Every finding on record at Vista Park Health and Rehabilitation

Based on observations, record reviews, interviews, and review of the facility's policy titled, Weight and Nutrition Management, the facility failed to ensure timely interventions and assessments were completed after a significant weight loss for one of seven Residents (R) (R115) reviewed for weight loss out of 43 sampled residents. This failure had the potential to lead to additional weight loss concerns and malnutrition.Findings include:Review of the facility's policy titled, Weight and Nutrition Management, reviewed 12/27/202024, revealed It is the intent of this center to review and assess nutritional aspects related to significant weight changes. Review of the Face Sheet located under the Resident Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted with diagnoses that included but not limited to Parkinson's disease and dementia. Review of the quarterly Minimum Data Set (MDS) for R115 located under the MDS Assessment Resident MDS List tab of the EMR with an Assessment Reference Date (ARD) of 8/12/2025 revealed a staff assessment for mental status was conducted with the resident assessed to have severely impaired cognition. The resident's weight was 179 pounds. Review of the physician orders for R115 located under the resident summary Orders tab of the EMR, revealed Diet: Regular Easy Chew. GR [ground] Meat., dated 6/12/2024, and Nutritional Treat. with Meals, dated 12/15/2024. Review of the care plan for R115, dated 6/5/2025 and provided by the facility, revealed a problem of risk for altered nutrition status. Interventions included monitor weight, dated 4/8/2024. Observe intake, dated 2/21/2024. Provide meal alternatives as needed, dated 5/19/2024. Provide supplements as ordered and flavor of choice, dated 2/22/2024. Review of the weights for R115 located under the resident summary Weights tab of the EMR, revealed:-8/7/2025: 179 pounds.-9/2/2025: 170 pounds. (This was a 5% triggered weight loss in one month) Review of the RD [Registered Dietitian] Nutritional Progress Note and Recommendations for R115 located under the resident data collection section under the Clinical Assessment List tab of the EMR, revealed the last RD assessment was conducted on 11/30/2024. Review of the Nutritional Screen for R115 located under the resident data collection section under the Clinical Assessment List tab of the EMR, revealed the last Dietary Manager (DM) note was conducted on 8/11/2025. Review of the EMR for R115 revealed, no progress notes, assessments, or patient at risk (PAR) notes were conducted after the weight loss trigger on 9/2/2025 through 9/10/2025. During a breakfast observation on 9/10/2025 at 8:30 am, R115 received yogurt, eggs, milk, coffee, berry magic cup, ground sausage, toast, and juice. She was able to tell the staff what foods she wanted and didn't want. She received staff assistance to eat. She ate 100% of the berry magic cup, spoons of yogurt, eggs, and sausage, along with sips of milk and coffee. There was no consumption of toast or juice. During a lunch observation on 9/10/2025 at 1:38 pm, R115 received pudding, berry magic cup, cookie, tomato soup, juice, ground pork with no gravy, lima beans, and pinto beans. She received staff assistance to eat. She ate 100% berry magic cup, spoons of ground pork, lima beans, pinto beans, about 50-60% tomato soup, about 75% cookie, and sips of juice. During an interview on 9/10/2025 at 10:20 am, the DM stated she went to the weekly PAR meeting, Wednesdays after the morning meetings. She stated the RD did not go to the meetings. The DM stated she was the one who conducted the weight loss portion of the meetings. She stated she did the weekly and monthly weights, and the system would trigger the weight loss percentage. During an interview on 9/10/2025 at 10:34 am with the RD and the DM, the RD stated she charted weight losses for one-, three-, and six-month losses. She stated she was in the facility last week, charting. She stated they were still getting the monthly weight losses, and she was waiting to see if the weight was accurate. The DM stated there was no PAR meeting the previous week and that R115 was on the list for PAR this Friday (10 days after the significant weight loss trigger). The DM reviewed the food interventions put into place and verified no new interventions since February 2024. The DM acknowledged they did not get the reweight and it should have been requested on the same day as the weight loss, last Tuesday. She stated they just obtained the reweight this date at 170 pounds (8-days after the significant weight loss trigger). During an interview on 9/10/2025 at 2:02 pm, the Director of Nursing (DON) stated they had PAR meetings weekly on Wednesdays, and they did one last week. She stated the monthly weights were put in last week The DON stated if the weight was triggered on Tuesday, they would do a reweight to make sure the weight was accurate. She stated a reweight the same day would depend on the resident. She stated the person who put the weights in the system would be the first to see the significant weight loss. The DON stated the DM was the one who put the weights in the system. She stated the DM would review the weights and reach out to the RD. She stated the DM was not present at the PAR meeting the week before. She confirmed the last RD note was dated 11/30/2024, prior to the one placed today, in which she recommended additional supplementation. The DON stated she became aware of R115's weight loss today, in preparation for the PAR meeting this Friday.

