, and hypertension. Observation on 04/30/2024 at 9:21 AM showed R11 had bilateral upper quarter rails on the bed. Review of R11's EMR Assessments tab showed a Bedrail Assessment Form completed 04/08/2024 which indicated the type of restraint as bed rails x [times] 2 and showed no documented alternatives attempted prior to the use of the bed rails. Review of R11's printed Care Plan showed he required the limited to extensive physical assist of one person for transfers and required the extensive assistance of one to two staff to turn and reposition in bed. 4. Review of R12's printed Admission Record showed a facility admitted [DATE], with medical diagnoses that included traumatic subdural hematoma, acute embolism and thrombosis of extremity deep veins, aphasia, osteoarthritis, epilepsy, anxiety, nocturia, restlessness and agitation. Observation on 04/30/2024 at 10:22 AM showed R12 had quarter bilateral upper rails. Review of R12's EMR Assessments tab showed a Bedrail Assessment Form dated 04/08/2024, did not document any attempted alternatives prior to the use of the bedrails. Review of R12's printed Care Plan showed R12 only needed supervision/set-up help only for bed mobility, and supervision / one-person physical assist for transfers. The Care Plan noted Resident uses bilateral bedrails/mobility bars as a mobility aid and to encourage independence. During an interview on 05/02/2024 at 2:00 PM, the Chief Operating Officer (COO) and Administrator both stated that there were no alternatives attempted prior to side rail use. Review of the facility policy titled, Bedrail Use - Safety, revised 09/21/2022, showed: .Prior to the use of bedrails, the facility will attempt to use appropriate alternatives prior to installing a side or bedrail . During an interview on 05/01/2024 at 2:29 PM, the Director of Plant Operations routinely completed safety checks on the beds with side rails. The Director of Plant Operations took measurements of the area between the mattress and the side rails but did not have evidence of this in the tracking records. The Director of Plant Operations confirmed he did assess the use of side rails and air mattress but did not have evidence of this in his records. Review of the facility's policy provided by the facility titled Bedrail Use-Safety dated 09/21/2022 indicated, .Prior to the use of bedrails, the facility will attempt to use appropriate alternatives prior to installing a side or bedrail. If a side or bedrail is used, the facility must ensure correct installation, use, and maintenance of bedrails, including but not limited to the following elements .

Based on observation and interview, the facility failed to ensure wheelchair armrest coverings were intact for 2 of 10 sampled residents (Resident 1 and Resident 11). The deficient practice had the potential to create areas that could be injurious to a resident's skin and a non-cleanable surface which could harbor bacteria that could infect any such injury. Findings include: Observation of Resident 11 (R11) on 04/30/2024 at 9:21 AM showed both armrests of the wheelchair were cracked, torn, missing areas of both wheelchair armrests exposing the white padding below the vinyl. Observation of Resident 1 (R1) on 04/30/2024 at 10:48 AM showed both armrests of the wheelchair were cracked, torn, missing areas of both wheelchair armrests exposing the white padding below the vinyl. During an observation and interview on 05/01/2024 at 4:01 PM, the Maintenance Director observed R1's wheelchair armrests cracked and torn and stated, They're done for. After observing R11's wheelchair armrests, the Maintenance Director confirmed the wheelchair armrests were cracked and uncleanable. No policy regarding wheelchair maintenance was provided.

Based on record review, interview and policy review, the facility failed to ensure 1 of 10 sampled residents (Resident 12) was provided with a written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. The deficient practice had the potential to affect the resident and their representative by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: A review of Resident 12 (R12) electronic medical record (EMR) Progress Notes tab showed a note on 01/2/2024 at 12:12 PM that stated R12 had a fall in the room while ambulating, hit their head, sustained a midline laceration above the forehead and had been taken to the emergency room . The EMR lacked documented evidence a written notice of transfer was provided to R12 or their representative. The facility was unable to provide a written notice of transfer from the facility to the emergency room . During a telephone interview on 05/02/2024 at 7:56 AM, R12's representative stated, He had a fall and a pretty good head gash. The representative stated he was notified right away, but it was only verbal. I'm looking through my file and I didn't receive anything in writing. During an interview on 05/02/2024 at 2:10 PM, the Administrator stated, Nothing has been sent out in writing to anyone regarding transfers. Review of the facility's policy titled Transfer and Discharge, dated 03/18/21, revealed: .Notice of Discharge: .When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer shall be provided to the resident and resident representative as soon as practicable.

