**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure adequate supervision, and precautions in place for falls for 1 of 3 residents (R2) reviewed for accidents in the sample of 8. This failure resulted in R2 falling off bed fracturing her femur and requiring surgical repair. Findings include: R2's Order Summary Report, undated, documented she had the following diagnoses: unilateral primary osteoarthritis, dependence on wheelchair, muscle weakness, unsteadiness on feet, unspecified lack of coordination, abnormal posture. R2's initial report to Illinois Department of Public Health (IDPH) dated 6/24/2025 documents R2 slid off the bed on 6/23/2025 at 8:00AM. The report documented CNA (Certified Nurse's Assistant) was assisting (R2) with her morning cares including dressing, personal hygiene, and transferring her from her bed to her wheelchair. (R2) was sitting up on the side of her bed and slide off the mattress onto the floor on her left side. The report documented Interventions put into place to ensure that resident has ‘gripper socks' on at all times while in bed. R2's X-ray report dated 6/24/2025 at 11:51AM documents R2 presented to the emergency room after a fall this morning. R2's x ray report documents distal femoral shaft fracture.R2's orthopedic report dated 6/25/2025 documents R2 requires surgery of left femur.R2's Fall Risk assessment dated [DATE] documents R2 is a high risk for falls. R2's fall risk assessment documents a score of 60. (High risk 46 or greater). R2's fall risk assessment documents R2 has fallen before and has impaired gait.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact with a Brief Interview Mental Status (BIMS) of 14. R2's MDS documents selfcare- 2 needed some help - resident needed partial assistance from another person to complete any activities. R2's MDS documents R2 has impairment of lower extremities on both sides. R2's MDS documents R2 is dependent on staff for toileting hygiene, showers, transfers from bed to a chair or wheelchair. The MDS documented regarding the ability to move from sitting on side of bed to lying flat on bed and the ability to move from lying on the back to sitting on the side of the bed with no back support R2 required substantial/maximal assistance. R2's Care Plan, revised 6/8/2025 documents R2 has an Activity of Daily living (ADL) selfcare performance deficit related to gait balance problems, CKD (chronic kidney disease), muscle weakness, diabetes, HTN (hypertension), CAD (coronary artery disease). R2's care plan documents the following interventions: 6/9/2025 transfer: R2 requires dependent staff assist times 2 with a mechanical lift with transfers.R2's Care Plan, dated 7/1/2025 documents R2 is a high risk for falls related to (r/t) Gait/balance problems, CKD, muscle weakness, diabetes, HTN, CAD. R2's care plan documents the following interventions: 6/26/2025 will continue to work with therapy as ordered, 4/30/2025 Anticipate and meet the resident's needs, Be sure my call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, educate me/family/caregivers about safety reminders and what to do if a fall occurs, follow facility fall protocol, my family has transferred me from one surface to another. Educate them and I that this is not safe and that all transfers should be done with staff only, Pt evaluate and treat as ordered or PRN. R2's Care Plan failed to document gripper socks as documented in fall investigation to ensure gripper socks in place.V7's, Certified Nurse's Assistant, CNA, witness statement dated 6/24/2025 documents V7 left R2 sitting on side of bed while V7 left the room to get the sit to stand lift. The statement documented I was assisting (R2) in bed to get ready for the day. I sat her on the side of the bed to empty out her (indwelling catheter) (and) to assist w (with) getting up. I was told she uses the sit to stand to get up. I left her sitting on the side of the bed because her feet were touching the ground, and she was holding onto the bed. When I came back in from getting the sit to stand (I was only out of the room for 15 secs (seconds) as it was right outside the room) (R2) was sliding down, kinda like she assisted herself to the ground.On 7/14/2025 at11:03AM, R2 stated she was a sit to stand transfer prior to breaking her femur. R2 stated she was sitting on side of bed and CNA left room to get the lift and was just getting back in room and turned to get sling, R2 stated she told CNA she was falling.On 7/16/2025 at 1:51PM, V1, Administrator, stated fall interventions are to be in place after each fall. V1 stated she would expect care plan to document all fall interventions.On 7/16/2025 at 1:55PM V2, Director Of