Based on observations, interviews, and review of the facility's policy titled, Meal Service, the facility failed to ensure ready-to-eat food was not touched with bare hands during meal assistance for one of seven Residents (R) (R115) reviewed for weight loss out of a total sample of 43 residents. This failure had the potential to lead to the spread of infection and food borne illness. Findings include: Review of the facility's policy titled, Meal Service, reviewed 12/27/2024, revealed Associates should not need to wear gloves with distributing foods to patients or when assisting residents to dine unless touching ready to eat foods.During a lunch observation on 9/10/2025 at 1:47 pm, Certified Medication Aide (CMA) 1 assisted R115 with feeding. She picked up a cookie with her bare right hand and placed the cookie in the resident's mouth. She picked up the cookie again with her bare right hand and placed the cookie in the resident's mouth. She kept her fingers on the cookie and proceeded to give the resident another bite. Her finger and thumb were pressed into the soft cookie and proceeded to give the resident another bite. During an interview on 9/10/2025 at 1:54 pm, the CMA1 revealed, she was taught not to use gloves during meal assistance and did not know what else she could have used to feed the resident the cookie. During an interview on 9/10/2025 at 2:02 pm, the Director of Nursing (DON) confirmed that the staff should have used a fork, spoon, or gloves for the bite sized pieces of food.

Based on observations, resident and staff interviews, record review, and review of the facility policies titled, Self -Administration of Drugs, the facility failed to ensure two of 25 residents (R) (R59 and R87) did not have unsecured, unauthorized medications stored at the bedside. This deficient practice had the potential to allow unauthorized access of medications to other residents and visitors in the facility. Finding include: Review of the facility policy titled, Self-Administration of Drugs dated 12/29/2023 under intent: It is the intent to promote safe medication administration practices for patients that choose to self-administer medications. Procedure: should the patient wish to self -administer his or her own drugs or medications, the patient should be permitted to do so; The care planning team should assess each patient's mental physical and visual ability to determine if the patient is capable of self-administration of drugs and medications. Record review for R59 revealed the following diagnoses but not limited to hypokalemia, hypertension, unspecified dementia, psychotic disturbance, and anxiety. The Quarterly Minimum Data Set (MDS) dated [DATE] assessed a Brief Interview for Mental Status Score (BIMS) of 13 indicating resident had little to no cognitive impairment. Observation on 3/5/2024 at 12:08 PM of R59's revealed an over the counter (OTC) medication (bottle) labeled cold Vicks for humidifier (at the bedside) positioned in a 2-tier plastic pulled out drawer container within view. At the time of observation, R59 reported using the medication last month for prior cold symptoms. She reported that her family brought the medication into the facility. An interview on 3/5/2024 at 12:10 PM, with Licensed Practical Nurse (LPN) AA confirmed the medication at the bedside and reported being unaware of medication at the bedside of R59. Further interview revealed LPN AA confirmed that R59 was not evaluated/ assessed to self-administer medications and She removed the medication from the room. LPN AA reported that the resident could possibly be at risk of an adverse drug reaction that would result from receiving duplicate cold medications from the nurse as well. Review of the clinical record for R59 did not reveal a completed assessment for Self-Administration of Medications. Record review for R87 revealed the following diagnoses but not limited to chronic obstructive pulmonary disease and cognitive communication deficit. The Admission MDS dated [DATE] revealed a BIMS score of 15 indicating resident had little to no cognitive impairment. Review of physician order form (POF) documented the following medication of similar value: Ventolin HFA 90 mcg/actuation Aerosol Inhaler (albuterol sulfate) two HFA (hydrofluoroalkane) Aerosol Inhaler Inhalation every four hours as needed SOB (shortness of breath)/Wheezing. Observation on 3/5/2024 at 12:18 PM revealed an OTC medication labeled Equate Nasal Spray stored on R87s' bedside table in view. R87 reported occasionally taking the medication every now and then that she had purchased a month ago while being diagnosed with COVID. Observation and interview on 3/5/2024 at 12:25 PM, with Resident Care Coordinator (RCC) Register Nurse (RN) BB confirmed the medication at R87's bedside. She confirmed that the resident had not been evaluated/assessed to self-administer medications and was unaware of the medication being in the residents' room. RN BB further reported that in order for any resident to self-administer medications a physicians' order is required followed by a self-administration assessment evaluation. RN BB removed the med from the room. Review of the clinical record for R87 did not reveal a completed assessment for Self-Administration of Medications. Interview on 3/7/2024 at 3:29 PM, the Director of Nursing (DON) confirmed that both residents R59 and R87 were not assessed for self-administration of medications. She reported that resident admission package includes a form stating prohibited items in the facility. She reported that her expectation is that her nursing staff monitor the resident 's to ensure there are no medications stored at the bedside that they have not been assessed to have.