Based on observation, interview, policy review, and review Centers for Disease Control (CDC) website, the facility failed to ensure one of one expired insulin vial and two of two undated, opened vials of Mantoux tuberculin purified protein derivative (PPD) were not available for residents' use. Findings include: During an observation of the long-term care medication room on [DATE] at 12:03 PM with Registered Nurse (RN) 9 and the Infection Preventionist (IP) revealed two undated open vials, put back in their boxes, of Mantoux tuberculin PPD skin tests and one vial of Humulin R (insulin) that had an open date of [DATE]. Interview on [DATE] at 12:06 PM, the IP confirmed there was no open date on the PPD vials and that once opened the PPD could be used for 30 days. The IP stated the insulin vial was expired. Review of the facility's policy titled Medication Storage in the Long-Term Care, revised [DATE], revealed it did not address outdated medication. Review of the CDC Mantoux Tuberculin Skin Test (cdc_25732_DS1.pdf on page 6) stated: .The label should indicate the expiration date. If it's been open more than 30 days or the expiration date has passed, the vial should be thrown away and a new vial used .

Based on document review and interview, the facility failed to ensure the daily nurse staff posting included the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for long-term resident care per shift. This deficient practice had the potential to affect all 13 of 13 residents and visitors of the facility. Findings include: Review of staff posting documents provided by the facility dated 04/22/2024 through 05/01/2024, failed to have the total and actual working hours identified for Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA). The staff posting document included the census for the acute and swing bed side of the facility. The document identified two RNs for all three areas of the facility, which included long-term care, acute, and swing beds. During an interview on 05/02/2024 at 10:26 AM, the Administrator confirmed the staff postings included the staff assigned to long-term care, acute, and swing beds. During a subsequent interview on 05/02/2024 at 11:14 AM, the Administrator stated the staff posting should have included the actual and total hours that the staff worked for only long-term care.

Based on interview, review of the payroll-based journal (PBJ) submitted to the Centers for Medicare and Medicaid (CMS), the facility failed to ensure one quarter (third quarter of fiscal year 2023) out of three quarters reviewed for PBJ that the direct care staffing information was submitted accurately to CMS. This failure had the potential for staffing issues related to Registered Nurse (RN) coverage for eight consecutive hours per day. Findings include: Review of the PBJ report from CMS showed no RN coverage for eight consecutive hours per day during the third quarter (October, November, December) of 2023. Review of documents provided by the facility and referred to as the staffing schedule for 10/2023 indicated there was RN coverage at least eight consecutive hours on 10/01/2023 and 10/15/2023. Review of documents provided by the facility and titled Time Report for 10/2023 indicated there was RN coverage for at least eight consecutive hours on 10/01/2023 and 10/15/2023. Review of documents provided by the facility and referred to as the staffing schedule for 11/2023 indicated there was RN coverage on 11/12/2023 and on 11/26/2023. Review of documents provided by the facility titled Time Report for 11/2023 indicated there was RN coverage for at least eight consecutive hours on 11/12/2023 and on 11/26/2023. Review of documents provided by the facility and referred to as the staffing schedule for 12/2023 indicated there was RN coverage at least eight consecutive hours on 12/09/2023, 12/10/2023, and on 12/31/2023. Review of documents provided by the facility titled Time Report for 12/2023 indicated there was RN coverage for at least eight consecutive hours on 12/09/2023, 12/10/2023, and on 12/31/2023. During an interview on 05/02/2024 at 8:40 AM, the Accounts Payable Clerk stated there was no PBJ confirmation that was received after entering the data to CMS. The Accounts Payable Clerk did not complete any audits of the data which was entered. The Accounts Payable Clerk stated the facility had RNs on duty.