Nursing (DON) stated R2 is a high fall risk and should not be left sitting on bedside. The Facility's Fall policy, revised 6/2024, documents it is the policy of the facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision for 1 of 4 (R2) residents, reviewed for falls in a sample of 4. This failure resulted in R2 sustaining a left hip fracture. Findings include: R2's Diagnosis list, dated 1/14/2025, documented diagnoses of high risk for injury related to falls, Dementia, and Lewy Body Dementia. R2's Morse Fall Scale, dated 1/8/2025, documented that she was a high fall risk. R2's Minimum Data Set, dated [DATE], documented that her cognition was severely impaired, that she was occasionally incontinent of urine and that she required substantial to maximum assistance with toilet transfers. R2's Care Plan, dated 1/8/2025, documented, Anticipate and meet the resident's needs. It continues, Be sure my call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. R2's Fall investigation, dated 1/12/2025, documented, Writer summoned to room by CNA. Writer observed pt lying on (Right) side in front of toilet. Resident Description: I tried to get up. Was this incident witnessed: (NO) It continues, Root Cause: Resident new to facility and attempted to walk back to her bed from her toilet without calling for assistance. R2's local hospital history and physical, dated 1/14/2025, documented, [AGE] year old lady who has a known history of dementia was recently admitted to the hospital for (non-s-t elevation myocardial infarction) and pneumonia and was discharged to rehab last week has been doing well in rehab. He (sic) is usually able to take a few steps on Sunday she was trying to walk and has a fall. At that time, she hit her head, and she was complaining of lower back pain yesterday she worked with physical therapy she was able to de (sic) few steps she was hunched over but still was able to do some therapy and this morning she was having difficulty with legs so was brought into the ER she was diagnosed with left hip fracture . R2's local hospital Xray result, dated 1/14/2025, documented, Findings Mildly displaced intertrochanteric fractur with resultant varus angulation. No pelvic or distal femoral fracture. Impression: Left intertrochanteric fracture. On 1/21/2025 at 2:20 PM, V6, LPN, stated that she knew R2 had a fall history and was a high fall risk. She continued to state that her shift, day shift, did not leave her on the toilet alone because they all knew she was a high fall risk and that there was a white board in R2's room that had written on it that she was a high fall risk. On 1/22/2025 at 9:43 am V7, Licensed Practical Nurse (LPN), stated that she was the nurse who assessed R2 after her fall. V7, stated, The CNA, (V11), came and got me because (R2) was on the floor in the bathroom. She was lying on her right side on the floor. She had a scrape above her right eyebrow and had no complaints of pain. V7 continued to state that she did active and passive range of motion of her legs and arms and there was no issues. V7 stated that she spoke with R2's granddaughter because her power of attorney did not answer the phone. V7 stated that her granddaughter told her that her grandmother falls all the time. V7 was asked, if she knew R2 was a high fall risk and she stated yes and that there was a call don't fall sign in her room and that all rooms have these signs. V7 also stated she did not think R2 knew how to use the call light or what it was for because of her dementia. V7 stated that she did not know why V11, Certified Nurse Assistant (CNA), put her on the toilet and then left the room, maybe to help another resident. On 1/22/2025 at 9:45 am V9, CNA, stated that on 1/14/2025, she went to get R2 up for the day, she assisted her with sitting on the side of her bed, because she wasn't sitting up very well. She was able to transfer R2 into her wheelchair, into the bathroom and on to the toilet with R2 using the assistance bar in the bathroom because R2 was having trouble standing up that day and usually she transferred pretty good. Once R2 was finished using the toilet, V9 stated that she assisted her back into her wheelchair, got her dressed and took her to the dining room for breakfast. V9 stated that R2's appetite was poor that morning, only taking in about 75% of her meal when she usually eats 100%. V9 stated that R2 told her that she was having pain in both of her hips and in her back. V9 stated that she let the nurse know (V10, LPN), they laid her down and (V10, LPN) checked her out. V9 stated that R2 was in pain and had facial grimacing when she transferred her. V9 stated that R2 was a high fall risk but she never