Based on observations, staff interviews, record review, and review of the facility policy, titled, Patient's Plan of Care the facility failed to follow the care plan for one of 20 Residents (R) R85 that required assistance with Activities of Daily Living (ADL). Findings include: Review of the facility policy titled, Patient's Plan of Care, dated 12/29/2023 revealed under Intent: to promote person-centered comprehensive care plan. Under Guideline: Each patient will have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patient's medical, physical, mental, and psychosocial needs. Record review revealed in Quarterly Minimum Data Set (MDS) Section C - Brief Interview for Mental Status (BIMS) was a 15 indicating resident had little no cognitive impairment; section GG - Functional Limitation in Range of Motion - impairment both sides upper extremity; impairment on one side lower extremity; uses wheelchair; needs set up or clean up assistance with eating; she is dependent on staff for oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, and personal hygiene. Medical Diagnosis include Chronic obstructive pulmonary disease, Heart failure, Pain, Restless legs syndrome, Need for assistance with personal care, Muscle weakness (generalized, osteoarthritis, Contracture of muscle, right lower leg. Review of the resident care plan revealed a problem noted as Self care deficit with Goal og Patient will accept assistance with ADL's and needs will be met during review period. Interventions Assist with ADL's as needed. Observation and interview on 3/5/2024 at 10:15 am with R85, she was observed lying in bed; right leg contracted towards chest; her hands are contracted, and she states she cannot open them; on the right hand the nails are digging into her hand and the skin is broken; she tried to put a towel in her hand, but it was too big. The towel is laying in the bed. Interview on 3/6/2024 at 9:01 am with Licensed Practical Nurse (LPN) JJ revealed she confirmed the Resident's right hand was contracted and her fingernails were digging into her hand. The nurse looked at the hand and stated she needs something in her hand to prevent injury to her skin. During an interview with R85 on 3/7/2024 at 10:13 am She confirmed her nails were cut on yesterday. Interview on 3/7/2024 at 2:48 PM with Director of nursing (DON) revealed the bath sheet for R85 was reviewed, and it did not indicate if nail care was provided; the DON says CNAs are educated to provide nail care as needed and the care is expected to be provided. Further interview revealed there is no documentation on the bath sheets for nail care specifically.

Based on observations, resident interview, staff interviews, and review of the facility policy titled, Care of fingernails/Toenails, the facility failed to ensure that nail care was provided for one of 20 residents (R) R85 with contractures. Findings include: Review of the facility policy titled, Care of fingernails/Toenails, dated12/29/2023 under Intent: It is the intent of this center to provide appropriate nail care to patients. Record review revealed the Quarterly Minimum Data Set (MDS) Section C - Brief Interview for Mental Status (BIMS) was a 15 indicating resident had little to no cognitive impairment; section GG - Functional Limitation in Range of Motion - impairment both sides upper extremity; impairment on one side lower extremity; uses wheelchair; needs set up or clean up assistance with eating; she is dependent on staff for oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, and personal hygiene. Medical Diagnosis include Chronic obstructive pulmonary disease, Heart failure, Pain, Restless legs syndrome, Need for assistance with personal care, Muscle weakness (generalized, osteoarthritis, Contracture of muscle, right lower leg. Observation and interview on 3/5/2024 at 10:15 am with R85, she was observed lying in bed; right leg contracted towards chest; her hands are contracted, and she states she cannot open them; on the right hand the nails are digging into her hand and the skin is broken; she tried to put a towel in her hand, but it was too big. The towel is laying in the bed. There is no splint or other device in her hands. Interview on 3/6/2024 at 9:01 am with Licensed Practical Nurse (LPN) JJ revealed she confirmed the Resident's right hand was contracted and her fingernails were digging into her hand. The nurse looked at the hand and stated she needs something in her hand to prevent injury to her skin. Interview on 3/7/2024 at 9:14 am with Certified Medication Aide (CMA) HH revealed the resident can make her needs known, she is total care, she can feed herself; nail care is with every bath and as needed. Further interview revealed that R85 gets her bath at night and would usually get her nails done at that time. During an interview with R85 on 3/7/2024 at 10:13 am She confirmed her nails were cut on yesterday. Interview on 3/7/2024 at 2:48 PM with Director of nursing (DON) revealed the bath sheet for R85 was reviewed, and it did not indicate if nail care was provided; the DON says CNAs are educated to provide nail care as needed and the care is expected to be provided. Further interview revealed there is no documentation on the bath sheets for nail care specifically.

