Every finding on record at Twin Willows Nursing Center

Based on interview and record review the facility failed to provide the consulting services of a Registered Dietician. This failure has the potential to affect all 22 residents that reside at the facility.Findings include:On 04/01/26 at 2:54 PM, V19 (previous Registered Dietician) stated, she is not familiar with any of the residents at the facility. V19 stated, she has not physically been at the facility since October 2023.On 04/01/26 at 3:10 PM, V8 (Dietary Manager) stated they currently do not have a RD (Registered Dietician), they have not had one since the end of 2023. V8 stated she does not do BMIs (Body Mass Index), goal weights, the amount of calories needed, or estimated calories given for the residents. On 04/01/26 at 3:17 PM, V2 (Director of Nursing) stated they do not currently have a RD, they have not had one for a little while. V2 stated, V19 was their last RD, and it could have been around October 2023 since she has been the facility's RD. The facility document titled, Facility Assessment Tool dated 02/10/26 documents: Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies staff type: food and nutrition services (Dietary Manager, support staff, Registered Dietician).The Long-Term Care Facility Application for Medicare and Medicaid form dated 3/30/26 documents there are 22 residents living in the facility.

Based on interview, observation, and record review the facility failed to maintain a safe, clean, sanitary environment in the common foyer area of the facility. This failure has the potential to affect all 22 residents residing at the facility.Findings include:On 03/30/26 at 8:50 AM the ceiling vent in the entrance foyer had a large accumulation of a black substance covering approximately 90 % of the vent with a concentration around the edges and the center of the vent.On 03/31/26 at 8:45 AM the ceiling vent in the entrance foyer had a large accumulation of a black substance covering approximately 90 % of the vent with a concentration around the edges and the center of the vent.On 04/01/26 at 8:30 AM the ceiling vent in the entrance foyer had a large accumulation of a black substance covering approximately 90 % of the vent with a concentration around the edges and the center of the vent.On 04/02/26 at 3:10 PM V2 (Director of Nursing) stated, the vents in the foyer area should be cleaned, she will get V20 (Maintenance Director) to clean it right away.The undated facility policy titled, Facility Environmental Policy documents: it is the policy of (facility name) to provide housekeeping and maintenance staffing to promote a safe and functional environment.The Long-Term Care Facility Application for Medicare and Medicaid form dated 3/30/26 documents there are 22 residents living in the facility.

Based on interview, observation and record review the facility failed to provide an accessible call light for the shower room on the north hall for 10 (R5, R7, R8, R9, R10, R12, R15, R18, R20, and R22) of 10 residents reviewed for assessable call lights in a sample of 22.Findings include:1.On 03/30/26 at 1:55 PM the shower room on the north hall had a call light but the call light did not have a string to activate it. On 04/02/26 at 9:55 AM the shower room on the north hall had a call light but the call light did not have a string to activate it. On 04/01/26 at 1:19 PM, V12 (Certified Nurse Aide) stated there are shower rooms on the north and the east halls. V12 stated, typically the residents on the north hall would be showered in the shower on the north hall. On 04/02/26 at 3:12 PM, V2 (Director of Nursing) stated the call light in the shower room works the string just broke off. V2 stated, she will have it fixed before she leaves for the day.On 3/30/26 the facility provided a list titled, Wing Group Assignments that documented: R5, R7, R8, R9, R10, R12, R15, R18, R20, and R22 reside on the north hall. The undated facility policy titled, Facility Environmental Policy documents: it is the policy of (facility name) to provide housekeeping and maintenance staffing to promote a safe and functional environment.

Based on interview, observation, and record review the facility failed to serve food in the appropriate texture for 4 (R7, R8, R15, and R22) of 10 residents reviewed for dining in a sample of 22.Findings include:The facility document titled, Patient Literal Orders by Category documents R7, R8, R15, and R22 receive a mechanical soft diet. On 03/31/26 between 11:30 AM and 12:05 PM R7, R8, R15, and R22 received a half a baked potato with the skin still on for their lunch meal. On 03/31/26 at 11:58 AM, R8 was sitting up in her bed in her room. R8 had half a baked potato and a piece of meatloaf on her food tray sitting in front of her. R8 was attempting break off pieces of the baked potato with her fork with her left hand. R8 was able to get a chunk of her baked broke off that was over 1.5 inches in length and put it into her mouth and attempted to chew. R8 then pulled pieces of the potato skin out of her mouth and placed them on the side of her tray. R8 struggled to chew the size of the piece of potato in her mouth. R8 then was able to break off another smaller piece of potato and chewed that piece with no problems. R8 then attempted to stab the piece of meatloaf that was approximately 2 inches by 3 inches in size, she was unable to acquire any of the meatloaf on her fork and gave up and went back to attempting to break pieces of her potato off and eating what she could break off. When R8's tray was picked up no meatloaf was eaten.On 04/01/26 at 2:23 PM V16 (Family) stated, R8 is nonverbal, but will make some facial expressions. R8 cannot use her right side at all and her food is supposed to be cut into manageable size pieces because eating has been challenging for her to eat with her nondominant hand (her left hand) but with the food in pieces sized that she can easily stab with her fork she does ok. V16 stated the facility has assured her that R8's food will be cut up into manageable size pieces for R8 to be able to handle. V16 stated, R8 loves potatoes. On 04/01/26 between 11:30 AM and 12:01 PM R7, R8, R15 and R22 received carrot slices with some of the slices being between 0.5 inches and 1.5 inches in diameter with their lunch meal.On 04/02/26 at 3:17 PM, V8 (Dietary Manager) stated, she does not know if she can find a menu with the baked potato actually on the menu, they have to hand write in in because it is not on the menu and the residents want baked potato on Tuesdays. V8 stated, she cannot access the recipe for the mechanical soft baked potato because they are locked out of the menu program when they lost their Registered Dietician. V8 stated the baked potato for the mechanical soft should not have the [NAME] on them. V8 stated, they substituted the carrot slices for the mechanical soft diet for the wax beans. V8 stated, the recipe states the carrots should be bite size pieces. V8 stated, some of the carrot slices were over 0.5 inches in diameter. On 04/02/26 at 3:40 PM, V8 (Dietary Manager) stated, R8's meatloaf should have been cut into bite size pieces and her potato should have been cut into pieces she could easily get onto her fork and chew.The facility document dated day 19 supper titled, Soft Chopped Carrots documents: 4. chop carrots into bite-size portions prior to serving.The facility document dated 2012 titled, Dental Soft (Mechanical Soft) Diet documents: 6. vegetables are cooked soft, moist and fork tender with no large chucks or pieces, 10. hard crisp fried potatoes and potato skins are excluded. Food guide: allowed: vegetables: all vegetables should be chopped or diced into bite-size pieces (1/2 inch or smaller), peeled, cooked potatoes; not allowed: potato skins.

Based on observation, interview and record review the facility failed to maintain adequate infection control practices including hand hygiene, identification of appropriate isolation, and proper handling of soiled linens for 6 of 6 residents (R2, R5, R7, R9, R18, and R20) reviewed to infection control in the sample of 22.Findings include:1. On 3/30/26 at 10:00 AM there were no signs on R20's door indicating she was on any type of isolation.R20's laboratory results dated [DATE], regarding her urine culture, documents she has a urinary tract infection with the causative bacteria identified as Escherichia coli (E.coli),extended-spectrum beta-lactamase (ESBL), and Proteus mirabilis.R20's Physician Order dated 3/16/2026 documents, Augmentin 875/125 milligram (mg) 1 tab by mouth twice daily for 10 days related to E Coli, ESBL, Proteus miabilis per vagina and urine.On 4/1/2026 at 1:55 PM, V4 (Certified Nursing Assistant/CNA) reported R20 has not been on contact isolation recently. V4 stated she had asked V2, Director of Nursing (DON), why R20 was not on isolation after ESBL was identified on her urine culture. V4 stated she had heard that R20's urine had come back with three different infections and one of them was ESBL. V4 stated she knows ESBL is very contagious. V4 stated V2 informed her that as long as standard precautions were used for R20, contact isolation was not necessary. V4 stated she was concerned because R20's laundry was being mixed with other residents' clothes. 2. On 4/1/2026 at 11:17 AM, V5 (CNA) and V10 (CNA), provided catheter care to R5. During care, V5 and V10 removed their gloves multiple times, when soiled, and donned new gloves without performing hand hygiene.3. On 3/30/2026 at 12:33 PM, V5 was feeding R18, and R2 walked up to R18's table. V5 took a plastic cup from R2 and held R2's straw with her ungloved hand to provide drinks to R2 while R2 was standing. V5 did not perform hand hygiene before drink was provided and she did not perform hand hygiene after giving R2 a drink and before resuming feeding for R18. 4. On 3/30/2026 at 1:11 PM, V4 left R7's room after performing incontinent care, with unbagged soiled linen in gloved hand, and walked down the facility hallway into north hall's shower room and discarded dirty linen in the hamper.5. On 3/30/2026 at 1:21 PM, V4 left R9's room after performing incontinent care, with unbagged soiled linen in gloved hand, and walked down the facility hallway into north hall's shower room and discarded dirty linen in the hamper.On 4/2/26 at 3:30 PM, V2 (Director of Nursing/DON) stated staff should perform hand hygiene any time they are going from one resident to another, when they touch contaminated surfaces and if changing gloves during care. The facility's undated policy, Laundry, documents, Inadequate processing of soiled linen and clothing can lead to infection in residents, and the laundry personnel themselves are at risk of infection if they do not take proper precautions themselves as they work. All soiled linen from all residents should be handled and treated as if it were contaminated with pathogenic microorganisms, including blood borne pathogens. It should be bagged (or placed into leak proof, covered carts) at the location where it was used.The facility's undated policy, Isolation Procedures and Infection Control, documents, Upon being informed of the existence of an infectious case the resident shall be placed in the appropriate type of isolation for the specific type of infection.The facility's undated policy, Feeding and Hydration of Residents, documents, When residents have to be feed by personnel, special attention should be given to preventing cross contamination. The Centers for Disease Control (CDC) in its guidelines for handwashing, states that hands do not have to be washed after handing a patient food. If the hands become contaminated with saliva or there is extensive contact with the resident when feeding him or her, however, the hands should be washed before feeding another resident.