Based on interview, record review, and facility policy review, the facility failed to provide a Form CMS-10123 (Centers for Medicaid and Medicare) Notice of Non-Coverage (NOMNC) and a Form CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to three of three residents (Resident (R) R1, R64, and R65) reviewed for liability notices out of a total sample of eight residents. This failure potentially prevented the residents from understanding their rights related to their skilled Medicare coverage and/or appealing the decision of the facility and/or making an informed decision related to the cost of continued therapy services. Findings include: The facility's undated Admissions/Registration Patient Financial Assessment and Required Forms Policy read, in pertinent part, ABN (Advanced Beneficiary Notice) forms are required to be filled out by Medicare beneficiaries at the time of service and before services are provided for any services that Admitting believes may not be covered by Medicare, or that are not medically reasonable or necessary. This form allows the patient to make informed decisions about whether they want to be financially responsible for the service PRIOR to having it done. The policy further stated, CMS NONMC 10123-Notice of Discharge Form is for inpatient/swing bed patients that are being discharged from their Medicare Part A covered stay. They must be given the 72-hour notice of Medicare Non-Coverage form. This form notifies the patient/patient representative that their current stay will end on a specific date. It gives them notice that they have the right to appeal the decision, should they decide they are not ready to be discharged from this level of care. It gives them what options they have for appeal. Form must be signed/dated and scanned to their account. If patient/patient rep (representative) is unable to sign in person, please complete for verbally, and note date, time and who you spoke with. 1. Review of the medical record revealed R1 was admitted to Medicare Part A therapy services on 01/28/23. Further review of the medical record revealed R1's last covered day of Part A therapy services was 02/02/23. Review of the medical record revealed no evidence R1 was ever issued a CMS Form-10123 Notice of Medicare Non-Coverage (NOMNC) to indicate, with advance notice, the resident would be discharged from Medicare A services on 02/02/23. In addition, R1 elected to remain in the facility for long-term care services after being discharged from Medicare A skilled services on 02/02/23 but was not issued a Form CMS-10055 SNFABN to indicate potential financial liability for uncovered services. 2. Review of the medical record revealed R64 was admitted to Medicare Part A therapy services on 01/09/23. Further review of the medical record revealed R64's last covered day of Part A therapy services was 01/13/23. Review of the medical record revealed no evidence R64 was ever issued a CMS Form-10123 Notice of Medicare Non-Coverage (NOMNC) to indicate, with advance notice, the resident would be discharged from Medicare A services on 02/02/23. In addition, R64 elected to remain in the facility for long-term care services after being discharged from Medicare A skilled services on 02/02/23 but was not issued a Form CMS-10055 SNFABN to indicate potential financial liability for uncovered services. 3. Review of the medical record revealed R65 was admitted to Medicare Part A therapy services on 02/15/23. Further review of the medical record revealed R65's last covered day of Part A therapy services was 02/19/23. Review of the medical record revealed no evidence R65 was ever issued a CMS Form-10123 Notice of Medicare Non-Coverage (NOMNC) to indicate, with advance notice, the resident would be discharged from Medicare A services on 02/02/23. In addition, R65 elected to remain in the facility for long-term care services after being discharged from Medicare A skilled services on 02/02/23 but was not issued a Form CMS-10055 SNFABN to indicate potential financial liability for uncovered services.