Based on observation, Infection Control Policy review and staff interviews, the facility failed to cover food items on resident meal trays during food delivery to resident's rooms on two (2) of two (2) halls. Findings include: Observations made on 05/11/2015 at 12:30 PM and 1:46 PM on North Wing Q and D halls revealed the resident lunch trays with beverage glasses and dessert bowls uncovered. Continued observations revealed that the trays were removed from the cart near the end of the hallways and carried through the hallway to the resident's rooms. Observations made on 05/13/2015 at 8:55 AM and 9:09 AM on South Wing B and C halls revealed the resident lunch trays with beverage glasses and dessert bowls uncovered. Continued observations revealed that the trays were removed from the cart near the end of the hallways and carried through the hallway to the resident's rooms. An interview on 05/14/2015 at 9:34 AM with the Clinical Dietary Manager revealed trays were prepared and covered one cart at a time in the kitchen for the residents that did not go to the dinning room. The plates had insulated top and bottom covers but beverage and dessert bowls were not covered. The trays were loaded on carts with plastic bag type covers on them and were taken to the halls. Once on the halls, the carts were to be taken room to room in order to keep trays covered until delivered directly from the cart to the room. An interview on 05/14/2015 at 4:34 PM with the administrator revealed that meal trays on the halls should be delivered from the cart room by room or have plastic lids covering the cups. A review of the Departmental policies for Dietary Services revealed procedural guidelines instructing prepared food should be transported to other areas in closed food carts or other containers. A review of April 2015 staff education revealed instructions to pass trays in order moving down hallways taking meal cart as you go.

Based on resident interview, staff interviews and record review, it was determined that the facility failed to honor one resident's ("A") choice to be provided showers daily from a total sample of 26 residents. Findings include: Resident "A" was admitted in June 2012 with [DIAGNOSES REDACTED]. Staff developed a 6/30/12 care plan with a problem of the resident being at risk for adjustment difficulties related to his/her new admission to the facility. There was an intervention for staff to identify and honor the resident's customary routines and preferences as appropriate. On 7/30/2012 at 4:08 p.m., the resident stated that he/she would like to have a shower every day as he/she did at home but, staff only gave him/her a shower on Tuesday, Thursday and Saturday. Resident "A" stated that, several weeks ago, he/she had told nursing staff that he/she wanted a shower every day which at that time staff said they would provide it. However, the resident stated that staff did not give him/her a shower daily. Review of the facility's Bath List revealed that, since his/her admission, staff bathed the resident every Tuesday, Thursday, and Saturday on the 7 a.m. to 3 p.m. shift. However, there was no indication that staff had provided a shower daily to the resident as he/she requested. On 8/01/12 at 9:05 a. am., licensed nurse "BB" stated that she/he had not been told that resident "A" had requested a shower every day but the resident could be provided a shower daily if that was his/her preference. During an interview on 8/01/12 at 5:10 p.m., licensed nurse "CC" stated that approximately 3 to 4 weeks ago, the resident told "CC" that he/she would like a shower every day. "CC" stated that the resident's family member was at the facility at that time and told "CC" that he/she would bathe the resident. "CC" stated, however, that the resident's family member did not visit the resident daily. "CC" stated that she/he did not know if the resident received a shower daily as he/she had requested because the 7 a.m. to 3 p.m. shift nursing staff would have provided the shower to the resident. On 8/2/12 at 9:15 a.m., the assistant director of nursing (ADON) stated that she was not aware that the resident had requested a shower every day but, there was no problem with the resident receiving a daily shower. The ADON stated that licensed nursing staff should have relayed the resident's request to supervisory staff by completing a grievance form or documenting the resident's request on the 24 hour report so, the resident's request could be honored. On 8/02/12 at 9:20 a.m., the director of nursing (DON) stated that she was not aware that the resident had requested daily showers.