tried to get up on her own. V9 stated that she would not leave R2 unattended on the toilet nor would she never depended on R2 using her call light when she needed to get off of the toilet and that she would stay with her until she was finished. On 1/22/2025 at 10:30 am V10, LPN, stated that R2 never asked for pain medication usually but said her hips and back hurts. V10, stated, The CNA (V9) was putting the footrest on (R2's) wheelchair, and her left leg was rotated outwardly, The CNA (V9) and myself, laid (R2) down in bed and I assessed her further. R2's left leg was rotated outward and shortened. I called her doctor for a stat Xray of those areas, and he wanted her sent to the ER immediately. V10 stated that R2 was a high fall risk by just looking at her diagnosis. V10 stated that she told her CNA's who she works with and the oncoming shift not to leave her alone when on the toilet and she should have never been left alone on the toilet. V10 also stated that with R2's dementia she would not know when or how to use the call light. On 1/22/2025 at 9:30 AM, V8, Licensed Physical Therapy Assistant, (LPTA), stated that she worked with R2 on 1/13/2025, the day after she fell, she did not complain of any pain. V8 also stated that R2 could not safely transfer herself on or off of the toilet. V8 stated that R2 could hold a call light but did not think she would understand how to use it. V8 stated that from a safety standpoint someone should have stayed in the bathroom with her. On 1/22/2025 at 9:45 am, a phone call was placed, and a message was left for V11, CNA, to return call. V11, did not return phone call. On 1/22/2025 at 11:00 am V2, Director of Nurses, when asked since R2 was a high risk for falls, should she have been left unattended on the toilet? V2 stated no. When asked if a resident, who is a high risk of falls, what type of interventions would be put immediately into place when they are admitted with a history of falls, she stated that some time a bed and chair alarm, and a call don't fall sign. V2 was asked how does the staff know, agency staff included, who is a high risk for falls and interventions? V2 stated that agency should check the residents care plan and also when they get report from the previous shift, they should be let known. An electronic mail document from V12, R2's Physician, containing questions from the state agency and his responses regarding R2's fall, cognition and safety, dated 1/27/2025, documented, 1. Could a fall from the toilet, onto the floor, possibly cause a left hip fracture even though she was found on her right side? Possibly. 2. Do you think that this injury could have been prevented if the facility staff would have stayed with her until she was ready to get off the toilet and not leave her unattended due to her severely impaired cognition and dementia? Yes. 3. Do you think (R2) could understand how to use a call light with her cognition being impaired? Unable to determine at this time. The facility's policy, Subject: Fall Assessment and Management Policy, dated 6/2024, documented, It is the policy of this facility to assess each resident's fall risk on admission, quarterly and with each fall. this will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. It continues, D. All staff providing care for the resident will have access to the care plan and/or [NAME].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify, monitor and provide treatments as ordered to prevent the worsening or formation of pressure ulcers for 3 of 4 residents (R41, R6 and R22) reviewed for pressure ulcers in the sample of 37. This failure resulted in R41's Stage III pressure ulcer worsening to an unstageable pressure ulcer. Findings include: 1. R41's Current Face Sheet Documents R41 was readmitted on [DATE] with diagnoses of Peripheral Vascular Disease, and Chronic Kidney Disease. R41's Minimum Data Set (MDS) dated [DATE] documents R41 is cognitively intact and requires extensive assistance of one staff member for transfer, dressing, toileting and personal hygiene. R41's Care Plan dated 8/4/22 documents to provide wound care per treatment order. R41's Braden Pressure Ulcer assessment dated [DATE] documents R41 is a high risk for pressure ulcers. R41's Physician Order (PO), start date 7/29/22 documents Silver sulfadiazine cream 1% Apply to Left lateral foot topically every day shift for Pressure Injury. Cleanse wound with normal saline, apply cream to open area, apply dry gauze and cover with optifoam daily. R41's Physician Order (PO), start date 7/29/22, documents Apply Double Cream to left inner ankle for excoriation daily, every day shift. On 08/09/22 at 11:16 AM, V14 Licensed Practical