Based on interview, record review, and facility policy review, the facility failed to ensure a bed hold notice, with all required information, was provided to a resident or the resident's responsible party for 1 of 1 residents reviewed for bed hold notification (Resident (R) 3). Due to this failure, R3 and their responsible party were not informed of the bed hold policy at the time of R3's transfer to the hospital. Findings include: Review of R3's undated Admission Record indicated R3 was readmitted to the facility on [DATE] (initial admission 04/02/16) with diagnoses of left femoral neck fracture, left artificial hip, anxiety disorder, hyperparathyroidism, and unspecified macular degeneration. Review of R3's Progress Notes revealed that the resident was transferred to the hospital for evaluation on 12/08/22 in response to a fall which occurred on 12/01/22. Review of R3's entire EMR revealed no evidence that a written bed hold notice, containing all required information, was provided to R3 or R3's family or representative. During an interview on 03/07/23 at 2:00 PM, the Social Services Director (SSD), stated was not responsible for completing and sending the written bed hold notification. During an interview on 03/07/23 at 2:05 PM the Administrator stated it was the responsibility of Social Services to complete the bed hold notification upon a resident's transfer. The Administrator stated it was possible that, during the current SSD's training with the previous social service director, the current SSD was not informed the bed hold notification task would be one of the SSD's responsibilities. Review of the facility's policy titled Notice of Bed Hold and Return, revised 07/19/17, indicated Policy: The long-term care facility shall provide written information to the resident and his/her family member or legal representative about the bed hold policy before a resident is transferred to the hospital .In the case of an emergency transfer, the resident's representative/family shall be provided with written notice within 24 hours after the transfer.

Based on observation, interview, clinical record and document review, the facility failed to ensure measures were taken to reduce the risk of pressure ulcer development for 3 of 10 sampled residents (Resident #1, #6 and #8). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], [DIAGNOSES REDACTED]. On 8/18/15 at 11:30 AM, the resident was observed in a recliner chair. The resident complained of buttock pain due to a sore on the buttock area which had been hurting for about one month. The resident indicated most of the day was spent sitting in the recliner chair and it was impossible to reposition due to pain, weakness and swelling. The resident had 4+ [MEDICAL CONDITION] to the bilateral extremities and reported shortness of breath with minimal exertion. On 8/18/15 at 12:01 PM, the Certified Nursing Assistant (CNA) caring for the resident reported the resident had open areas to the backside on and off since admission. The CNA reported caring for the resident on a regular basis and indicated nursing staff had been verbally informed of the open areas at least four times. The CNA was unable to recall which nursing staff members had been notified. The CNA indicated any and all issues have been reported to the RNs. On 8/18/15 at 11:30 AM, the CNA reported the resident was not repositioned while sitting in the reclining chair but was repositioned in the bed. The Director of Nursing (DON) was present and acknowledged the resident should have been repositioned. On 8/18/15 in the afternoon, the Registered Nurse (RN) caring for the resident indicated she could not recall any CNA verbal reports of skin breakdown. On 8/18/15 in the afternoon, the RN and CNA lifted the resident, two open areas were observed to the inner bilateral buttocks. On 8/18/15 in the afternoon, the RN indicated the pressure reducing device on the chair was too compressed and would not have provided pressure redistribution. On 8/18/15 and 8/19/15, the CNA was heard reporting constipation, skin concerns and resident complaints to the RN in charge of the residents. The RN reported the resident was bathed twice weekly and normally the CNA would inspect the resident's skin and report changes to nursing staff. This resident was typically bathed twice weekly in the evening. Resident observations 8/18/15 and 8/19/15, supported the resident was seated in the chair for between six to eight hours daily. On 8/20/15 in the afternoon, a second CNA who frequently cared for the resident reported the resident had skin breakdown which had come and gone for about one month. Nursing staff had been made aware of the skin breakdown on five or more occasions. The CNA indicated the resident had not been repositioned while sitting in the chair. On 8/21/15 in the morning, the RN caring for the resident on a regular basis could not recall being made aware of or noticing skin breakdown. The Admission History and Physical dated 6/19/15, documented the resident's skin was normal, no rashes or sores. The Nursing Admission Physical assessment dated [DATE], documented the skin was intact with redness to the sacral area, no decubitus ulcers noted. The Minimum Data Set ((MDS) dated [DATE], documented there was no skin breakdown upon admission. A Skin Breakdown Care Plan dated 7/2/15, documented the goal was for the resident to maintain intact skin. Interventions included, pressure measures such as a crate mattress, heel