**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents received adequate supervision and services to prevent an accident/hazard. Resident #1, who had a diagnosis of multiple sclerosis (nerve damage resulting in weakness), type 2 diabetes mellitus, muscle weakness and history of falling was initially admitted to the facility on [DATE]. The facility failed to implement fall interventions and updating the care plan following a fall on 1/28/23. Due to the facility's failures, and the staff's failure to take proper and reasonable care after the first fall (1/28/23) when the resident was suffering from increased weakness due to the flu, resulted in the resident falling again on 1/30/23, while she was alone in the bathroom and found down on the bathroom floor for an unknown amount of time. It resulted in the resident sustaining injuries of lumbar (S1 endplate) fracture and a right hip (femur) fracture after falling requiring surgical repair of right hip on 2/4/23. These injuries resulted in a decrease in her functional ability and she required evaluation and treatment at the emergency department (ED) and was hospitalized from [DATE]-[DATE] (17 days). The facility failed to timely implement appropriate interventions and when the resident returned from the hospital on 2/15/23, the facility failed to provide and implement consistent two person transfer assistance after the fall with the femur fracture; according to record review, interviews and in the post fall intervention and care plan. Findings include: I. Facility policy and procedure The Fall Prevention policy and procedure, revised March 2023, was provided by the director of nursing (DON) on 6/15/23 at 4:35 p.m. It read in pertinent part, Purpose: To identify patients at risk of falls-initiate interventions to decrease risk of fall and thus reduce the risk of injury due to falls. All falls will be documented, reported and interventions will be put into place. II. Resident #1 A. Resident status Resident #1, age [AGE], was initially admitted on [DATE] and readmitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included fracture of right femur (hip), multiple sclerosis (MS), type 2 diabetes mellitus, muscle weakness and history of falling. The 3/2/23 significant change in status minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required total dependence assistance with two persons physical assistance for bed mobility, transfers and toilet use. She required total dependence with one person for bathing and personal hygiene and extensive assistance with one person for dressing. Locomotion on/off units required total dependence of one person. B. Resident interview Resident #1 was interviewed on 6/5/23 at 12:42 p.m. She said she had a second fall on 1/30/23 and had walked to the bathroom alone and she fell in the bathroom. Resident #1 said a certified nurse aide (CNA) found her on the floor in the bathroom wrapped around the toilet. Resident #1 said she did not know what happened but she thought she blacked out. Resident #1 said she had completed therapy services but did not walk anymore since the fall like she used to. Resident #1 was interviewed on 6/15/23 at 2:56 p.m. Resident #1 said the care staff usually have two persons to assist her with transfers since the fall although occasionally they have one person assistance with transfers when the staff gets busy. C. Record review Care plan: Review of the activities of daily living (ADL) care plan revealed the resident had self-care performance deficits related to limited mobility and incontinence with the last revision on 1/4/22. -There was no revision or update to the ADL care plan following the first fall on 1/28/23. The ADL care plan following the second fall on 1/30/23 revealed the following interventions, dated 3/6/23. Bathing/showering total assistance since fall with fracture; bed mobility total assistance since fall with fracture; toilet use total assistance since fall with fracture; transfers total assistance with mechanical lift since fall with fracture. -However, after the fall with a fracture, the facility did not consistently provide the resident with two person total assistance with transfers per the care plan. -The ADL care plan revealed it had not been developed to include two persons physical assistance consistently as indicated by the 3/2/23 MDS assessment the resident required total dependence assistance with two persons for transfers, bed mobility and toilet use. Review of the safety/mobility/falls care plan revealed the resident was at risk for falls related to deconditioning, gait/balance problems, incontinence, MS, history of falls, and muscle weakness, date initiated 9/27/2020, and revised on 3/27/23. -There was no revision or update to the safety/mobility/falls care plan following the first fall on 1/28/23. The safety/mobility/fall care plan following the second fall on 1/30/23 revealed the following interventions: Grab bars, two to increase mobility, date revised 4/27/23; Not using power operated vehicle at this time related to tolerance, enjoys sitting in her