Nurse, Wound Nurse, provided wound dressing changes to R41. R41's left heel and left outer ankle (lateral foot) old dressing was dated 8/7. R41's left lateral foot had a black scabbed area with a small amount of clear drainage on R41's old left lateral dressing noted. No measurement was taken. R41's right heel old dressing was dated 8/6. V14 verified the dates on R41's dressing. On 8/10/22 at 9:31 AM, V14, stated she wasn't able to get all the treatments done on Monday so R41 had left R41's wound dressings to be done by the staff nurses and they did not get done. V14 verified that R41 had an order for daily silver sulfadiazine and double cream and that R41 had old dressing dated 8/7/22 on left foot and a right heel dressing dated 8/6/22 that had not been changed daily. V14 states she notified day and night shift and they were supposed to do the treatments if she is not here, and they did not get to since date is from 8-6 and 8-7. V14 states resident gets silver and double cream daily but has not gotten as ordered. R41's Skin assessment dated [DATE] documents R41 has a left heel pressure ulcer 3 centimeters (cm) by (x) 2.8 cm, right heel pressure 5.7cm x 4.8 cm and a left outer ankle pressure ulcer 3.4 cm x 2 cm x 0.2 cm, stage 3 pressure ulcer. R41's Skin assessment dated [DATE] documents R41's left heel pressure ulcer is 2.1cm x 1.3 cm, Right heel pressure, 4.7cm x 4.5 cm x 0.1cm and left outer ankle (lateral foot) pressure ulcer 4.3 cmx 3.2 cm x .01 cm stage 3. R41's Treatment Administration Records document R41 received ordered daily treatment to left inner ankle and left lateral foot on 8/6 and 8/7/22, however observation on 8/9/22 of R41's intact wound dressing and interview with V14 verified treatment had not been completed since 8/6 and 8/7/22. On 08/11/22 11:18 AM V2, Director of Nursing (DON) stated she expects staff to measure wounds weekly, expects staff to document accurately when treatments are done and expects wound treatment to be done per physician orders. 08/11/22 11:51 AM, V15, R41's Medical Doctor stated she was not aware R41 had not been getting the ordered topical medications of silver and double cream. R41 stated she expects the facility to follow the order. The Facility's Wound and Ulcer Policy and Procedure dated 1/10/2018 documents: It is the policy of this facility to provide nursing standards and for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. Protocols may include any or all of the following based upon the needs and condition of the resident. Additional measures may be added at the discretion of the facility. Weekly skin checks, changes in condition are promptly reported. When a resident is found to have a wound: document assessment of the wound, initiate treatment protocol, document wound/ulcer treatment on treatment administration record, Assessment of progress toward healing is completed at least weekly, if there is regression, the physician is notified of the condition change. treatment per physician orders until the wound and/or ulcer is healed. 2. R22's admission Record, print date of 8/10/22, documents that R22 was admitted on [DATE] with diagnoses of End Stage Renal Disease, Type 2 Diabetes, Hypertension and fracture of the left femur (7/22/22). On 8/9/22 at 8:31 AM, R22 was in the dining room with left leg immobilizer covering her pants. R22's MDS, dated [DATE], documents that R22 is cognitively intact, requires extensive assistance of 2 staff members for bed mobility and R22 is totally dependent on 2 staff members for transfers. R22's Ulcer/Wound documentation, dated 7/23/22, document, Date ulcer/wound was initially identified: 7/23/22. L (left) heel outer Pressure 0.3 (cm) length, 0.4 (cm) width, 0.1 (cm) depth. Suspected Deep Tissue Injury. Peri wound Skin: Deep purple tissue over bony prominence. R22's Ulcer/Wound documentation, dated 7/27/22, document, Date ulcer / wound was initially identified: 7/23/22. Left heel. Pressure 1.7 length, 1.3 width, 0.1 depth. Suspected Deep Tissue Injury. Peri wound Skin: area is purple in color, skin intact. There were no documented Ulcer/Wound assessment in R22's medical record from 7/27 through 8/10/22. R22's July and August 2022 Treatment Administration Records (TARs), documents, Left heel: Cleanse area with skin integrity, pat dry, apply xeroform open area, cover with optifoam gentle. Change daily. Float heels on pillow when in bed. Start date 7/25/22. There was no documentation R22's treatment was done on 7/26/22, 7/28/22 and 8/1/22. R22's Physician's Order, dated 8/1/22 with start date of 8/2/22, documented Left heel: Cleanse area with skin integrity, pat dry, apply skin prep, cover with optifoam gentle. Change daily. Float