Based on interview, observation and record review the facility failed to provide assistance with eating assistance in a timely manner and failed to ensure that residents who require assistance with showering received a shower for 2 of 4 residents (R2, R7) reviewed for Activities of Daily Living in a sample of 22.Findings include:1. R2's admission record documents an admission date of 02/18/26 with diagnoses including: neurocognitive disorder with Lewy Bodies, anxiety disorder, progressive spinal muscle atrophy, and insomnia. R2's Minimum Data Set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) of 01 indicating severe cognitive impairment. Section GG documents R2's eating performance as independent. This same MDS documents R2 needs partial/moderate assistance from one staff member for showering R2's care plan for 3/9/26 documents a focus area of: potential for excessive weight gain or loss related to Lewy body dementia, progressive atrophy, confusion and hand tremors. Interventions to include: R2 can feed himself, he often requests seconds of foods he likes, attempt to second helping when he requests, monitor meal intake with every meal. R2's care plan does not address showering/bathing R2's Malnutrition Risk assessment dated [DATE] documents in part that R2 feeds self slowly and only part of the meal and his food intake is poor eating less than 25% of most meals. This assessment is signed by V11 (Registered Nurse). On 03/31/26 at 11:39 AM, R2 was observed trying to eat his food, R2's hand was shaking so bad his food was falling off of his fork and he was getting very little food into his mouth, less than 10 percent. On 03/31/26 at 11:54 AM, V4 (Certified Nurse Aide) sat down to assist R2 with his lunch, R2 then ate 100% of his lunch. On 04/01/26 at 12:04 PM R2 was served his lunch. At 12:05 PM R2 attempted to pick up his drink with his right hand and was shaking so badly R2 struggled to pick up his drink and the drink glass kept hitting the table and clicking against the table. R2 then received his lunch of chili, cottage cheese, carrots, and fruit cocktail, with R2's lunch sitting in front of him he attempted to pick up his drink glass several times but his right hand had severe tremors making it difficult for him to lift the glass and be able to drink out of the straw. At 12:27 PM R2 picked up his spoon and attempted to eat some cottage cheese but his hand was shaking so bad most the cottage cheese came off the spoon before he was able to get it to his mouth, by 12:51 PM R2 had only been able to eat approximately three bites of food. At 12:51 PM, V4 (Certified Nurse Aide /CNA) told R2 he should try to use his left hand to eat, it is not shaking as bad, at 12:58 PM V4 sat down and assisted R2 with his lunch and was able to eat 85% of his food by 1:12 PM. On 04/02/26 at 12:01 PM, R2 received his lunch of baked chicken and gravy, mashed potatoes, peas, bread with butter, and cake. At 12:07 PM, R2 picked up the buttered bread and ate it. R2 sat and stared at his food until 12:29 PM when he tried to get a piece of the cake onto his fork which shortly after fell off his fork into the gravy of the chicken. R2 tried to get the cake back onto his fork with the gravy on it and get it into his mouth. R2 then tried to get a second bite of cake onto his fork and attempted to keep it on his fork with his left hand and attempted to get it into his mouth. At 12:33 PM, V14 (CNA) asked R2 if he was doing ok but, did not stop to assist R2. At 12:42 PM R2 still had only been able to get the two bites of cake into his mouth and V9 CNA sat by R2 and assisted him with his lunch and by 12:52 PM R2 had eaten 100 % of his lunch. On 04/02/26 at 12:56 PM, V9 stated R2 has been shaking bad for a bit now. V9 stated, if she sees he is shaking bad she will stop and assist him with his lunch. V9 stated, she has never seen R2 with weighted silverware. On 04/01/26 at 1:19 PM, V12 (CNA) stated she has never heard R2 ask for seconds, V12 stated, she rarely hears R2 say anything. V12 stated, R2's right hand does shake a lot, it does cause him problems eating with silverware. On 04/01/26 at 3:10 PM, V2 (Director of Nursing) stated, she expects the staff to feed R2. On 04/02/26 at 1:06 PM, V2 stated if the staff see a resident has not been able to eat for 30 minutes or maybe less, they should assist the resident with eating. 2. The facility's shower list for the week of February 14-20, 2026, document R2 was scheduled for a shower on Friday 2/20/26 but did not receive a shower any day during that week. The facility's shower list for the week of February 21-27, 2026, document R2 was scheduled for a shower on Friday 2/27/26 but did not receive a shower any day during that week. The facility's shower list for the week of February 28-March 6, 2026, documented R2 was showered on Friday 3/6/36 and had not received a shower since being admitted to this facility on 2/18/26, which was 16 days later. The facility's shower list for the week of March 14-20, 2026, documented R2 received a shower on Friday 3/20/26, but missed his scheduled shower the week of March 21-27, 2026 which was due on Friday 3/27/26 and had not been showered as of today's date of 4/2/26. According to the documentation R2 was not showered between 3/21/26-4/2/26. (12 days total) R2's nurse's notes for February/March 2026 does not address why R2 missed his scheduled showers during that time period. R7's admission Record documented admission date of 10/28/2024. R7's Physician Orders sheet (4/1/26-4/30/25) documents R7's admission diagnoses of alerted mental status, dementia, hypertension, and diabetes mellitus. R7's MDS dated [DATE], documents R7's BIMS of 6 out of 15 total, which indicates R7 has severe cognitive impairment. This same MDS documents R7 needs partial/moderate assistance from one staff member to shower/bathe. The facility's shower list for the week of February 7-13, 2026, documented R7 received a shower on Sunday 2/8/26. The facility's shower list for the week of February 14-20,2026 document R7 did not get her shower, which was scheduled for Sunday 2/15/26. R7's shower sheets documents R7 did not receive a shower until her next scheduled shower day of Sunday 2/22/26. According to the shower list R7 was scheduled for a shower on Sunday 3/1/26 but was not showered until her next scheduled shower day of Sunday 3/8/26. According to the shower list R7 was not showered/bathed from 2/9/26-2/21/26 a total of 13 days during this period and was not showered/bathed from 2/23/26-3/7/26 a total of 12 days. R7's nurses notes for February or March 2026 does not address why R7 was not showered during her missed scheduled shower during that time period. On 4/2/2026 at 2:00pm, V2 (Director of Nursing) said she has not received any requests to change or alter R2 or R7's shower schedule. V2 said she expected all residents, including R2 and R7 to be bathed according to the shower schedule. V2 said two weeks without a bath is too long and she would address the issue. V2 said she has not been informed of R1 or R7 refusing any scheduled showers. Facility policy (none dated) titled Shower policy, Purpose: To provide each resident with a method to receive proper hygiene. Each wee a shower schedule will be posted with names, dated, and special instructions. CNAs are to shower/bathe each resident per the posted schedule. If a scheduled shower must be changed for days, times, certain personal, etc., notify the DON (Director of Nursing) to request a posted change to meet the resident's wishes/needs. If a scheduled shower cannot be done as posted, notify the charge nurse, who will make different plans to ensure the resident receives showers/baths as needed/requested.

Based on observation, interview, and record review the facility failed to provide a safe, clean, sanitary environment for one (R2) of ten residents reviewed for a safe, clean, sanitary environment in a sample of 22. Findings include:On 03/30/26 at 10:20 AM the bathroom on the east hall had 10 1 inch by 1 inch tiles missing in the floor near the toilet and 20 1 inch by 1 inch tiles missing in another location on the floor. There was also a build up of dirt and debris around pedestal of the toilet. On 04/02/26 at 3:10 PM, V2 (Director of Nursing) stated, R2 is the only resident that uses the bathroom on the east hall. V2 stated she will get V20 (Maintenance Director) to clean and repair it right away.The undated facility policy titled, Facility Environmental Policy documents: it is the policy of (facility name) to provide housekeeping and maintenance staffing to promote a safe and functional environment.

Based on interview, observation and record review the facility failed to provide eating assistance with respect and dignity for 2 (R12, R18) of 3 residents reviewed for dignity in a sample of 22. Findings include:1.R18's admission record documents an admission date of 06/10/21 with diagnoses including: dementia, anemia, major depressive disorder, cataract, gastro-esophageal reflux disease, and age related osteoporosis. R18's Minimum Data Set (MDS) dated [DATE] documents no brief interview of mental status (BIMS) should be conducted due to resident is rarely/never understood. Section GG documents R18's eating performance is dependent, indicating helper does all the effort. On 3/30/2026 at 12:13 PM, V5 Certified Nurses Assistant (CNA) answered her personal cellphone during the lunch meal while she continued to provide bites of food to R18 while talking on her phone. At end of her phone conversation V5 was heard stating, I have to get off here, I'm feeding. The conversation lasted 2 minutes. On 3/30/2026 at 12:43 PM, V5 was feeding R18 a mixture of orange colored pureed food (baked beans) and dark brown colored pureed pudding. R18 was observed making disgruntled faces while eating the bites of mixed food R18 was feeding her. On 04/02/26 at 12:19 PM, V5 was assisting R18 with the lunch meal, from 12:18 PM until 12:25 PM R18 had pureed food from under her nose to down past her mid chin before V5 wiped her mouth. 2. On 4/2/2026 from 12:04 PM to 12:26 PM, V14 CNA was assisting R12 with the noon meal of pureed mashed potatoes, peas, chicken and gravy and lemon cake. R12 had a large amount of pureed food substance under lower lip and across her chin and dripping off chin onto her clothing protector. V14 did not wipe excess food off R12' s face and continued to offer bites of food and drinks to resident who sat with eyes closed during meal. On 4/2/26 at 3:00 PM, V2 Director of Nursing stated she does not have a policy specific to dignity of residents. On 4/2/2025 at 3:30 PM V2 stated staff should not be answering phone calls while providing care, including assisting with eating, but it would be allowed if there was an emergency. On 4/3/2026 at 9:41 AM during phone interview, V2 stated that it is expected that staff who are feeding a resident would tap the spoon on the side of the bowl or plate when going from one food item to another to avoid mixing the food, but she can't guarantee that some food might get slightly mixed with others and they can't use fourteen spoons per tray. V2 stated she would expect staff to clean off a resident's face if they have food on their face during feeding. The facility's document, Residents' Rights, revised 2/07, documents, 1. Your rights to safety and good care: Your facility must provide services to keep your physical and mental health, and sense of satisfaction with yourself, at their highest practical levels.