recliner chair in her room, date initiated 5/1/23; Needs assist at this time to eat, no swallowing issues, revised 3/27/23; Needs two staff assist for all transfers, uses hoyer (mechanical) lift, date initiated 3/27/23. -However, after the fall with a fracture the facility did not consistently provide the resident with two person total assistance with transfers per the care plan (see documentation below). -The resident discharged from hospital back to the facility on 2/15/23, however the ADL care plan was not updated until 3/6/23 (20 days later) and the fall/safety care plan was not updated until 3/27/23 (41 days later). Review of Resident #1's electronic medical record (EMR) revealed the following transfer task support provided for the past 30 days documentation revealed the following: 5/18/23 at 9:05 a.m. one person physical assistance was provided. 5/19/23 at 10:29 p.m. one person physical assistance was provided. 5/21/23 at 6:29 a.m. one person physical assistance was provided. 5/25/23 at 9:53 p.m. one person physical assistance was provided. 5/30/23 at 7:00 p.m. one person physical assistance was provided. 6/1/23 at 7:06 p.m. one person physical assistance was provided. 6/3/23 at 12:11 a.m. one person physical assistance was provided. 6/5/23 at 4:03 p.m. one person physical assistance was provided. 6/11/23 at 4:35 a.m. no set up or physical help from staff for transfer. -The fall/safety care plan revealed Resident #1 needed two person assistance and utilized a mechanical lift, the facility continued to provide one person assistance many times (over eight), placing Resident #1 at a continued risk of another fall. The quarterly morse fall scale, dated 1/12/23 revealed Resident #1 was a high risk for falling. Review of Resident #1's medical record (EMR) revealed the following progress notes documented in pertinent part: 1/28/23 at 6:21 p.m., Patient had an assisted fall this shift at 5:45 p.m. Writer was called to the resident's room where she was on the floor. Patient was found lying on her left lateral position. According to the assigned aide, the patient was sliding from the Sara lift (Sit to stand lift) and so she assisted her to the floor. Aide stated the patient did not hit her head on the floor. No new injuries, skin tears, or bruises noted at this time. Range of motion at resident's baseline. She denies any pain but scheduled Tylenol was administered. M.D. (medical doctor), family member, and supervisor notified. Vitals within normal limits (WNL). A new order for Flu swab was given by M.D. Specimen collected and waiting for pick up. 1/28/23 at 7:40 p.m., No visible injury from assisted fall. Resident reports soreness and some discomfort from increased use of the hoyer/Sara lift. Resident reports she is having 'more issues with my MS since I have this cold going on.' Encouraged to notify the nurse if pain becomes worse, verbalized understanding. 1/29/23 at 8:39 p.m., Flu results received and are positive, on call provider notified. Orders received for Tamiflu 75 mg (milligrams) per mouth, twice a day for five days. Start when available from the pharmacy. Encouraged use of surgical mask when in the hallway and discussed the importance of hand hygiene. 1/29/23 at 8:51 p.m., Infection note: positive cough, rhinitis, congestion, and myalgia. Has Mucinex ordered. Vital signs are stable, afebrile, no change in per mouth intake. No respiratory distress. Fluids encouraged in addition to frequent hand hygiene throughout the shift. Rapid COVID is negative. 1/30/23 at 10:52 a.m., Residents son was notified at 10:38 a.m. of fall and sending resident out. MD was made aware of the fall, and being sent out to the hospital. Neuro (neurological checks) started related to fall. Resident resting in bed with call light in reach, aware she is being sent out. Resident complaint of right hip pain. 1/30/23 at 11:55 a.m., Resident left via ambulance at 11:55 a.m. Ambulance taking her to hospital. 1/30/23 at 12:54 p.m., This RN (registered nurse) called by unit staff to resident's room around 10:00 a.m. and upon entrance to her bathroom noticed that resident was lying down on the floor on her right side of body legs flexed, head towards the wall and legs to the toilet. Resident stated that, 'I was transferring myself to the toilet and fell to the floor.' Resident assessed for pain and complained of pain 5/10 (with 10 being the worst pain on the scale) to right leg/hip, she stated that, 'that's my cramp.' Four staff members gently slid bed sheet under resident, pulled her out of the bathroom and then transferred to bed by using Hoyer. Residents bilateral upper extremities and left leg moves with no issue, PERRLA (pupils equal, round, reactive to light and accommodation), abrasion to top of head noted. Neurological assessment initiated right away, vital signs 96/46 (blood pressure), 98.2 (temperature), 87 (heart rate), 20 (respiration), O2 sat (oxygen saturation) is 70% on room air noted. Resident was tested positive for Flu-Lung sounds diminished throughout; Supplemental oxygen via nasal cannula administered 5 liters per minute. Pulse oximeter reading came up to 91%. Unit nurse administered as needed Tylenol for pain, resident rested in bed. Resident kept saying that, 'My muscle cramp to right leg.' Resident had anti-hypertensive medications in morning per unit nurse, blood pressure was in low reading. Stat X-Ray order obtained for right leg to rule out fracture, but technician will be in the building in four to eight hours window. Per MD ordered resident transferred to hospital for evaluation and treatment, accompanied with two EMT (emergency medical technicians) ambulance via stretcher around 11:50 a.m. All papers and notification made by unit manager and unit nurse. 