protectors, weekly documented skin inspections and turning/repositioning every two hours. The clinical record lacked documented evidence of weekly skin inspections and repositioning. The clinical record lacked documented evidence of skin breakdown until 8/18/15. The nursing documentation dated 8/18/15, documented two small areas to the inner bilateral buttock cheeks, +/- .25 centimeters with no drainage. The resident reported the area was tender. The physician was notified, treatment orders were obtained. The nursing pressure ulcer documentation was not documented in accordance with the facility's policy. Resident #8 Resident #8 was admitted to the facility on [DATE] with a recent [MEDICAL CONDITION] that included left sided hemaparesis, dementia, depression and [MEDICAL CONDITION]. On 8/19/15 at 9:30 AM, Resident 8 requested to meet personally to discuss care concerns. On 8/20/15 at 10:00 AM, the resident reported an over the bed trapeze had been in place upon admission, was removed shortly after admission which prevented the resident's ability to self perform repositioning in bed. The resident reported the trapeze had been requested on multiple occasions from nursing staff but it was not replaced. The resident also reported feeling increased anxiety and concern over the spouse's recent [DIAGNOSES REDACTED]. On 8/20/15 in the morning, a CNA reported the resident requested an over bed trapeze but there were concerns about the safety of Hoyer lift transfers with the bed trapeze. On 8/20/15 in the morning, the DON reported being unaware of the resident's trapeze request. A Skin Care Plan dated 4/1/13, updated 7/28/15, documented a risk of skin breakdown due to immobility and incontinence. Interventions included, heel protectors as needed, fleece pad and egg crate mattress, inspect weekly head to toe body skin assessment and document results. Resident #8's clinical record lacked documented evidence weekly head-to-toe skin assessments were conducted and documented. Resident #8's clinical record lacked documented evidence of every two hour repositioning. On 8/20/15 at 9:00 AM, the resident indicated being chair and bedbound. The resident indicated the comfort concern had been shared with nursing staff on many occasions. The resident reported staff had not provided frequent repositioning in bed or the wheelchair. Observations from 8/19/15 through 8/21/15, confirmed the resident's manual wheelchair did not provide torso support to maintain an upright position. The resident's body was slumped to the right or left side with positioning pillows. On 8/20/15 in the afternoon, the resident was observed in bed. There was no pressure redistribution device on the bed. The resident was not wearing heal protectors, staff and the resident confirmed the resident heel protectors had not been applied. Redness was observed on the resident's left heel and sacral area. The clinical record lacked documented evidence on the MAR indicated [REDACTED]. On 8/20/15 in the afternoon, the DON reported documented turing/repositioning could have been documented in the nursing notes or a paper turning/repositioning paper sheet which had been used for some residents and provided an example. The turning/repositioning papersheet had not been utilized for the resident. The weekly skin evaluations were normally documented under nursing notes. The DON acknowledged the weekly skin evaluation had not been documented in accordance with the care plan. The DON acknowledged the resident's bed did not have a pressure redistribution device. Resident #6 Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's admission order for Decub precautions was written. The Director of Nursing was interviewed on 8/20/15. The DON stated Decub precautions were not defined by the facility. Resident #6's Initial Minimum Data Set (MDS), dated [DATE] indicated the resident was admitted with a Stage II pressure ulcer. The resident's Plan of Care, dated 12/19/14 stated Skin Breakdown At risk for developing related to Immobility/Incontinence. The document stated the Stage II was present on admission. The identified Interventions included Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudates. On 8/21/15 the DON was interviewed. The DON stated weekly documentation of the measurements of the pressure ulcer could not be located. On 8/21/15 Employee #4, a Registered Nurse, was interviewed. The RN stated Resident #6's pressure ulcer was present upon admission and the facility had been treating the ulcer with Comespectine Ointment. an order for [REDACTED]. The facility provided the policy titled Pressure Sore Risk Assessment dated 3/2/12, stated in part, All patients will be assessed on admission, quarterly, and PRN (as needed) for significant change in condition for risk of developing pressure sores, using the Nursing History and Assessment, and the Minimum Data Set (MDS) form .A pressure sore or decubitus ulcer is a circumscribed area in which cutaneous tissue has been destroyed, and there is a progressive destruction of the underlying tissue. Reddened, irritated and tender skin is the forerunner of broken skin and the formation of decubiti. Any reddened or irritated skin should be reported promptly and given special attention to prevent further irritation . .A 'Nursing History and Assessment' form will be completed within 24 hours of the patient's admission . .A Minimum Data Set (MDS) form should be completed within 14 days of the patient's admission and then quarterly .