Based on interview, observation and record review the facility failed to assess, monitor and document meal intakes on resident who is considered underweight for weight gain/loss for 1 of 5 residents (R9) reviewed for weight loss in a sample of 22.Findings include:R9's admission record documents an admission date of 02/12/15 with diagnoses including: Alzheimer's disease, dementia, methicillin resistant staphylococcus aureus infection, essential hypertension, extended spectrum beta lactamase resistance, major depressive disorder, gastro-esophageal reflux disease (GERD), and hypothyroidism.R9's Minimum Data Set, dated [DATE] documents the question; should brief interview for mental status with no marked indicating resident is rarely/never understood. Section GG documents eating status of dependent indicating helper does all of the effort. Section K documents a height of 65 inches and a weight of 102 pounds.R9's care plan last revised 3/3/26 documents a problem area indicating R9 has the potential for excessive weight loss related to short attention span, difficulty staying focused to eat, is fed by staff, sometimes she is so sleepy she can't stay awake to eat, and she has a potential for excessive vomiting related to GERD. Intervention to include: give resident supplements as ordered, alert nurse/dietitian if not consuming on a regular basis and R9 is on a regular pureed diet with fortified foods, she receives super cereal at breakfast, health shakes with all 3 meals, and she receives 8 ounces health shake in the morning and afternoon.R9's Care Plan Conference Summary dated 3/3/26 documents R23 had a March weight of 98 pounds, February 102 pounds and January 103 pounds. This summary documents R23 consumes 50% of meals, is on a regular puree diet, supercereal at breakfast, fortified supplements at meals 10am and 2pm.R9's physician's order sheet documents dietary orders for health shakes at 10:00 AM and 2:00 PM dated 04/23/21, regular diet with a pureed diet dated 09/04/19, super cereal at breakfast related to weight loss dated 09/04/19, health shakes 8 ounces with meals dated 05/02/19 and fortified foods dated 04/14/21. R9's Quarterly Nutritional Re-evaluation documents: diet orders/snacks/supplements: with health supplement at meals, 10:00 AM and 2:45 PM the box dated 08/25/25 documents: regular puree, super cereal at breakfast and fortified, this same line documents the same box dated 11/25/25 and 02/25/26 documents same, the line of height/weight documents: 65 inches and 102 pounds dated 08/25/25, 65 inches 101 pounds dated 11/25/25 and 65 inches and 102 pounds dated 02/25/26. The line titled, Nutrition related Medications with low aspirin, Colace, Bisacodyl, metoprolol, Synthroid, MiraLAX, acidophilus, and Zocor dated 08/25/25 with same written in the columns for 11/25/25 and 02/25/26. The evaluations dated 08/25/25, 11/25/25, and 02/25/26 were all signed by V8 (Dietary Manager). The section that allows for written in comments documents: 08/25/25 - remains on same diet, feeder, weight stable, intakes good, 11/25/25 - remains on same diet, feeder, weight stable, intakes good, and 02/25/26 - remains on same diet, weight stable, intakes good, feeder all signed by V8. The page titled, RD (Registered Dietician) Assessment is blank. The facility document titled, Weight Entry (in Pounds) documents R9's January 2026 weight as 103.0 pounds, February 2026 weight as 102.0 pounds, and on March 16 2026 at 12:48 PM as 98.0 pounds. The Center for Disease Control and prevention's website: https://www.cdc.gov/bmi/adult-calculator documents a weight of 102 pounds at 65 inches tall is a body mass index (BMI) of 17.0 % and a weight of 98.0 pounds is a BMI of 16.3%. This same website documents a BMI under 18.5% is considered underweight. The facility document titled, CNA (Certified Nurse Aide) ADL (activities of daily living) Daily Record dated March 2026 documents: for breakfast: list % taken: there is no documentation for the dates 1, 5, 7, 14, 15, 23, 27, 28, and 29, 100% is documented for the dates 2, 3, 4, 9, and 19, and 125% is documented for the dates 6, 8, 10, 11, 12, 13, 16, 17, 18, 20, 21, 22, 24, 25, 26, 30, 31. The line documenting 10 AM snack: list % taken with no documentation for the dates 1, 5, 7, 9, 14, 15, 19, 23, 27, 28, and 29, 100 % is documented for the dates 2,3,4,6,8,10,11,12,13,16,17,18, 20, 21, 22, 24, 25, 26, 30, 31. The line documenting lunch: list % taken has no documentation for the dates: 1, 5, 7, 14, 15, 23, 27, 28, and 29, 75% is documented for the date 9, 100 % is documented for the dates: 19, 22, and 25, 125% is documented for the dates: 2, 3, 4, 6, 8, 10, 11, 12, 13, 16, 17, 18, 20, 21, 24, 26, 30, and 31. The line for 3:00 Snack: list & taken has no documentation, the line supper: list % taken documents 75% for the 19th, 50 plus for the 31st, and the rest of the line is blank. The line for bedtime snack: list % taken has no documentation. The facility document titled, CNA ADL Daily Record dated February 2026 documents: for breakfast: list % taken: there is no documentation for the dates 1, 3, 4, 5, 10, 14, 15, 20, 23, and 28, 125% is documented for the dates: 2, 6, 7, 8, 9, 11, 12, 13, 16, 17, 18, 19, 21, 22, 24, 25, 26, and 27. The line for 10 AM snack: list % taken: there is no documentation for the dates: 1, 3, 4, 5, 10, 14, 15, 20, 23, and 28, 100 % is documented for the dates: 2, 6, 7, 8, 9, 11, 12, 13, 16, 17, 18, 19, 21, 22, 24, 25, 26, and 27. There is no documentation for the 3:00 PM snack: list & taken. The line for supper: list % taken has 50% documented for the dates 3 and 9, 75% plus is documented for the 26th, and 75% is documented for the 28th, the rest of the dates are blank. On 04/01/26 at 12:01 PM, V4 (CNA) was assisting R9 with her lunch, V4 stopped feeding R9 and R9 started waving her arms, V4 switched sides that she was sitting on, V4 told R9, I'm still here and gave her another bite of food and R9 calmed down and quit waving her arms. R9 then finished all of her food. On 04/01/26 at 12:21 PM V4, stated R9 usually finishes all of her lunch, R9 is a pretty good eater. On 04/02/26 at 1:03 PM, V15 (CNA) stated they are supposed document the amount the residents eat everyday and their eating ability. V15 stated, 125% amount eaten means they ate all their food and their supplement usually. On 04/01/26 at 3:10 PM, V8 (Dietary Manager) stated they currently do not have a RD (Registered Dietician), they have not had one since the end of 2023. V8 stated, she does not do BMIs (Body Mass Index), goal weights, the amount of calories needed, or estimated calories given for the residents. On 04/02/26 at 3:42 PM, V17 (Medical Director) stated he remembers talking about R9's weight but he does not recall it being an in-depth conversation. V17 stated, he doesn't believe R9 has lost weight but she is thin and probably underweight. V17 stated, he does not think medication to stimulate her appetite would be good because her health is not great. V17 stated they have not discussed double portion or extra protein for R9, but that is not a bad idea. V17 stated, an RD consult would be nice. The undated facility policy titled, Weight: Reporting and Recording documents: purpose: 1. to identify weight variance above or below ideal/usual body weight and assess reason for weight variance. 2. establish a measurable goal for resident to fain or lose weight as appropriate to attain ideal/usual body weight range. 3. develop a plan in consultation with the physician and dietician to alter the desired weight gain or loss. The section titled, procedure documents 2. staff nurse: maintain control of procedure by monitoring for: need for dietician consultation and need for quality assurance review. 4. make notes on weight sheet under comments, example (Dr (doctor) notified, see progress notes 1-1-91 or reweighted on different scale.

Based on interview and record review the facility failed to ensure Uniform Practitioner Orders For Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout resident health record for 1 of 2 residents (R19) reviewed for advanced directives in a sample of 22.Findings include:R19's admission Record documented R19 was admitted to this facility on [DATE]. R19's Physician's Order Sheet dated [DATE] documented admitting diagnoses of congestive heart failure, and chronic kidney disease stage 4 among others.R19's MDS (minimum data set) dated [DATE] documented a BIMS (brief interview for mental status) score of 15 out of 15 total, which indicates R19 is cognitively intact.R19's Physician Order Sheet dated [DATE]-[DATE] documented R19 as DNR (do not resuscitate). R19's Physician Order Sheet dated [DATE]-[DATE] documented R19 as DNR. R19's Physician Order Sheet dated [DATE]-[DATE] documented R19 as DNR.R19's Social Service assessment dated [DATE] documents under section titled Advanced Directives documented R19 as a DNR. R19's Advanced Directive/ POLST (practitioners order for life sustaining treatment) form dated [DATE] documented R19 wants CPR attempted but does not want to be intubated or receive dialysis for life sustaining treatment in the event of cardiac arrest.On [DATE] at 3:30pm, R19 said she understood what CPR was. R19 said she wants CPR performed if her heart stopped.On [DATE] at 10:00am, V3 (Registered Nurse) said the resident's advance directives/POLST forms are kept in each resident's chart under the Advanced Directives section in the back of the chart. V3 said the facility does not keep this information anywhere else except the residents' chart and the facility does not keep a special binder or location for this information outside of the resident's chart.On [DATE] at 10:50am, V3 identified R19 as a DNR by looking at R19's Physician's order sheet dated [DATE]-[DATE]. V3 stated as far she knew R19 was a DNR and she would not perform CPR on R19 if R19 had cardiac arrest, V3 found R19's Advanced Directive/POLST form (dated [DATE]) in the back of R19's medical chart. V3 said she was wrong, R19 is supposed to have CPR performed in the event of a cardiac arrest. V3 said someone made a mistake and she would correct the issue.Facility's undated policy titled Advance directives documented in part: Purpose: to ensure all residents are given the right to choose in advance, their end-of-life decisions. Upon admission, the Director of Nursing or designee shall receive resident's directive's concerning end of life decisions.