Based on observation, interview and record review, it was determined that the facility failed to ensure that a licensed nurse ("AA") used correct technique to administer medication through a gastrostomy tube ([DEVICE]) for one resident (# 189) of the 26 residents sampled. Findings include: According to the 43.26-30. "Georgia Practical Nurses Practice Act," the practice of licensed practical nursing included the administration of medications. According to the internet site of "factsandcomparisons.com," Medication Administration in Patients with Feeding Tubes, oral immediate release tablets were to be crushed to a fine powder and mixed with 15 to 30 milliliters (ml) of water to form a slurry. Oral immediate-release capsules were to be crushed to a fine powder and mixed with 10 to 30 ml of water to form a slurry. However, licensed nurse "AA" did not administer [MEDICATION NAME] correctly through resident #189's [DEVICE]. The facility's "Enteral Tube Medication Administration" policy, that was reviewed and updated January 20, 2009, documented at Step 8c that the nurse should dissolve crushed tablets in 10 to 15 ml per cubic centimeters (ml/cc) of water or other appropriate liquid. Step 9 of the facility policy was to flush the tube with 30 ml of water. Step 10 was to administer medications. The primary concern was to avoid obstructing the tube and the complete delivery of all of each medication to the stomach. However, medication nurse "AA" failed to implement those steps in the facility's policy during medication administration for resident #189. It was observed on 7/31/12 at 12 noon that licensed nurse "AA" prepared [MEDICATION NAME] to be administered through the [DEVICE] to resident #189. Licensed nurse "AA" crushed the [MEDICATION NAME] tablet. She attached a 60 ml syringe to the end of the [DEVICE] and checked it for placement and the presence of residual. Nurse "AA" then poured the dry, crushed [MEDICATION NAME] directly into the 60 ml syringe but did not dissolve the crushed tablets in 10 to 15 ml/cc of liquid. She did not flush the tube with water. She poured crushed [MEDICATION NAME] into the syringe and poured 50 ml of water into the syringe after it. The medication became clogged in the syringe tip and did not flow through the resident's [DEVICE]. Nurse "AA" stated, at that time, that this had never happened to her before and that the medication usually drained right in. After 10 minutes, nurse "AA" poured the water and partially diluted medication out of the syringe into a cup. She removed the syringe tip from the [DEVICE] and commented that the syringe was clogged with medication. She rinsed the syringe out with water at the sink then, re-attached the syringe to the [DEVICE] and attempted to flush it with the remaining 50 cc of water. The [DEVICE] was clogged with the dry crushed [MEDICATION NAME]. Nurse "AA" milked the [DEVICE] below the clamp and repeatedly inserted the plunger into the syringe and popped it out without actually pushing the [MEDICATION NAME] through the syringe with the plunger. Five minutes later, the clogged [DEVICE] cleared and the 50 cc of water drained through resident #189's [DEVICE]. Resident #189 did not receive the complete dose of [MEDICATION NAME] that had been ordered. In an interview on 07/31/2012 at 2:51 p.m., medication nurse "AA" said that she normally dissolved the crushed [MEDICATION NAME] with water before putting it in the [DEVICE] but, she was so nervous today that she forgot to dissolve the medication. The Director of Nursing (DON) was notified on 07/31/12 at 4:00 p.m. about this observation of the licensed nurse failing to adhere to the facility's policy or professional standards of practice for the administration of medication through a feeding tube.