1/30/23 at 5:47 p.m., This nurse called hospital for an update on resident at 5:30 p.m. ER (emergency room) nurse stated resident broke her hip, right intertrochanteric femur, that she is also septic (widespread infection causing organ failure and low blood pressure) and that her troponin level was 1600 (indicating a heart problem). This nurse notified DON and family. The hospitalist discharge summary revealed in pertinent part, admit date [DATE], discharge date [DATE]. Resident is a [AGE] year old female with a history of diabetes, hypertension, and poor mobility due to MS who presented with acute hip fracture and lumbar fracture after falling. She was diagnosed with the flu (1/29) one day prior to admission, but had symptoms of upper respiratory infection for seven days. She was weakened from the flu and getting up to the bathroom when she fell sustaining a right hip fracture and S1 endplate fracture. On presentation, also noted acute congestive heart failure with elevated troponin and BNP (B-type natriuretic peptide-gives information about how your heart is working). Cardiology and orthopedics were consulted. Hospital course: fracture of right hip and status post right hip osteosynthesis using intramedullary nailing (hip surgery) on 2/4/23. Cognitive evaluation score 15/30 so should involve her proxy on any major decisions. Osteoporotic compression fracture of vertebra with routine healing, acute to subacute endplate fracture. Cystitis present on admit, she completed antibiotic course. MS, used a motorized wheelchair but can walk short distances with her walker at baseline. She is markedly weaker now than baseline and needs skilled nursing level care. 2/15/23 at 6:08 p.m., admission summary: Resident arrived from hospital accompanied by EMT. Alert and oriented x3-4. Pain consisting throughout body due to scaly skin due to reaction to chlorhexidine, in addition to 18 staples to lateral right hip and eight to lateral upper thigh. Weight is 173.78 lbs (pounds), mucus membranes are dry and intact. Currently on one liter of oxygen. Head of bed is raised, pillow supporting right hip for comfort; as well as small pillow between legs. Resident presented with pain with confessing all throughout body. Oxycodone administered at time of leaving hospital with therapeutic effect reaching at time of arrival to facility. Diet remains to be regular with thin liquids, assistance needed with feeding. Medication able to be administered whole with fluids followed. Incontinent of bowel and bladder, as well as ability to use bedpan with urgency. Able to use call light appropriately. Staples cleaned and covered with abdominal pads due to observation needed. Yeast infection to upper groin and buttocks observed with redness, moist skin,and odor. As of this time zinc is applied until new orders are released to point click care (electronic medical record system). Resident currently laying comfortably in bed with positioned to left side to provide comfort. Monitoring will be for three days due to readmission. D. Facility's investigation of Resident #1's falls Fall #1 dated 1/28/23: The facility post fall investigation noted in pertinent part, Fall investigation: Fall 1/28/23 at 5:45 p.m. -Fall in room. Using a sit to stand lift (Sara lift) due to increased weakness due to illness (flu). Resident slipped out of the Sara lift, and was assisted to the floor. Interventions: Resolve infection (flu). Fall root cause analysis 1/28/23: Patient was in the bathroom prior to fall. Resident interview: 'I was coming out of the bathroom after using the toilet and was sliding, and the aide laid me on the floor.' What does the resident think might have prevented the incident? 