Based on interview, observation and record review the facility failed to accurately assess a resident eating abilities for 1 of 1 resident (R2) reviewed for accuracy of assessments in a sample of 22.Findings include:R2's admission record documents an admission date of 02/18/26 with diagnoses including: neurocognitive disorder with Lewy Bodies, anxiety disorder, progressive spinal muscle atrophy, and insomnia. R2's Minimum Data Set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) of 01 indicating severe cognitive impairment. Section GG documents R2's eating performance as independent.R2's care plan for 3/9/26 documents a focus area of: potential for excessive weight gain or loss related to Lewy body dementia, progressive atrophy, confusion and hand tremors. Interventions to include: R2 can feed himself, he often requests seconds of foods he likes, attempt to second helping when he requests, monitor meal intake with every meal.R2's Malnutrition Risk assessment dated [DATE] documents in part that R2 feeds self slowly and only part of the meal and his food intake is poor eating less than 25% of most meals. This assessment is signed by V11 (Registered Nurse).R2's CNA (Certified Nurse Aide) ADL (activities of daily living) daily record dated March 2026 under eating documents R2 is a 6, independent with eating on all meals except lunch for the days of 1, 7, 14, 15, 23, 27, 28, 31; for dinner the days of: 4, 7 8, 13, 25, and 28. The meals are left blank. On 03/31/26 at 11:39 AM, R2 was observed trying to eat his food, R2's hand was shaking so bad his food was falling off of his fork and he was getting very little food into his mouth, less than 10 percent. On 03/31/26 at 11:54 AM, V4 (Certified Nurse Aide) sat down to assist R2 with his lunch, R2 then ate 100% of his lunch. On 04/01/26 at 12:04 PM R2 was served his lunch. At 12:05 PM R2 attempted to pick up his drink with his right hand and was shaking so badly R2 struggled to pick up his drink and the drink glass kept hitting the table and clicking against the table. R2 then received his lunch of chili, cottage cheese, carrots, and fruit cocktail, with R2's lunch sitting in front of him he attempted to pick up his drink glass several times but his right hand had severe tremors making it difficult for him to lift the glass and be able to drink out of the straw. At 12:27 PM R2 picked up his spoon and attempted to eat some cottage cheese but his hand was shaking so bad most the cottage cheese came off the spoon before he was able to get it to his mouth, by 12:51 PM R2 had only been able to eat approximately three bites of food. At 12:51 PM, V4 (Certified Nurse Aide /CNA) told R2 he should try to use his left hand to eat, it is not shaking as bad, at 12:58 PM V4 sat down and assisted R2 with his lunch and was able to eat 85% of his food by 1:12 PM.On 04/02/26 at 12:01 PM, R2 received his lunch of baked chicken and gravy, mashed potatoes, peas, bread with butter, and cake. At 12:07 PM, R2 picked up the buttered bread and ate it. R2 sat and stared at his food until 12:29 PM when he tried to get a piece of the cake onto his fork which shortly after fell off his fork into the gravy of the chicken. R2 tried to get the cake back onto his fork with the gravy on it and get it into his mouth. R2 then tried to get a second bite of cake onto his fork and attempted to keep it on his fork with his left hand and attempted to get it into his mouth. At 12:33 PM, V14 (CNA) asked R2 if he was doing ok but, did not stop to assist R2. At 12:42 PM R2 still had only been able to get the two bites of cake into his mouth and V9 CNA sat by R2 and assisted him with his lunch and by 12:52 PM R2 had eaten 100 % of his lunch.On 04/02/26 at 12:56 PM, V9 stated R2 has been shaking bad for a bit now. V9 stated, if she sees he is shaking bad she will stop and assist him with his lunch. V9 stated, she has never seen R2 with weighted silverware.On 04/01/26 at 1:19 PM, V12 (CNA) stated she has never heard R2 ask for seconds, V12 stated, she rarely hears R2 say anything. V12 stated, R2's right hand does shake a lot, it does cause him problems eating with silverware.On 04/01/26 at 3:10 PM, V2 (Director of Nursing) stated, she expects the staff to feed R2.On 04/02/26 at 1:02 PM, V15 CNA stated R2's right hand shakes, sometimes it will shake worse than other times. V15 stated, she feels it has been about the same since he has been at the facility. V15 stated, he is better with finger foods so he will eat the bread with butter probably first and he is pretty good if you hand him a peanut butter and jelly sandwich. V15 stated, with today's lunch she would think R2 would have been documented for eating assistance as a two, because he was slightly helping, not a six because he only ate the bread by himself. V15 stated, she has not seen R2 ever attempt to eat with weighted silverware.On 04/01/26 at 3:10 PM, V8 (Dietary Manager) stated, she does not assess residents, she does not do BMIs (Body Mass Index), estimated calories, or goal weights for any of the residents. V8 stated, they do not currently have a Registered Dietician and have not since approximately October 2023. V8 stated, she believes R2 should have been assessed for weighted silverware.On 04/01/26 at 3:17 PM, V10 (Medical Records/MDS Coordinator) stated she puts the MDS together, she gets the eating information from the CNA books, meaning how much assistance they have had to give him.On 04/02/26 at 3:42 PM, V17 (Medical Director) stated, he is familiar with R2. V17 stated, he doesn't remember having an in-depth conversation about R2's nutrition or eating assistance. V17 stated, R2's hand does shake. V17 stated, some intervention for R2 would be reasonable and weighted silverware could be beneficial for R2.On 04/02/26 at 3:54 PM, V2 (Director of Nursing) stated, she does not know if she has a policy for assessment.On 04/03/26 at 10:00 AM, V2 stated, she assessed R2 when he came to the facility.

Based on observation, interview and record review, the facility failed to supervise residents who are at risk of choking during meals for 1 of 1 resident (R23) reviewed for supervision in the sample of 22. Findings include:R23's admission Records documents R23 was admitted on [DATE] with diagnoses to include: muscle wasting and atrophy, gastro-esophageal reflux disease, muscle weakness, need for assistance with personal care.R23's Minimum Data Set (MDS) dated [DATE] documents R23 is severely cognitively impaired and she requires partial to moderate assist with eating.R23's care plan dated 1/14/2026 documents, Potential for nutritional problem related to: she is unsatisfied with the idea of gaining weight, Lasix therapy, and choking hazard. The interventions for this care plan include, Staff supervision with all meals related to choking hazard. Monitor for any signs or symptoms of aspiration, or dysphagia: choking, fever coughing.On 3/30/26 from 12:54 PM to 1:11 PM R23 was observed feeding herself chicken strips, baked beans, potato salad, and pudding during the lunch meal. There were no staff present in the dining room during that time frame to supervise residents who were still eating their meal.On 4/2/2026 from 12:42 PM to 12:46 PM R23 was being assisted with eating by V15 Certified Nursing Assistant (CNA) during lunch noon meal. R23 began coughing while eating her food and V15 asked R23 if she was okay. V14, another CNA, also asked R23 if she was alright. R23 continued to cough, then nodded her head that she was alright, and V15 gave R23 a drink of fluid. V15 told V14 that R23 started choking on the last bite she had fed her. After giving her a drink, V15 asked R23, Do you feel better? and R23 nodded yes. R23 continued to cough on and off for several more minutes while continuing to eat. On 4/2/26 at 12:58 PM, V15 stated she has worked for the facility for about a year and this was the first time R23 had a coughing episode while she was being fed.On 4/2/26 at 3:30 PM V2, Director of Nursing (DON) stated there should always be a staff member in the dining room any time there are residents in there eating their meal.On 4/2/26 at 3:45 PM V5, CNA stated the reason R23 is assisted with feeding is because R23 will stop eating and they encourage her to eat more. V5 stated she has never witnessed R23 choke or have a coughing fit while eating.On 4/3/26 at 9:41 AM, during a phone interview, V2 stated she is not sure if the facility has a policy regarding staff being present in the dining room while residents are eating. She stated she will check.The facility's policy, Dining policy does not address supervision by qualified staff during mealtimes for resident safety.

Based on interview, observation and record review the facility failed prevent cross contamination of drinking glasses during meal service. This failure has the potential to affect all 24 residents residing at the facility. Findings include: On 01/13/24 at 11:43 AM, V4 (Certified Nurse Aide/CNA) delivered drinks to the residents in the dining room by the rim of the glass, where the residents drink from, after touching the kitchen door, the drink cart handle, her jeans, and the handles of several wheelchairs without any hand hygiene performed. On 01/13/24 at 11:40 AM, V4 delivered the drink cart to the hall with the drinks in a tote with ice in the bottom and no lids or covering over the drinks. On 01/14/24 at 11:47 AM, V4 delivered drinks to the residents in the dining room by the rim of the glass, where the residents drink from, after touching the drink cart handle, her jeans, and the handles of several wheelchairs without any hand hygiene performed. On 01/14/24 at 11:45 AM, V11 (CNA) was serving uncovered drinks from the hall cart, by the rim after touching the handle of the drink cart and resident's doors. On 01/15/24 at 11:37 AM, V11 delivered drinks to the residents in the dining room by the rim of the glass, where the residents drink from, after touching the drink cart handle, her jeans, and the handles of several wheelchairs without any hand hygiene performed. On 01/15/24 at 1:35 PM, V17 (Dietary) stated drinks should not be delivered by the rims of the glass where the residents would drink from. V17 stated, she was plating food this week, so she is unsure about the hall drinks, but usually they are covered, she does not know why they were not covered, they should have been covered. On 01/16/24 at 10:50AM, V15 (Dietary Manager) stated drinks should not be transferred by the rims of the glass and the hall drinks need to be covered, She will have an in-service with the CNA's about dietary service. The Long-Term Care Facility Application for Medicare and Medicaid form 671 dated 1/14/25 documents there are 24 residents living in the facility.