Based on observation, record review and staff and resident interview, it was determined that the facility failed to ensure that one resident (#15) was positioned correctly in his/her wheelchair to accommodate his/her needs from a sample of 26 residents and, failed to ensure that four of six residents in the Group interview meeting were provided fresh water and ice every shift. Findings include: 1. Resident #15 had [DIAGNOSES REDACTED]. He/She was coded on the 8/11/10 quarterly Minimum Data Set (MDS) assessment as being totally dependent on staff for mobility. On 11/17/10 between 12 noon and 12:30 p.m., the resident was sitting in his/her wheelchair in the hall beside the nurse's station. The resident's left foot was hanging down, unsupported between the footrests of the wheelchair. On 11/18/10 at 8:20 a.m., the resident was in his/her wheelchair in the dining room being fed by staff. The resident's right foot was hanging down, unsupported between the footrests. On 11/18/10 at 9:30 a.m., the resident was in his/her wheelchair in the hall beside the nurse's station. Both of the resident's feet were hanging down, unsupported between the footrests of the wheelchair at that time. On 11/18/10 at 10:30 a.m., the resident was in his/her wheelchair in the dining room for Group exercises. The resident's feet were hanging down, unsupported between the footrests. On 11/18/10 at 11:10 a.m., the resident was transported from the dining room to his/her room by restorative nursing staff. The resident's left foot was hanging down, unsupported between the foot rests during the transport. On 11/18/10 at 11:30 a.m., the supervisory nursing staff responsible for restorative services stated that she was unaware that the resident's feet were not maintained in a correct position on the footrests of his/her wheelchair. Although staff had applied heel boots to the resident's feet for pressure sore prevention and the resident's feet did not touch the floor during the above observations, staff had failed to maintain correct positioning and support of the resident's feet while in his/her wheelchair to prevent potential injury and/or decline in the range of motion of the resident's feet and ankles. 2. During the Group Interview on 11/17/10 at 9:00 a.m., four of the six residents in attendance complained that nursing staff failed to provide them with fresh ice and water every shift.

Based on observation, record review, and staff interview, it was determined that the facility failed to implement care plan interventions to prevent injury from skin tears and falls for one resident (#3), from a total sample of 26 residents. Findings include: Resident #3 had a plan of care since at least July 2008 to address his/her risk for falls. The plan of care was most recently reviewed in September 2010 and included an intervention for brake extenders to be applied to his/her wheelchair brakes. However, during observations on 11/17/10 at 9:15 a.m., 10:35 a.m., 11:35 a.m., and 3:20 p.m., and on 11/18/10 at 8:30 a.m., staff had not applied brake extenders to the resident's wheelchair. Resident #3 had a plan of care since at least July 2010 for his/her risk of developing skin tears. There was a care plan intervention since 7/6/10 for staff to pad the "assist rails" on the resident's bed. However, during observations on 11/17/10 at 10:45 a.m. and on 11/18/10 at 9:50 a.m., staff had not padded the assist rails on the resident's bed. See F323 for additional information regarding resident #3.

Based on observation, record review and staff interview, it was determined that the facility failed to implement interventions to prevent injuries from skin tears and falls for one resident (#3), from a total sample of 26 residents. Findings include: Resident #3 had [DIAGNOSES REDACTED]. He/She was coded on the 6/18/10 annual and the 9/29/10 quarterly Minimum Data Set (MDS) assessments as non-ambulatory and as needing extensive assistance with locomotion. There was a care plan intervention since 7/6/10 for staff to pad the "assist rails" on the resident's bed to decrease his/her risk of injury from skin tears. However, on 11/17/10 at 9:15 a.m., 10:35 a.m., 11:35 a.m. and 3:20 p.m., staff had not padded the assist rails on the resident's bed. There was a care plan intervention since at least September 2010 for brake extenders to be applied to the resident's wheelchair to prevent falls. However, on 11/17/10 at 10:45 a.m. and 11/18/10 at 9:50 a.m., staff had not applied the brake extenders to the resident's wheelchair. During an interview on 11/18/10 at 9:50 a.m., the licensed nurse unit manager stated that she did not know that the resident's assist rails on his/her bed had ever been padded. She confirmed that there were not any brake extenders on the resident's wheelchair.

Based on staff and resident interviews, it was determined that the facility failed to offer bedtime snacks to three of six residents in the Group interview in a census of 134 residents who received oral nutrition. Findings include: During the Group Interview on 11/17/10 at 9:00 a.m., three of six residents in attendance stated that staff did not offer them a bedtime snack every night. On 11/17/10 at 3:30 p.m., the Dietary Supervisor said that snacks for residents were put in containers each afternoon and delivered to each hall with a list of the residents and their diet orders. On 11/17/10 at 3:30 p.m., certified nursing assistant (CNA) "CC" stated that he/she passed snacks to the residents before supper but, seldom passed snacks at bedtime. On 11/17/10 at 3:35 p.m., CNA "DD" stated that "most of the time" snacks were offered to residents before supper but, not at bedtime.