Based on interview, and clinical record review, the facility failed to ensure their policy for weight management was followed for 1 of 12 sampled residents (Resident #2). The facility failed to ensure 1 of 12 sampled residents (Resident #2) received care and services to meet their nutritional status. Findings include: Facility's documentation entitled Weight Management Guidelines (undated), documented under policy: Residents with significant weight variance should be identified and appropriate intervention implemented. The Weight Management Guidelines documented residents were to be re-weighed when there was a weight variance of plus or minus 5 pounds. A Nutritional at risk review should be completed within 72 hours of the identified event of a significant weight loss. In the Nutritional risk review process identify why the weight loss/weight gain occurred and intervene appropriately. Nursing should notify the physician and family of a significant weight loss. The Weight Management Guidelines documented the best practice guidelines were to weigh the residents weekly for the first month after admission to ensure the nutritional plan of care was adequate. The documentation contained a Significant Weight Change Table. According to the table, a resident with an initial weight of 100 pounds with a weight loss of 5 pounds (weight decrease to 95 pounds) was equivalent to 5% weight loss. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 2/16/12, a physician's orders [REDACTED]. The Nursing History and Assessment form dated 2/18/12, documented Resident #2 was 5 ' 3" inches tall and weighed 100 pounds. The weight chart for Resident #2 documented the following weights: On 3/4/12, the first Sunday in March: 95 pounds (weight loss of 5 pounds or 5%) On 4/1/12, the first Sunday in April: 91.8 pounds (a total weight loss of 9 pounds or 8.2%). The weight chart lacked documentation Resident #2 had been re-weighed in March or April 2012, to ensure the documented weights were accurate. The Nurse's notes lacked documentation Resident #2 had been re-weighed on 3/4/12, after a 5 pound weight loss or that Resident #2's physician had been notified of the 5 pound weight loss. The medical record lacked documentation interventions had been put in place to decrease/slow down or stop the resident's weight loss in March 2012. The Nutritional Risk Review dated 3/5/12, indicated Resident #2 had been admitted on [DATE], her height was 5' 3 inches and weight was 100 pounds. The resident's ideal weight range was 103-127 pounds. The documentation indicated Resident #2 's [MEDICATION NAME] results on 2/21/12 were low at 2.7. The Nutritional Assessment form dated 3/5/12, documented Resident #2 was a moderate risk for [MEDICAL CONDITION]/weight loss. The summary note documented current weight at 100 pounds. The resident's Body Mass Index (BMI) was at 17.7 which indicated the resident was underweight. The low [MEDICATION NAME] indicated poor visceral protein stores. Will recommend the addition of Special Nutrition Program (SNP) to the diet order to help maintain her weight and prevent skin breakdown. The resident's oral intake was greater than 80% for most meals. The Dietary Recommendations dated 3/6/12, documented the Registered Dietician's (RD) nutritional concern for Resident #2 was decreased [MEDICATION NAME]. The recommendations were to change the diet order to regular diet with SNP and for a pre-[MEDICATION NAME] level. The dietary recommendation lacked documentation the RD had been concerned regarding the resident's 5 pound weight loss from 2/18/12 to 3/4/12. On 4/18/12 at 1:00 PM, a Licensed Nurse (LN) stated a new resident was weighed upon admission and then monthly by the Certified Nursing Assistants (CNA). The LN stated weekly weights could be initiated by the nursing staff as a nursing intervention. The LN verbalized Resident #2 was not placed on weekly weights after the weight loss. The LN verbalized when there was a weight loss it was the nurse's responsibility to notify the resident's physician and the RD. During the interview on 4/18/12, the LN stated after the monthly weighs were completed they were reviewed by the nurse for weight changes. If a significant change was noted the RD would be contacted to see if she had any dietary recommendations. The nurse would contact the resident's physician with the recommendations. The LN verbalized after the RD visit, the dietary recommendations were sent to the physician. Once the recommendations were signed by