Based on observation, interview, and record review the facility failed to provide a safe, sanitary, and clean home-like environment for the residents. This has the potential to affect all 24 residents residing at the facility. Findings including: On 01/13/24 at 12:53 PM, the shower room on the 200 hall had an accumulation of dirt and mildew along the edges between the floor and the wall in the caulk of all three walls of the shower stall. In this same room there is was accumulation of dirt on the floor in between the 1 inch by 1 inch tiles. There is an accumulation of dirt and debris along the edge of the bottom of the toilet where the toilet meets the floor. There was an approximate 2 millimeter black ring inside the toilet bowl. There was a large linen barrel and trash can blocking access to the hand washing sink. On 01/13/24 at 12:57 PM, in shower room on the 400 hall there was an accumulation of a black substance between the floor and wall on the left side of the shower stall and at the ridge between the shower stall and the bathroom floor. There are three 4 inch by 4 inch tiles missing along the wall of the shower stall. On 01/13/24 at 12:59 PM, in the hall bathroom on the 400 hall the toilet had an accumulation of dirt and debris along the base of the toilet in the caulk and areas where the caulk is missing. The bowl of the toilet had an approximate 3 millimeter black ring inside of it. Inside the shower stall there was a section of tiles missing of 3 inches by 3 inches and another section of tiles missing of 5 inches by 4 inches. There was an accumulation of items, a large linen barrel on a hand cart, a large trash can, and a wheelchair with leg rests laying in the seat of the chair blocking access to the handwashing sink. On 01/14/24 at 1:26 PM, R7's handwashing sink filled to the point of almost overflowing onto the floor in approximately 36 seconds and the sink drained in 8 minutes and 52 seconds. On 01/14/24 at 1:31 PM, R7 stated the sink takes a long time to drain. R7 stated, (while surveyor was timing the sink draining) you might not want to wait that long, it takes a long time (for the sink to drain). R7 stated, the sink has been that way for a while she has told them about it. R7 is alert and oriented to person, place, and time. On 01/15/24 at 12:42 PM, R6's room had an accumulation of spider webs around the heating unit in the area between the unit and the wall and along the floor. On 01/15/24 at 12:45 PM, the shower room on the 200 hall had an accumulation of dirt and mildew along the edges between the floor and the wall in the caulk of all three walls of the shower stall. In this same room there was an accumulation of dirt on the floor in between the 1 inch by 1 inch tiles. There was an accumulation of dirt and debris along the edge of the bottom of the toilet where the toilet meets the floor. There was a large linen barrel and trash can blocking access to the hand washing sink. On 01/15/24 at 12:49 PM, in the hall bathroom on the 400 hall the toilet had an accumulation of dirt and debris along the base of the toilet in the caulk and areas where the caulk is missing. Inside the shower stall there was a section of tiles missing of 3 inches by 3 inches and another section of tiles missing of 5 inches by 4 inches. There was an accumulation of items, a large linen barrel on a hand cart and a large trash can, and wheelchair with leg rests laying in the seat of the chair blocking access to the handwashing sink. On 01/14/25 at 3:00 PM, V13 (Housekeeping) stated the shower rooms on the 200 and the 400 halls are the only shower rooms. All the residents use those shower rooms. The residents on the 400 hall do not have toilets in their rooms so they have to use the ones on the hall but other residents will use the hall bathrooms sometimes also. On 01/16/25 at 2:20 PM, V13 (Housekeeping) stated the shower rooms always look like they have dirt and grime on the floors. She stated she doesn't clean the bathrooms that the other housekeeper does. She said they do consult with her if they can't get something clean. She said they do try to clean the floors, but they always look bad. She said the toilet always has the ring in it. She said they try to get rid of the ring in the toilet they have even tried some comet and that seemed to help. She said the bathrooms probably looks bad in the morning they don't usually clean them until later in the day. She said they have a lot of guys that go in the bathroom and throw stuff around and pee all over the floors all the time. She said that they don't have a housekeeper in the evening only the two on day shift. On 01/15/24 at 2:55 PM, V2 (Director of Nursing) stated, she does not know if they have an environmental cleaning policy, she will have to look if she can find one. The Long-Term Care Facility Application for Medicare and Medicaid form 671 dated 1/14/25 documents there are 24 residents living in the facility.

Based on observation, interview and record review, the facility failed to ensure call lights were within reach for 6 of 7 residents (R1, R5, R11, R19, R21, R24) reviewed for call lights on the sample list of 23. Finding include: 1. R19's Admission Record documents diagnoses including in part dementia and an admitted [DATE]. R19's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 7, indicating R19 has severe cognitive impairment. R19's MDS dated [DATE] documents R21 has had falls with injury, including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains or any fall related injury that causes the resident to complain of pain since admission/entry or reentry or the prior assessment. R19's Care Plan with review date of 12/27/24 documents a problem area of potential for injury related to falls related to decreased strength. Activities of daily living function decline, cognitive loss, history of falls, intermittent vertigo. R19 does ambulate as desired in room to the bathroom. R19 will often ambulate out in hallway pushing her wheelchair. Interventions for this problem include in part: have call light within reach and encourage R19 to use it for assistance as needed. On 1/13/25 at 9:00 AM, R19 stated no one came to help her out of the bathroom this morning and she had to walk herself back to her chair and her wheelchair was in her way. Call light was in the floor behind the recliner out of reach. R19 stated there isn't a call light, so I guess I will have to crawl across the floor to the bathroom next time. On 1/14/25 at 8:50 AM, R19 was in bed. One call light was in floor behind the recliner and one call light was wrapped around wall light, both call lights were not in reach. 2. R5's Admission Record documents diagnoses including in part dementia and was admitted on [DATE]. R5's MDS dated [DATE] documents a BIMS score of 9, indicating R5 has moderate cognitive impairment. MDS dated [DATE] documents R5 has had falls with injury since admission/entry or reentry or the prior assessment. R5's Care Plan with a review date of 12/23/1024 documented a problem area, Potential for injury related to falls related to decreased strength and periods of confusion. She was admitted from home with a history of dementia, edema (swelling) bilateral extremities, restless leg syndrome, and neuropathy. She ambulates up without assistance with wheeled walker. Sometimes she propels walker backwards and needs reminder to turn walker around. Sometimes, she becomes overly tired with ambulation and needs reminder to sit and rest. She is on Lasix (water pill) therapy. Interventions for this problem include in part: have call light within reach and encourage her to use it for assistance as needed and assist her to the bathroom, chair, etc as needed. On 1/14/25 at 8:57 AM, observed R5 in chair in room, one call light was under the covers on the bed out of reach and the other call light is wrapped around a wall light out of reach. On 1/14/25 at 10:17 AM, observed R5 in chair in room, one call light was under the covers on the bed out of reach and the other call light is wrapped around a wall light out of reach. 3. R21's Admission Record documents an admitted [DATE] and diagnoses including in part dementia, major depressive disorder and Alzheimer's disease. R21's MDS dated [DATE] documents a BIMS score of 4 which indicates Severe cognitive impairment. MDS dated [DATE] documents R21 has had falls with no injury and with injury, including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains or any fall related injury that causes the resident to complain of pain since admission/entry or reentry or the prior assessment. R21's Care Plan with review date of 12/27/24 documents a problem area, potential for injury related to falls related to history of falls, slightly unsteady gait, activities of daily living function decline, cognitive loss, frequent ambulation tires him out. He ambulates ad lib about facility via wheelchair. He will transfer self from wheelchair to chair and back again without locking wheels. Resident and POA direct for resident to be allowed to be ad lib (up as desired) freely. Interventions for this problem include in part: have call light within reach and encourage him to use it for assistance as needed. On 1/13/25 at 1:15 PM, observed R21 in wheelchair in room and call light in floor behind recliner, not in reach. On 1/13/25 at 2:20 PM, observed R21 in wheelchair in room and call light in floor behind recliner, not in reach. On 1/14/25 at 8:59 AM, observed R21 in recliner in room and call light was in floor behind recliner, not in reach. 41610 4. R24's Admission Record documents an admitted [DATE] with diagnoses including: Parkinsonism, anemia, Alzheimer's disease, and cerebral infarction. On 01/13/25 at 9:50 AM, R24's call light was laying on the middle of her bed, approximately 3 feet from her reach. R24 was in her reclined back wheelchair. On 01/13/25 at 11:40 AM, R24's call light was laying on the middle of her bed, approximately 3 feet from her reach. R24 was in her reclined back wheelchair. On 01/13/24 at 1:21 PM, R24 was heard yelling help two times at 1:24 PM when surveyor looked in R24's room to check on R24, V6 (Certified Nurse Aide) came out of a different resident's room and looked down the hall and seen surveyor and asked, did I hear someone yell help ? This surveyor stated, yes and V6 came down and checked on R24. R14 was in R24's room with his wheelchair right next to her reclined wheelchair. R24 stated, I want him out of my room. V6 asked R24, why did you not use your call light? R24 responded, Because I can not reach it. V6 stated, let me get him out of your room and get this call light in your reach. 5. R11's Admission Record documents an admitted [DATE] with diagnosis including Parkinson's disease. On 01/13/24 at 9:53 AM, R11 was in her recliner, her call light was on the floor over by her bed, not within R11's reach. On 01/13/24 at 2:29 PM, R11 was in her recliner with no call light within her reach. 48356 6. R1's admission record dated 03/27/23 documents an admitted [DATE] with diagnoses in part of anxiety, chronic obstructive pulmonary disease, low back pain and muscle weakness. R1's Minimum Data Set, dated dated dated [DATE] documents in Section C a Brief Interview of Mental Status (BIMS) score of 15 which indicates cognitively intact. Section GG documents independent with toileting. R1 uses a wheelchair and is independent with wheeling self. Walking was not attempted due to medical condition or safety concerns. R1'S Care Plan dated 12/13/24 documents a Problem of Potential for injury r/t (related to) decreased strength, severe kyphosis, and diabetes. Interventions for this problem include in part- have call light within reach and encourage R1 (her) to use it as needed and R1 (she) needs prompt response to all request for assistance. On 01/14/25 at 9:10AM, R1 was sitting in her recliner. R1 had no call light within reach of her. R1's call light was observed on the floor next to her bed. R1's call light was observed 5 feet away (measured with tape measure) from her on the floor. On 01/14/25 at 9:12AM, R1 stated she could see her call light on the floor. R1 said if she needed to use the call light, she might be able to slide down out of her recliner or maybe crawl on to the floor and get the call light. R1 said that she thinks if she needed to get to her call light it might be challenging but she thought that she might be able to reach it if she tried. On 01/15/25 at 2:52PM, V2 (Director of Nursing) stated that every resident in the facility should have a call light next to them when they are in their room. V2 said some residents can't use the call light but that they should still have the call light next to them at all times when in the room in case they need to call for help. V2 stated that R1 is able to use her call light. On 01/16/25 at 10:43AM, V6 (Certified Nurse Assistant/CNA) stated that all residents should always have their call light next to them. V6 said that not all residents can use them, but the call light should be by them at all times when in their room. V6 stated that R1 can use her call light. V6 said that R1 is independent when in her wheelchair but needs help sometimes getting in her chair and she does not walk. On 01/16/25 at 2:52PM, V10 (CNA) stated that all residents should have a call light next to them at all times when in their room in case they need something. V10 said if a resident cannot use their call light, then they should have frequent checks. A Call Lights policy undated documents, call lights are to be available to all residents when in their rooms.