'I'm ok, I did not hit my head.' Interdisciplinary team (IDT) recommendations: Resolve infections, Huddle with staff concerning resident status and PT (physical therapy)screen. -The root cause analysis: was blank and the suggestion to prevent further falls was blank. Fall #2 dated 1/30/23: The facility post fall investigation noted in pertinent part, Fall investigation: Fall 1/30/23 at 10:00 a.m. -Fall in the bathroom. Prior to the fall resident was in her wheelchair and ambulated from wheelchair to bathroom. Neuros were initiated. Fall root cause analysis: Where was resident prior to the incident -in her wheelchair. What were they doing: Ambulated from wheelchair to bathroom. What does the resident think might have prevented the incident? Resident did not say. Neuros initiated-Yes. When was the last time resident was toileted or used the bathroom? On her way to the bathroom. Resident did not call for assistance. Positive flu, pulse oxygen saturation at 78 percent. Root cause: Why-self ambulating to the bathroom. Positive flu and possible de-saturation. Summary: Resident fell, self ambulating has positive flu with symptoms. Did not use the call light. Based on root cause analysis: suggestions to prevent further falls: Frequent offers of toileting by staff. Therapy eval (evaluation) and tx (treatment) for safe transfer and for toileting self. Is the occurrence potentially reportable? -No. IDT recommendations: Send to ER for eval and treatment. E. Staff interviews The DON, licensed practical nurse (LPN) #1, MDS coordinator (MDS #1) were interviewed on 5/4/23 at 1:30 p.m. They said the first fall on 1/28/23 occurred in the resident's room when staff was using a sit to stand lift (Sara lift) with Resident #1 because she had increasing weakness due to her illness (flu). Resident #1 slipped out of the Sara lift and was assisted to the floor. They said the main intervention was to resolve the flu infection. There was a plan for a staff huddle to warn that the resident was weaker and a physical therapy screen but they did not occur since the first fall occurred on Saturday 1/28/23, a team huddle could not be done before the second fall on 1/30/23. They said they determined the fall was related to the resident being ill and weak and was not related to poor use of the Sara lift. They said the second fall occurred on 1/30/23 and the resident fell in the bathroom. They said the resident had ambulated from her wheelchair to the bathroom. They said administration had a fall meeting (a huddle) generally the next day after a fall but that did not occur after fall 1/28/23 and the resident was sent out to hospital after fall on 1/30/23. They said they would begin implementing a risk management review that was more of a comprehensive review in addition to the huddles. The nursing home administrator (NHA) and quality specialist (QS) were interviewed on 6/15/23 at 9:56 a.m. They said Resident #1 was assisted to the floor after fall on 1/28/23 and a new order for flu swab was given by the MD. They said Resident #1 reported having more issues with MS since she thought she had a cold. They said interventions included a RN assessment, received orders for mucinex, the MD notified, equipment check of lift and the nurse continued to monitor her condition. MDS #1 was interviewed on 6/15/23 at 11:13 a.m. She provided the assessment log/inventions care plan log (yellow paper) that was an initial care plan when a resident fall occurred. It read, event #3 date 1/28/23 it was blank with no interventions; event #4 date 1/30/23 'found laying on the floor in the bathroom. Intervention: Send to ER for eval and treatment; assess for therapy upon return.' MDS #1 said the ADLs were revised on the care plan for Resident #1 after the fall when she returned from the hospital to show that she was no longer independent. MDS #1 said the ADL care plan was revised 3/6/23 for total assistance of two persons for the mechanical lift (hoyer) since the fall with fracture. MDS #1 said the fall/safety care plan was updated 3/27/23 to two staff assists for all transfers and the resident used a hoyer lift. MDS #1 said Resident #1 was no longer walking/ambulating. MDS #1 said Resident #1 received physical/occupational therapy services after the fracture but discharged after reaching her maximum potential. The DON, MDS #1 and NHA were interviewed on 6/15/23 at 3:26 p.m. MDS #1 said the main intervention for Resident #1 after the fall with fracture was to provide two person assistance with transfers for overall well being, safety and fall prevention. MDS #1 said the CNAs documented the assistance provided in the task section of electronic medical record (EMR). MDS #1 looked at the task documentation for transfers and said the care staff were not consistently providing two person assistance for transfers (mechanical lift). MDS #1 said per the facility policy and residents' safety all transfers should be with two person assistance. CNA #1 was interviewed on 6/15/23 at 4:04 p.m. CNA #1 said she documented in the resident's EMR how much assistance a resident needed with care. CNA #1 said if a resident needed a mechanical lift for transfers she would never complete the transfer without two person assistance. CNA #2 was interviewed on 6/15/23 at 4:11 p.m. He said he documented in the resident's EMR how much help a resident needed, like one or two persons. CNA #2 said he used two people when using a mechanical lift. CNA #2 said two persons was safest for both the resident and the staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure residents were weighed weekly as ordered by the physician for three (Resident #36, Resident #47, and Resident #90) of three sampled residents reviewed for nutrition. The failed practice resulted in a delay in identifying