the physician, either the physician or the nurse would write the orders for the approved dietary recommendations. The LN stated the dietary recommendations dated 3/6/12, were signed by the physician. The LN verbalized she did not know why the recommendations dated 3/6/12, were not written in the medical record as a physician's orders [REDACTED]. On 4/18/12 at 1:00 PM, the LN was not able to locate documentation Resident #2 had been re-weighed after the 5 pound weight loss was documented on the weight chart. The LN was not able to locate documentation the resident's physician or the RD had been notified regarding the 5 pound weight loss. The LN verbalized there was no documentation Resident #2 had been seen in April by the RD to address the continued weight loss from 95.0 pounds to 91.8 pounds. On 4/19/12 at 9:20 AM, the RD stated new admits were weighed upon admission and monthly on the first Sunday of the month. The RD stated on the Monday/Tuesday after the monthly weights were done she would come into the facility and review the resident weights and assess for weight loss and needed. The RD verbalized she had not been notified of Resident #2's weight loss of 5 pounds until she arrived at the facility in March 2012. The RD stated the weight loss from 100 pounds to 95 pounds was a 5 pound or 5% weight loss in 2 weeks. The RD verbalized she did not think Resident #2 had been re-weighed after the 5 pound weight loss. The RD stated it was the nurses responsibility to contact the physician with a weight loss. The RD was asked if she had been aware of Resident #2's weight loss on 3/5/12, when the Dietary Note was written. The RD verbalized "I must not have been because I used the weight I had in front of me" which was 100 pounds. The RD verbalized she usually intervened when a resident had a 3-4% weight loss, she did not want the weight loss to reach 5%. The RD verbalized if she had been aware of Resident #2's weight loss when the dietary recommendations were made it would have been documented and addressed as a concern. The RD stated the weight loss was missed and should have been addressed. "I don' t know what happened." The RD verbalized she had not been aware the dietary recommendations dated 3/6/12, had not been completed until she the interview with the Bureau of Health Care Quality and Compliance on 4/19/12. The RD stated Resident #2 had not been on daily or weekly weights while in the facility. The RD stated the resident was not put on weekly weights after the 5 pound weight loss. The RD verbalized the resident should have been placed on weekly weight after the weight loss. The RD verbalized the nurses were able to place a resident on weekly weights but that they usually waited for direction from the RD. The RD indicated if the dietary recommendations were not accepted by the physician the nurse's would contact her. If she did not hear back from the staff she would assume they had been accepted. The RD was asked why the new admission had not been weighted weekly times four per the facility's policy. The RD stated "I guess it was not enforced like we should." The RD stated on the first Sunday in April Resident #2's weight was 91.8. This was a weight loss of 9 pounds or 8.2 %. The RD was asked what interventions had been put into place after Resident #2's weight loss in April. The RD stated she had not documented interventions or made dietary recommendations. The RD stated possible interventions could include snacks, high protein shakes or Ensure. These interventions could have decreased the weight loss, but they were not tried. The RD stated she had attended the care plan conference for Resident #2. The RD stated the care plans were developed by the Minimum Data Set (MDS) Coordinator. The RD verbalized she was not sure where the documented interventions on the care plan came from, because they did not match the physician's orders [REDACTED].#2's care plan did not. The RD confirmed Resident #2 had a weight loss of 8.2 % with no interventions done. The care plan indicated Resident #2 was at Nutrition Risk related to eating alone, low weight and with a history of eating small amounts. The high protein diet was current as of 4/10/12. The documented interventions included: provide supplement and /or snack, high protein diet as per the physician's orders [REDACTED]. The documented goal was Resident #2 will maintain/improve her nutritional status as evidenced by: weight maintenance or gain and encourage the resident to consume 75% of meals.