Based on interview, observation and record review the facility failed to promote dignity for 1 of 4 (R17) reviewed for dignity in a sample of 23. Findings included: 1. R17's Admission Record dated 3/8/2022 documents an admitted [DATE] with diagnoses in part of unspecified dementia, dysphagia oral phase, and weakness. R17's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) that interview could not be completed due to R17 is rarely or never understood. Staff interview for mental status documents short- and long-term memory problems. This indicates R17 has severally impaired cognition. Section GG documents under eating that R17 requires substantial to maximal assistance with eating. R17' Care Plan dated 12/20/24 documents under problem: Potential for significant weight loss r/t (related to) GERD (Gastroesophageal Reflux), peptic ulcer, poor appetite, weakness, slow eater, dyspnea. R17 is resistant at times to allow staff assist with meals. R17 tends to take food and smear it on the table. R17 likes milk. Intervention document in part CNA (Certified Nurse Assistant) are to attempt to assist R17 with meals. If R17 does not 50% of meal, a second person is to attempt to assist resident to eat, CNA is to show assigned nurse the tray for verification of intake, and/or potential ideas to increase meal intake, assigned nurse should then attempt to assist R17 to eat, and spoon in each bowl. On 01/13/25 at 11:58AM, R17 was served a tray. The tray was placed in front of R17 with individual bowls and one spoon in a bowl. R17 was then observed placing her fingers in all the bowls and trying to eat the food off her fingers. R17 did try to grab the spoon that was in the bowl, but the spoon flipped out of the bowl on to R17's lap. On 01/13/25 at 12:05PM, an unknown staff member sat down at R17's table and began to assist another resident that was sitting at the table. R17 continued to try to eat with her fingers sticking her hands and fingers in all the bowls and licking the food off of her hands. On 01/13/25 at 12:10PM, V11 (Certified Nurse Assistant) sat down next to R17 to assist her with eating. V11 wiped off R17's hands and then went to the kitchen and got several plastic spoons and placed them in each of R17's bowls. On 01/13/25 at 12:30PM, observed R17's tray she consumed a 100% of her meal with assistance. On 01/15/25 at 2:52PM, V2 (Director of Nursing) stated that R17 is dependent with eating. V2 said R17's tray should not have been placed in front of her or served to her until someone was available to assist R17 with eating. V2 said that R17's tray should not have been placed in front of her so that she could not put her fingers in her food. On 01/16/25 at 10:43AM, V6 (Certified Nurse Assistant/CNA) stated R17 needs assistance with eating. V6 stated R17's food should never be placed in front of her without someone being there to assist her. 41610

Based on interview, and record review the facility failed investigate a bruise of unknown origin for 1 (R13) of 1 resident reviewed for bruises of unknown origin in a sample of 23. Findings include: R13's Admission Record documents an admitted [DATE] with a diagnosis including: progressive supranuclear ophthalmoplegia (Steele-[NAME]-[NAME]). R13's Minimum Data Set, dated dated dated [DATE] documents a brief interview of mental status (BIMS) score of 2 indicating severely cognitively impaired. R13's nurse's note dated 11/10/24 at 10:00 AM documents: dark purple bruise observed on Rt (right) buttocks (5.5 cm (centimeters) - length, 4.5 cm - width) No open areas. Bruise of unknown origin. Resident denies having any pain or discomfort. Resident does not know how bruise was obtained. POA (power of attorney) aware and the doctor notified with no new orders. No edema to the bruise. On 01/15/24 at 1:22 PM, R13 stated she does not remember what happened when she had the bruise on her bottom. On 01/16/24 at 1:05 PM, V2 (Director of Nursing) stated, she does not have any further information on the injury of unknown origin other than the nurse note. She does remember it being mentioned in a meeting but there is no investigation or report for it. They probably should have. The undated facility policy titled, Abuse Investigations documents: All reports of resident abuse, neglect and injuries of an unknown source shall be promptly and thoroughly investigated by facility management. 1. should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the administrator, or his/her designee, will appoint a member of management to investigate the alleged incident.

Based on interview, observation and record review the facility failed to provide necessary services that are consistent with professional standards to prevent the worsening of pressure ulcers for 1 of 2 residents (R4) reviewed for pressure ulcers in a sample of 23. Findings include: R4's admission record dated 03/01/2022 has an admitted [DATE] with diagnoses in part of Type 2 diabetes mellitus, morbid obesity, venous insufficiency, muscle weakness and need for assistance with personal care. R4's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R4 is cognitively intact. Section M documents this resident at risk of developing pressure ulcers/injuries answers as yes. Does this resident have one or more unhealed pressure ulcers/injuries answers as no. R4's Care Plan last revised 11/18/24 documents in part a problem of R4 currently has excoriation and darkened areas on his buttocks. R4 is totally incontinent of bowel and bladder. R4 is resistive to lying on his side as a preventative. Interventions include in part 10/20/24 zinc oxide to Lt (Left) hip TID (three times a day) and PRN (as needed) t/h (till healed). R4's Physician's order dated 01/01/25-01/31/25 documents under treatments start date 10/20/24 zinc oxide may apply to area every shift U/H (until healed) L (left) hip. Gold Bond (no start date given) original powder ES (every shift) and PRN (as needed) r/t (related to) MASD (Moisture Associated Skin Damage) prevention apply to buttocks/ABD (Abdomen) folds /peri (perineal) area. R4's Skin Progress notes documents on 11/25/24 Left hip stage II with a diameter 0.5cm (centimeter) x 0.5cm depth of 0.1cm no drainage no odor progress left hip clean edge and center, 12/02/24 left hip no stage listed a diameter of 0.5cm 0.5cm with a depth of 0.1cm no drainage no odor progress Lt hip pink edge and center, 12/23/24 left hip no stage with a diameter 0.5cm x 0.5cm with a depth of 0.1cm no drainage no odor Lt hip reducing pink edge and center, 12/30/24 left hip no stage with a diameter 0.5cm x 0.1cm with a depth of 0.1cm no drainage no odor progress Lt. hip reducing pink edge and center 01/06/25 Left Hip no stage diameter 0.5cm x 0.1cm with a depth of 0.1cm no drainage no odor progress Lt. hip same pink edge and center. No further notes. R4's treatment record for the month of January documents start date of 10/20/24 zinc oxide- may apply to area every shift U/H L hip with no certain time documented under hours only a schedule of PRN. No signature on treatment record documenting that the treatment had been administered at any time during the month of January for this left help area. On 01/14/25 at 2:00PM, V12 (Registered Nurse) went to perform treatment to R4's buttocks and left hip. V12 stated that she wasn't going to do the treatment to R4 buttocks and hip because the CNA's (Certified Nurse Assistants) do the treatment. V12 said the CNA's usually put the zinc oxide or moisture barrier on R4's buttock and left hip. V12 stated that the treatment was already done for the day and would not be done again until evening shift. On 01/14/25 at 2:05PM, V2 (Director of Nursing/DON) stated that the CNA's do not apply zinc oxide to R4's buttocks or left hip that he gets medicated powder to his buttocks and the nursing staff is to apply all treatments. V2 then went to talk to V12 and told her that the CNA's do not do the treatment to R4 that the nursing staff is the one to do the treatments. On 01/14/25 at 2:07PM, V12 stated that she would be able to do the gold bond medicated power to R4 now along with R4's left hip treatment. On 01/14/25 at 2:10PM, V12 went into R4's room where staff was already in room trying to assist with turning R4 on his side so that V12 could perform treatment. At that time V12 (CNA) was removing a foam wedge from R4's left side V12 stated she had to be careful because R4 has a sore area on his left hip. Observed area to R4's left hip which appeared to measure approximately 5cm x 2cm with several spots that appeared open and other parts with scabbed areas on it. No redness noted or drainage. No treatment observed to the area. V12 cleansed area to left hip then removed gloves then completed hand hygiene put on new pair of gloves and applied zinc oxide to left hip area. V12 then cleansed buttocks area removed soiled gloves completed hand hygiene then put on new gloves and applied gold bond medicated powder to buttocks. V2 (DON) was in the room during treatment. On 01/15/25 at 2:52PM, V2 stated that R4 should have had a treatment to his left hip done every day. V2 said that she is aware that R4's treatment to his left hip has not been signed off for any day for the month of January. V2 said she knows that the nursing staff has been doing some kind of treatment to R4's left hip, but she doesn't know what treatment. V2 said if staff didn't think the zinc oxide was a good treatment for R4's left hip then staff should have contacted the doctor and told him that the zinc treatment wasn't working and ask if they could change it to gold bond medicated powder or another treatment that doesn't make the left hip wet. The facility policy titled Decubitus Ulcer (Care and Prevention of) undated documents under Purpose to prevent and treat further breakdown of pressure sores. Under Treatment it documents treatment of decubitus ulcers will vary depending on the orders of the attending physician. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for the implementing measures to prevent decubiti.