and intervening to address a severe weight loss of 9.28% of Resident #90's total body weight over a period of three months and three weeks. Findings included: Review of an undated facility policy titled, Policy for Weighing Resident revealed, Individuals will be weighted [sic] upon admission or readmission to establish a baseline weight. They will then be weighted [sic] for the first 4 weeks after admission and at least monthly thereafter to help identify and document trends such as a gradual/subtle weight loss/gain. 1. Review of an admission Record revealed the facility admitted Resident #90 on 05/23/2022 with diagnoses including Alzheimer's disease and major depressive disorder. Review of a physician's order dated 05/23/2022 revealed Resident #90's weight and vital signs were to be checked weekly. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #90 had moderately impaired cognitive skills for daily decision-making per a staff assessment of mental status and had short and long-term memory problems. The MDS indicated the resident required only set-up assistance with eating. The resident's weight was not rcorded on the MDS assessment. The MDS indicated the resident had not experienced a weight loss of 5% or more in the past month or 10% or more in the past six months. During an interview on 09/13/2022 at 10:02 AM, Resident #90 stated he/she had only been weighed once since being admitted to the facility. During an interview on 09/13/2022 at 10:10 AM, Certified Nursing Assistant (CNA) #1 stated Resident #90 was supposed to be weighed weekly. During an interview on 09/13/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #1 revealed all residents were weighed on admission and then either weekly or monthly thereafter. LPN #1 stated Resident #90 was admitted on [DATE] and had an order for weekly weights. LPN #1 reviewed Resident #90's weight record and stated she only saw one weight, recorded on 05/23/2022. LPN #1 stated the concern with the weekly weight order not being followed was that if the resident had weight loss, it would not be identified, and the resident could have a bad outcome. According to LPN #1, if she had been given a list of residents who needed to be weighed, she would have done the weights herself or told the staff she needed the weights. She stated if staff on her shift were unable to obtain the weights, she would pass the information on to the next shift. Review of the Weight Summary in Resident #90's electronic medical record revealed the resident weighed 148.6 pounds on 05/23/2022. No further weights were documented until 09/13/2022 at 12:35 PM, at which time the resident weighed 134.8 pounds. This was a loss of 13.8 pounds, or 9.28% of the resident's total body weight over a period of three months and three weeks, which was considered a severe weight loss. Review of a Progress Note-Nutrition/Dietary Note, dated 09/13/2022 at 12:17 PM, revealed Resident #90 experienced a weight loss of 9.8% over a four-month period. The note indicated the resident's current weight was 134 pounds, and the body mass index (BMI) was 17.2, which is considered underweight for [his/her] height and age. The note indicated the resident received a regular diet and usually consumed greater then 75% of most meals over the past 20 days. The note also indicated the resident received Ensure Plus daily, with 100% acceptance. Per the note, staff reported the resident had always eaten well and usually accepted the Ensure. The note indicated the resident reported he/she got plenty to eat and enjoyed the Ensure. The note indicated the resident stated he/she would accept 2 Cal HN (a higher calorie nutritional supplement). According to the note, staff reported that when they had discussed with the resident's family member, he/she stated weight loss was expected due to the diagnosis of Alzheimer's disease. The note indicated an order would be added for the resident to receive 2 Cal HN daily and to continue the Ensure Plus. During an interview on 09/13/2022 at 1:46 PM, the Dietary Manager (DM) revealed she ran a weight report weekly and looked at the report to see if there was any weight loss and/or gain. Per the DM, if there were any missing weights, she would notify the nurse that the resident needed to be weighed, but this practice had failed for Resident #90. The DM stated she had now realized Resident #90 had not been weighed since admission to the facility. The DM stated she reminded the staff if there were missing weights but realized she had not followed through to make sure all the weights were completed, and this could have a negative outcome. The DM stated she realized that if the staff would have weighed the resident, Resident #90's weight loss would have been identified, and staff could have offered the resident more portions, higher calories, or more snacks. During an interview on 09/13/2022 at 12:40 PM, the Dietary Consultant (DC) stated he was unaware that Resident #90 had not been weighed weekly. Per the DC, the facility failed to monitor the resident's weight. The DC explained the