heels on pillow when in bed. Every day shift. R22's Ulcer/Wound documentation, dated 7/23/22, document, Date ulcer/wound was initially identified: 7/23/22. Right buttock 2.5 cm length, 3.3 cm width, 0 depth. Stage 1. Peri wound Skin: intact but fragile. Scant drainage. There was no documented Ulcer/Wound assessment in R22's medial record from 7/23/22 through 8/9/22. R22's July 2022 TAR documents, Right buttocks: Cleanse area with Skin integrity, pat dry and apply Exuderm change Q (every) 3 days every day shift every 3 day(s) for open area -Start Date 07/25/2022 0600 D/C (discontinue) 07/28/2022. R22's August 2022 TAR documents Right buttocks: Cleanse area with Skin integrity, pat dry and apply Exuderm change Q 3 days every night shift every 3 day(s) for open area -Start Date 07/28/2022. R22's Ulcer/Wound documentation, dated 8/9/22, document, Date ulcer / wound was initially identified: 7/23/22. Right buttock 1.5 cm length, 1.6 cm width, 0.1 depth. Stage II. Peri wound Skin: Area has a 100% granulation tissue with macerated edges. Scant drainage. R22's pressure ulcer had increased in depth and was now classified as a Stage II pressure ulcer. R22's Ulcer/Wound documentation, dated 7/23/22, document, Date ulcer/ wound was initially identified: 7/23/22. Left ankle (outer) bruising 0.7 cm (centimeters) length, 0.7 cm width, 0 depth. Unstageable. There was no other Ulcer/Wound documentation in R22's medical record regarding R22's left outer ankle pressure ulcer/pressure injury. There were no treatments orders documented in R22's medical record for R22's left ankle pressure ulcer. R22's Ulcer/Wound documentation, dated 7/23/22, document, Date ulcer / wound was initially identified: 7/23/22. Right inner ankle (outer) pressure 0.5 cm (centimeters) length, 0.8 cm width, 0.1 depth. Suspected Deep Tissue Injury. Peri wound Skin: Deep purple tissue over bony prominence. There was no other wound/pressure documentation for R22's medical record regarding R22's right ankle pressure ulcer/pressure injury. There were no treatments orders documented for R22's right ankle in R22's medical record. R22's Ulcer/Wound documentation, dated 8/9/22, documents, Date ulcer / wound was initially identified: 7/23/22. Right heel: Pressure. 1.0 length, 0.9 width, 0.1 depth. Suspected Deep Tissue Injury. Peri wound: Area is purple in color skin intact. There was no other wound/pressure ulcer documentation in R22's medical record prior to 8/9/22 regarding R22's right heel pressure ulcer/pressure injuries. R22's July and August TARs document, Right heel: Clean heel with skin integrity, pat dry, apply skin prep and allow to air dry. Cover with Optifoam gentle. Change daily. Float heels on pillow when in bed every day shift for soft heel. -Start Date 07/25/2022 0600. R22's TAR does not document R22's treatment to her right heel was completed on 7/26/22 and 7/29/22. R22's Ulcer/Wound documentation, dated 8/9/22, documents, Date ulcer / wound was initially identified: 8/09/22. Coccyx. Pressure. 10 (cm) length. 8.5 (cm) width. 0.1 (cm) depth. Stage II. Peri wound: Area has small stage 2 pressure injuries with DTI (deep tissue injury) surrounding. New treatment in place. Scant drainage. R22's August 2022 TAR documents, Cleanse area on coccyx and apply exuderm to coccyx and change every three days and PRN. start date of 8/9/22. On 08/10/22 at 09:04 AM, V14, stated, that one week was really busy and that is why the measurements weren't done and that she did not realize that she had went over 2 weeks without measurements. On 08/10/22 3:35 PM, V14, Licensed Practical Nurse/Wound Nurse changed R22's dressings to the left heel and right heel. V14 removed R22's left heel old dressing. R22's left outer heel has an area the approximate size of a quarter that is covered in a scab, then there is a line that runs down to the back of the heel with a small open slit in the heel. The area was cleansed, and sure prep was applied then covered with a foam dressing. R22's left outer upper ankle had a deep tissue injury the approximate size of a dime. The area appears to be from the immobilizer brace that R22 is wearing. No dressing/treatment was applied. R22's right outer heel pressure ulcer has pale pink skin over it. R22's coccyx wounds were unable to be observed related to R22's extreme pain. R22's Order Summary Report, print date of 8/10/22, documents, Cleanse area on coccyx and apply exuderm to coccyx and change every 3 days and PRN (as needed). as needed. Cleanse area on coccyx and apply exuderm to coccyx and change every three days and PRN. every night shift every 3 days. Left heel: Cleanse area with skin integrity, pat day, apply skin prep, cover with