Based on observation, interview and record review the facility failed to implement active, cognition appropriate and progressive interventions to prevent falls for three (R5, R19, R21) of six residents reviewed for falls in a sample of 23. Findings include: 1. R5's Admission Record documents diagnoses including in part dementia. Admission Record documents R5 was admitted on [DATE]. R5's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 9, indicating R5 has moderate cognitive impairment. MDS dated [DATE] documents R5 is independent with transfers, has no impairment in the upper or lower extremities and uses a walker for mobility and usually understands others during conversation. R5's MDS documents R5 has had falls with injury, including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains or any fall related injury that causes the resident to complain of pain since admission/entry or reentry or the prior assessment. R5's Care Plan with a review date of 12/23/2024 documents a problem area, Potential for injury related to falls related to decreased strength and periods of confusion. She was admitted from home with a history of dementia, edema bilateral extremities, restless leg syndrome, and neuropathy. She ambulates up without assistance with wheeled walker. Sometimes she propels walker backwards and needs reminder to turn walker around. Sometimes, she becomes overly tired with ambulation and needs reminder to sit and rest. She is on Lasix (water pill) therapy. Interventions listed without dates include: Anticipate needs to prevent overreaching and obstructions in pathways, educate resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage to participate in activity that promotes exercise, physical activity for neuro needs, self-care management, propelling own wheelchair, and therapeutic gait, she ambulates ad lib (as desired) with wheeled walker, when she is propelling walker backwards, remind her to turn walker around and put hands on brakes for safety reasons, have call light within reach and encourage her to use it for assistance as needed, assist her to the bathroom, chair, etc as needed, and R5 needs activities that minimize potential for falls while providing diversion and distraction. R5's Incident/Accident Report dated 12/10/2024 at 7:50 PM documents R5 states she was trying to sit on bed and sat on edge and slid down. R5 was found in front of bed 1. Report documents that R5 was confused. R5's Post Fall/Incident assessment dated [DATE] documents the resident was advised to scoot back further on bed when sitting down. Assessment documents there were no new interventions added to care plan the intervention was already covered in the current Care Plan. R5's Care Plan included a handwritten note: 12/10/24 Fall: no abrasions, denied hitting head, Neuro's started. R5's Incident/Accident Report dated 12/17/2024 at 1:20 AM, documents R5 was found on the floor in the hallway. R5 stated she was coming to ask for someone to curl her hair and bumped her head on the wall. Neuro checks as a precaution. No injuries noted. R5's Post Fall/Incident assessment dated [DATE] documents R5 lost balance while walking without her walker. Staff instructed to remind her to use walker when observed without one. Report documents there was a new intervention added to care plan. R5's Care Plan included a handwritten note: 12/16/24 Fall: No bruising, redness, swelling, or abrasions noted, neuros started. 12/18/24 Bruising noted to bilateral lower eyes. R5's Incident/Accident Report dated 12/30/24 at 7:00 PM, documents yelling was heard coming from R5's room. R5 was found in the floor by the door. R5 stated she slipped and hit her head on the wall. Bump to front of head. Denies any other discomfort. Neuro's initiated. Report documents R5 was confused at the time. R5's Post Fall/Incident assessment dated [DATE] documents R5 slipped while using her walker. Thirty-minute visual checks with toileting every 2 hours during waking hours is checked. Assessment documents there were no new interventions added to care plan the intervention was already covered in the current Care Plan. R5's Care Plan with a revision date of 12/23/24, documents no documentation was added pertaining to the 12/30/24 fall. R5's Incident/Accident Report dated 1/9/2025 at 6:00 AM, heard someone yelling and found R5 sitting on the floor by her bed. R5 stated she rolled off her bed and hit her head on the floor. R5 has a bump to top of left side of head and complains of pain to right shoulder. R5's Post Fall Incident assessment dated [DATE] documents resident stated, I must have rolled out of bed and hit my head on the floor. Assessment documents R5 is short and when sits on regular bed her legs are short which causes potential to slip off bed. Resident has a low bed but was trying not sleep in taller bed. Taller bed was removed and her room was rearranged so she could hold onto furniture to increase safety. Thirty-minute visual checks with toileting every 2 hours during waking hours is checked. Report documents there was a new intervention added to care plan. R5's Care Plan included a handwritten note: 1/9/24 Fall: Slid out of bed, high/low bed related to falls and upper siderails on bed related to bed mobility, furniture rearranged for safety, neuro checks and monitor bruising. R5's Incident/Accident Report dated 1/13/2025 at 12:10 AM, documents R5 was found on the floor in room yelling own name. R5 said she fell when she got up from sleeping. R5 was found between bed and dresser on floor. Hematoma (bruise) noted to left side of head and left hand. The report documents R5's bed was in the down position and the resident condition was normal and confused. R5 was taken to local hospital by ambulance. R5's Post Fall/Incident assessment dated [DATE] documents the resident stated, I lost my balance and fell . The assessment documents a question, is it necessary to equip the resident with an alarm device that monitors his/her attempts to rise? The box next it stating device offered along with put in place but resident is not changing her pattern or waiting for help. Thirty-minute visual checks with toileting every 2 hours during waking hours is checked. Report documents there were new interventions added to care plan. R5's Care Plan with a revision date of 12/23/24, documents no new interventions were added after the 1/13/25 fall. R5's (name of local hospital) physician's orders dated 1/13/25 at 3:40 AM documents R5 to be placed in bed with bed alarm. Ambulation with assistance and walker. On 01/13/25 at 12:41 PM, observed R5 in the dining room after lunch scooting to edge of reclining chair then R5 pushed up to standing. Chair was not locked and was rolling backwards and there was no alarm pad in the chair. Surveyor's intervened R5 from falling then called for help and V5 (Certified Nursing Assistant, CNA) came over to assist resident. V5 assisted resident to standing, then V5 CNA walked with resident with wheeled walker to room with no ambulation belt. Resident had large amount of dark purple bruising and swelling to eyes, lips, cheeks, forehead, and left hand. On 01/14/25 at 08:57 AM, observed R5 in chair in room and personal alarm pad was sitting in a different chair not in use. One call light was under covers on bed out of reach and other call light was wrapped around a wall light out of reach. R5 had more swelling to face and lips and bruising had spread further down neck compared to 1/13/25. On 01/14/25 at 10:17 AM, R5 in chair in room and one call light under covers on bed out of reach and other call light was wrapped around a wall light out of reach. Alarm pad was not under R5. On 01/14/25 at 2:03 PM there was a power box with cord laying in the floor of R5's room in front of R5's bed. R5 was sitting in recliner sitting on chair alarm that is not turned on. On 01/14/25 at 2:05 PM, V9 (Certified Nursing Assistant, CNA) stated that was the power box and cord for R5's recliner that does not work and the box and cord are usually pushed under the bed. V9 stated she doesn't know why it is laying in the floor, it is not hooked up to anything. V9 stated she doesn't know if alarm pad was on, she hasn't used chair alarm pads before and has not received training on it. On 01/16/25 at 10:10 AM, V2 (Director of Nursing) stated she didn't know R5 almost fell and wheels should be locked on chairs when they are pushed up to the table. V2 stated they investigate all falls and on the report, there is a question that asks if the care plan has any new interventions and V2 stated most of the time the resident is covered under the current interventions, and she can't think of a new intervention. V2 stated the thirty-minute visual checks with toileting every 2 hours during waking hours are not charted, they should be in the care plan. V2 stated every resident should have a call light in their room and it should be within reach. 2. R21's Admission Record documents an admitted [DATE] and diagnoses including in part dementia, major depressive disorder, and Alzheimer's disease. R21's MDS dated [DATE] documents a BIMS score of 4 which indicates severe cognitive impairment. MDS dated [DATE] documents R21 has had falls with no injury and with injury, including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains or any fall related injury that causes the resident to complain of pain since admission/entry or reentry or the prior assessment. R21's care plan with revised date of 12/27/24 documents a problem area, potential for injury related to falls related to history of falls, slightly unsteady gait, activities of daily living function decline, cognitive loss, frequent ambulation tires him out. He ambulates ad lib about facility via wheelchair. He will transfer self from wheelchair to chair and back again without locking wheels. Resident and POA direct for resident to be allowed to be ad lib freely. Interventions listed without dates include: anticipate and meet resident's needs to prevent overreaching and obstructions in pathways, have call light within reach and encourage him to use it for assistance as needed, R21 ambulates with wheeled walker. If he does not have his walker, remind him to use it and then assist in locating the walker, encourage to participate in activities that promote exercise, physical activity for strengthening and improves mobility, Restorative therapy, ensure that appropriate footwear with non-skid sole is worn when ambulating or mobilizing in wheelchair, encourage him to take time to rest for periods of time throughout the day, R21 needs activities corresponding with his cognitive level that minimize the potential for falls while providing diversion and distraction, assess his likes and dislikes to encourage meal intake to increase strength, and notify the physician if becomes unstable due to complaints of dizziness or light headedness. R21's Incident/Accident Report dated 4/24/24 at 9:30 PM, documents heard walker fall on floor in room. Found walker tipped over and R21 was laying on the floor. Small skin tear to right forearm. Report is not filled out entirely. Date and time of physician notification is missing. There were no new interventions listed. R21's Incident/Accident Report dated 5/15/24 at 5:00 PM, documents R21 was pivoting into chair at table and slipped causing himself to hit head and causing a 2.5 CM skin tear to right index finger. There were no new interventions listed. R21's Incident/Accident Report dated 6/10/24 at 4:45 AM, documents R21 stated he was trying to use the bathroom and slipped and landed on bottom. Skin tear to left arm. Resident reminded to call for help when trying to take self to bathroom. R21's Incident/Accident Report dated 7/12/24 at 4:12 AM, documents R21 walked up to nurse's station with blood on shirt. Gash to right eyebrow. Blood was on floor next to bed. No indication that physician was notified of fall. Report documents there was a new intervention added to R21's care plan. Thirty-minute visual checks with toileting every 2 hours during waking hours is checked. R21's Incident Reports for 7/13/24, 7/16/24 and 8/16/24 document R21 had falls in which the intervention listed was to do thirty-minute visual checks with toileting every 2 hours during waking hours. R21's Incident/Accident Report dated 10/5/24 at 2:00 PM, documents R21 found sitting on floor at Nurse's Station. Intervention listed was to remind resident to call for help to walk if he is tired. R21's Incident/Accent Report dated 12/6/24 at 2:40 PM, documents R21 transferred self from wheelchair to bed and fell . R21 stated he hit his head. Intervention listed as set up 30-minute checks, dementia, makes poor safety choices. On 1/13/25 at 1:15 PM, observed R21 in wheelchair in room and call light in floor behind recliner, not in reach. On 1/13/25 at 2:20 PM, observed R21 in wheelchair in room and call light in floor behind recliner, not in reach. On 1/14/25 at 8:59 AM, observed R21 in recliner in room and call light was in floor behind recliner, not in reach. 3. R19's Admission Record documents diagnoses including in part dementia and an admitted [DATE]. R19's MDS dated [DATE] documents a BIMS of 7, indicating R19 has severe cognitive impairment. R19's MDS dated [DATE] documents R21 has had falls with injury, including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains or any fall related injury that causes the resident to complain of pain since admission/entry or reentry or the prior assessment. R19's Care Plan with review date of 12/27/24 documents a problem area of potential for injury related to falls related to decreased strength. Activities of daily living function decline, cognitive loss, history of falls, intermittent vertigo. R19 does ambulate as desired in room to the bathroom. R19 will often ambulate out in hallway pushing her wheelchair. Interventions listed without dates include: anticipate and meet resident's needs to prevent overreaching and obstructions in pathways, have call light within reach and encourage her to use it for assistance as needed, R19 does propel herself about facility in wheelchair. R19 ambulates as desired in room to bathroom. At times she will ambulate to the hallway pushing her wheelchair from behind, encourage to participate in activities that promote exercise, physical activity for strengthening and improve mobility, ensure that appropriate footwear with non-skid sole is worn when ambulating or mobilizing in wheelchair, encourage her to ask for assistance when needed, R19 needs activities corresponding with her cognitive level that minimize the potential for falls while providing diversion and distraction, assess her likes and dislikes to encourage meal intake to increase strength, notify the physician if becomes unstable due to complaints of dizziness or light headedness. R19's Incident/Accident Report dated 4/7/24 at 12:00 PM, documents R19 fell while transferring self to chair. Small laceration to left side of face and broke glasses. Intervention listed as thirty-minute visual checks with toileting every two hours during waking hours is checked. R19's Incident/Accident Report dated 7/29/24 at 6:15 PM, documents R19 fell on way to bathroom. R19 hit the back of her head on bedside table. 4-centimeter gash present to back of head. Pressure was applied until ambulance arrived. R19 was taken to the local hospital by ambulance. Intervention listed as thirty-minute visual checks with toileting every two hours during waking hours is checked. R19's Incident/Accident Report dated 11/7/24 at 1:15 PM, documents R19 was found on floor and hit head on over bed table. Hematoma to right head. Intervention listed as thirty-minute visual checks with toileting every two hours during waking hours is checked. On 1/13/25 at 9:00 AM, R19 stated no one came to help her out of the bathroom this morning and she had to walk herself back and her chair was in her way. Call light was in the floor behind the recliner out of reach. R19 stated there isn't a call light so I guess I will have to crawl across the floor to the bathroom next time. On 1/14/25 8:50 AM, observed R19 in bed. One call light was in floor behind the recliner and one call light was wrapped around wall light, both call lights were not in reach. A policy titled Fall Prevention that is undated documents After a fall has occurred, a post fall/accident assessment shall be completed and turned into the director of nursing and the care plan will be updated to reflect any changes for fall prevention.