nursing staff were given a list of residents with missing weights, but he failed to follow up to make sure the staff completed the task. The DC indicated that he, the DM, and the staff had failed to discuss the resident's weights because if the weights had been discussed, Resident #90's weight loss would have been identified and the staff could have provided interventions. On 09/13/2022 at 5:30 PM, a telephone interview was attempted with the Certified Registered Nurse Practitioner (CRNP) and left a voicemail requesting a return call. On 09/13/2022 at 6:35 PM, the return call from the CRNP was received. The CRNP stated, per her company's policy, she was not allowed to be interviewed and suggested the notes she had documented in the resident's electronic medical record should be reviewed instead. During an interview on 09/14/2022 at 9:56 AM, the Director of Nursing (DON) acknowledged that Resident #90 was supposed to be weighed weekly. The DON explained that obtaining weekly weights for Resident #90 had been overlooked, and the staff had failed to obtain the weekly weights as ordered. During an interview on 09/14/2022 at 10:20 AM, the MDS Nurse stated the weekly weights for Resident #90 were overlooked because the resident resided on a hall that was typically for residents receiving hospice services. During an interview on 09/14/2022 at 10:53 AM, the Administrator stated the staff recognized that the weekly weights for Resident #90 were not obtained as ordered. The Administrator stated she expected the DM to monitor and notify her and the nurse if the weights were not being done. Per the Administrator, if the weights were not completed, the resident's care and well-being could be affected. 2. Review of an admission Record revealed the facility admitted Resident #47 on 05/23/2022 with diagnoses including malignant neoplasm of an unspecified part of the bronchus or lung (lung cancer), dementia, depression, and irritable bowel syndrome. Review of a significant change MDS dated [DATE] revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS indicated the resident required only set-up assistance with eating, weighed 131 pounds, and had no weight loss or gain of 5% or more in the past month or 10% or more in the past six months. Review of physician's orders dated 05/23/2022 and 09/02/2022 revealed the resident was to be weighed weekly. Review of the Weight Summary in Resident #47's electronic medical record revealed the resident was weighed on 05/25/2022, 07/21/2022, 09/02/2022 and 09/09/2022. According to the summary, the resident's weight had increased from 123.5 pounds to 133.2 pounds (7.28% increase) over a period of three months and two weeks. 3. Review of an admission Record revealed the facility admitted Resident #36 on 07/08/2022 with diagnoses including hypertensive heart disease, type 2 diabetes mellitus, and gastroesophageal reflux disease. Review of an admission MDS dated [DATE], revealed Resident #36 had a BIMS score of 15, indicating the resident was cognitively intact. Per the MDS, the resident required only set-up assistance with eating, weighed 165 pounds, and had no weight loss or gain of 5% or more in the past month or 10% or more in the last six months. Review of a physician's order dated 07/08/2022 revealed Resident #36 was to be weighed weekly. Review of the Weight Summary in Resident #36's electronic medical record revealed the resident was weighed on 07/12/2022 and 08/31/2022. The summary indicated the resident's weight increased from 164.6 pounds to 165.4 pounds in a seven-week period. During an interview on 09/13/2022 at 10:15 AM, LPN #1 confirmed Resident #36 and Resident #47 were admitted to the facility with orders for weekly weights. During an interview on 09/13/2022 at 12:40 PM, the Dietary Consultant (DC) stated he was unaware Resident #36 and Resident #47 had not been weighed weekly. Per the DC, the facility failed to monitor the residents' weights. The DC explained the nursing staff were given a list of residents with missing weights, but he failed to follow up to make sure the staff had completed the task. During an interview on 09/14/2022 at 9:56 AM, the Director of Nursing (DON) stated Resident #36 and Resident #47 were supposed to be weighed weekly. The DON explained that obtaining weekly weights for Resident #36 and Resident #47 was overlooked, and the staff failed to obtain weekly weights on these residents as ordered. During an interview on 09/14/2022 at 10:20 AM, the MDS Nurse stated the weekly weights for Resident #36 and Resident #47 were overlooked, because these residents resided on a hall that was typically used for residents receiving hospice services. During an interview on 09/14/2022 at 10:53 AM, the Administrator stated the staff recognized the weekly weights for Resident #36 and Resident #47 were not obtained as ordered. The Administrator stated she expected the DM to monitor and notify her and the nurse if the weights were not being done. Per the Administrator, if the weights were not completed, the residents' care and well-being could be affected.