optifoam gentle. Change daily. Float heels on pillow when in bed. every day shift. Right heel: Clean heel with skin integrity, pat dry, apply skin prep and allow to air dry. Cover with Optifoam gentle. Change daily. Float heels on pillow when in bed every day shift for soft heel. On 8/11/22 at 11:19 AM, V2, Director of Nursing stated, I would have expected that the nurses would have caught (R22's) coccyx wound before it got as big as it did. 3. R6's admission Record, dated 8/10/22, documents that R6 was admitted [DATE] and has diagnoses of Major Depressive Disorder and Hypertension. R6's MDS, dated [DATE], documents R6 is severely cognitively impaired and requires extensive assistance of 1 staff member for dressing. R6's Health Status Note, dated 7/31/22, documents, Area on res (resident) left outer ankle has re-opened, area measures 1cm (centimeters) X 1cm. TX (treatment) was initiated as follows: Cleanse with wound cleanser, pat dry and sure prep peri wound. Apply Xeroform to wound bed and cover with dry drsg (dressing). R6's Ulcer/Wound documentation, dated 7/3/22, documents, L (left) outer heel blister 3.0 (cm) x 2.5 (cm) x 0.1 (cm). R6's Ulcer/Wound documentation, dated 8/2/22, documents, L lateral heel blister 2.7(cm) x 2.3 (cm) x < 0.1 (cm). Peri wound: Blistered opened up. Area is 75% macerated with some drainage and 25 % granulation tissue. R6 has no other wound documentation available for review regarding R6's pressure ulcers from 7/3/22 through 8/2/22. On 08/08/22 at 1:53 PM, V14 removed R6's shoe to change R6's pressure ulcer dressing on his left outer foot. There was no pressure ulcer dressing on R6's pressure ulcer. The wound bed is red and approximately the size of a dime. On 8/8/22 at 1:55 PM, V14 stated, He should have a had a dressing on it maybe it was his shower day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify, monitor and implement interventions to address weight loss for 1 of 3 residents (R34) reviewed for weight loss in the sample of 37. This failure resulted in R34 having a significant weight loss of 47.3 pounds indicating a 28.3% weight loss in 6 months. Findings include: R34's admission Record, print date of 8/10/22, documents that R34 was admitted on [DATE] and has diagnoses of Neuropathy, Gastro - Esophageal Reflux Disease without esophagitis. R34's Minimum Data Set, dated [DATE], documents that R34 is cognitively intact and requires supervision and one staff member physical assist for dining. R34's Weight Record documents the following dates, times and pounds weighed: 8/9/2022 10:01 119.5 Lbs. (pounds) 8/3/2022 14:02 119.0 Lbs. 8/3/2022 10:18 119.0 Lbs. 8/2/2022 12:26 119.0 Lbs. 8/2/2022 10:43 119.0 Lbs. 8/2/2022 08:49 119.0 Lbs. 7/27/2022 11:36 131.0 Lbs. 5/3/2022 17:55 161.6 Lbs. 4/19/2022 10:35 158.5 Lbs. 4/19/2022 09:49 158.5 Lbs. 4/1/2022 11:26 163.6 Lbs. 3/14/2022 15:50 155.0 Lbs. 3/1/2022 09:51 175.2 Lbs. 2/22/2022 16:26 168.0 Lbs. 2/21/2022 09:44 168.4 Lbs. 2/20/2022 10:57 168.0 Lbs. 2/19/2022 10:30 166.8 Lbs. 2/18/2022 12:19 166.8 Lbs. There was no documented weight in June 2022. This weight log documents R34 had a significant weight loss of 47.3 pounds indicating a 28.3% weight loss in 6 months. R34's Health Status Note, dated 6/3/22, documents, Another call out to (V16 Physician) office to request orders regarding res. c/o (complaint of) gastric reflux. Also requested a PRN (as needed) order for Zofran per res (resident). R34's Health Status Note, dated 6/15/22, documents, RD Note-Weight/Skin Review-HT:62 in (inches). Wt:145#'s. BMI=26.5 wnl (within normal limits). DBWR (desired body weight range) =104-148#'s. Wt. within DBWR. Per weight exception report resident had 10.3% decrease in weight times 1 month and 13.1% decrease in weight times 4 months. Noted resident currently on ABT for UTI. Diet Rx: Reg, Reg, thin liquids Appetite is ~51% at meals currently. Meds reviewed and noted tramadol and Amoxicillin added since last review that may decrease appetite and weight; and gabapentin added that may increase appetite and weight. Per 6/13-pressure wound report resident has pressure wounds on left heel, left big toe, and LLE rear times 2. Resident remains on Vit C, Zinc and MVI w/minerals that supports healing. See recommendation to add Liquid Protein 30ml's one time per day to meet her needs for weight maintenance and wound healing of multiple wounds. Monitor and refer to RD Prn. R34's Health Status Note, dated 7/13/22, documents, per 7/13 wound report resident has pressure wound on left heel and left big toe and DTI (Deep Tissue Injury) on right heel. Diet Rx (prescription): Reg (regular), Reg, thin liquid with Liquid Protein 30 ml one time per day. Appetite is ~26-50% of meals currently. Current wt. (weight): 157#'s. BMI (body mass index) =28.7H DBWR (desired body weight range) =104-148#'s. Wt. above DBWR but within UBWR for resident. Per weight exception report resident had 8.3% increase in weight times 1 month and 10.4% decrease in weight times 4 months. No new nutrition related med (medication) changes since last review. Resident remains on MVI (multivitamin) w (with)/minerals, Vit C (vitamin C) and Zinc that supports healing. No new labs to assess. No changes recommended at this time. Diet and wound supplement along with vitamins and minerals remains appropriate to support healing. Monitor and refer to RD Prn. (Registered Dietician) On 8/11/22 at 11:19 AM, V2, Director of Nurses (DON), stated that she just noticed (R34's) weight loss at the end of July. V2 also stated that the facility does weekly meeting to discuss weight loss and (R34) did not get noticed until the end of July. V2 also stated that R34 should have been weighed every month. V2 stated that R34 was moved from the rehabilitation wing to the room that she is in and maybe that caused some of the weight loss and also, she was put on Tramadol. V2 stated that R34 did have complaints of acid reflux and she has been seen and received medication for it. V2 stated that she did have an esophagram and she needs to see a specialist. On 8/11/22 at 1:19 PM, V16, Physician, stated, I am an outpatient internal medicine doctor. (R34) is usually brought to my office by someone. I last saw her on July 27, 2022 and she was concerned about her wounds and her pain. I was unaware. I can only treat what I am told. I was unaware of her weight loss. She is now malnourished. This will not help her wound healing. She needs to be on a calorie count, fortified foods and supplements. I am not sure if her weight loss is a medical problem or it's just because she does not feel good. She has pain from those wounds. We should try and get her pain under control and maybe that will help. R34's August 2022 Order Summary Report, documents, Weekly weights x 4 in the morning every Tue (Tuesday), Wed (Wednesday) for maintenance for four weeks. Start date 7/27/22. Regular diet, thin texture. Liquid Protein 30 ML (milliliters) in the morning for wound healing. The Facility's Weight Management Policy and Procedure with a revision date of 2/2016 documents, Each resident will be weighed at least once a month on a predetermined schedule. All residents will be monitored for significant weight changes to assure maintenance of acceptable parameters of body weight. Residents will be weighed using the same scale and in a consistent manner unless clinical condition warrants the use of a different scale or an altered manner. A change in scale or method will be noted if this occurs. A resident with a weight fluctuation of greater than five pounds (+ or -) will be re-weighed for accuracy. The new weight will be recorded in the medical record. Monthly weights will be obtained by the 10th of each calendar month and the Dietary Manager or designee will review the monthly weights by the 10th of the month. All scales will be calibrated at least monthly by the Facilities staff or their designee. At least monthly, resident weights will be compared to prior weights to identify any significant, severe or insidious weight changes. The Weight and Vitals Exception Report will be reviewed weekly by dietary staff to determine significant weight changes. Parameters of a significant weight change per OBRA (Omnibus Budget Reconciliation Act) guidelines will be used. Weight loss that occurs quicker than the OBRA guideline parameters will be addressed as they occur. (Example: If a 10% weight loss occurs in four months, the weight loss will be addressed at that time.) OBRA weight change parameters document significant change as 5% in 30 days or 10% change in 180 days. Any resident with a significant or insidious weight change will be referred to the dietitian for assessment of the residents' condition. They dietitian will implement any necessary clinical interventions or make recommendations regarding diet and supplementation to the physician. The physician will be notified of any significant weight change and be made aware of any recommendations made by the dietitian. The POA (power of attorney) for health care will be notified of significant weight changes. The interdisciplinary care plan team will assess the resident's overall condition to see if the weight change impacts more than one area of the resident's health status. A significant change assessment will be completed if there is a consistent pattern of changes, with either two or more areas of improvement/decline.