Based on interview, observation and record review the facility failed to follow the facility policy for weight loss for one (R24) resident of 3 residents in a sample of 23. Findings include: R24's Admission Record documents an admitted [DATE] with diagnoses including: Parkinsonism, anemia, Alzheimer's disease, and cerebral infarction. R24's Current Care Plan documents: problem: Potential for excessive weight loss r/t (relating to) forgetting to eat r/t Parkinson's, dementia, Alzheimer's/cognitive loss. R24 tends to be a very pick eater. The intervention section documents: undated interventions of: R24 is on regular diet, likes and dislikes assessment, R24 reports that her favorite foods include meatloaf, potatoes of all kinds, hamburgers, banana pudding, ice cream, she reports that she does not like mixed vegetables, broccoli, spinach or many vegetables of any kind, follow likes/dislikes assessment and honor her other verbal dislikes for food, R24 can feed herself. She does not request alternate foods instead of what is served, if she does not eat what is on her tray, ask if she would like something else instead, offer substitutes for disliked foods, if weight gain persists of 5% in one month, 7.5% in 3 months or 10% in 6 month values, notify the physician, monitor and record meal intake with every meal, monitor for any s/sx (signs or symptoms) of aspiration or dysphagia: choking, fever, coughing, weigh monthly, monitor and evaluate weight, and family supplies nutritional drink as she so choses (by family). R24's Extra Care Plan sheet documents, 10/7/24, Problem #4. Failure to thrive, refusing care, food and drink. Short term goal: to increase food and water intake by 10/30/24. Approach: send to ER (emergency room ) for evaluation. The facility document titled weights and vital summary dated 12/04/24 documents weights on: 08/07/24 of 178 pounds, on 09/09/24 of 175 pounds, on 10/18/24 of 166 pounds, and on 11/08/24 on 158 pounds. The facility document located in R24's chart titled, RD (Registered Dietician) Assessment had not been filled out. R24's Quarterly Nutritional Re-evaluation dated 11/04/24 documents: R24's weight is 172 pounds and documents a pressure ulcer to R24's right lower leg. Resident (R24) on regular diet, refused to eat as first but doing better now, weight stable with intakes poor but getting better. R24 nurse notes dated 10/14/24 documents: (R24) returned from hospital on 10/07/24 - 10/14/24 with sepsis EBSL (extended spectrum beta-lactamase) in urine, and BLE (both lower extremities) cellulites. The facility document dated 07/22/24 titled, Malnutrition Risk Assessment documents: total score: total score above 10 represents high risk, the score totaled is listed as 11. This score is the most current listed on the assessment form. R24's Physician's Order sheet dated 10/01/24 - 10/31/24 documents an order dated 10/23/24 of: referral to (town name) wound center. The facility document dated 10/03/24 titled, Patient Literal Orders by Category category: diet: documents R24's diet as: regular. There are no supplements documented for R24. On 01/13/24 at approximately 10:30 AM, V15 (Dietary Manager) provided the facility document dated 10/03/24 titled, Patient Literal Orders by Category Category. V15 stated, the document is the updated list of resident diets and supplements. On 01/16/24 at 1:10 PM, V15 (Dietary Manager) stated she does not do anything with weight loss, that information comes from V2 or nursing. They give her any residents with weight loss information, she does not receive their weights or calculate any weight loss. She just receives the order and implements it. On 01/16/24 at 1:40 PM, V16 (Licensed Practical Nurse) stated, R24 was weighed a few days after she returned from the hospital on 10/14/24 and she weighed 166 pounds on 10/18/24. On 09/09/24 she weighed 175 pounds. That is a 9 pound weight loss in around 30 days which is over 5%, but she was given a diagnosis of adult failure to thrive when she returned. Her weight on 11/08/24 was 158 pounds, which was still down some more. She does not know why her chart has different weights listed on different forms, the weights and vital summary sheet is the correct weights. She does not see in her chart where a note or referral was sent to the registered dietician or any supplements given to R24 to assist with any further weight loss. She stated the facility did not do anything to follow through with R24's weight loss including implementing any supplements or forwarding the weight loss information to the registered dietician. She would expect a resident that had been sick or had wounds in conjunction with over 5% weight loss in 30 days would benefit from a nutritional supplement. The undated facility policy titled, Weight and Length Measurement documents: documentation: 1. record date and weight 2. all weights to be completed by the first week of the month. Do according to the schedule. 3. Office nurse - figure the loss or gain the second week of the month. 4. Notify physician by phone, dietary supervisor in writing of: loss or gain: 5% in one month, 7.5% in three months, 10% in six months. 5. If weight loss occurs in the hospital or during any other stay while out of facility, it must be reported to the physician upon return. Resident care plan: 1. Identify weight variance above or below ideal/usual body wt (weight). Assess reason for weight variance. 2. Establish a measurable goal for resident to gain or lose wt as appropriate to attain ideal/usual body weight range. 3. Develop a plan in consultation with the physician and dietician to attain the desired weight gain or loss.