Based on observation, interview, and record review, the facility failed to implement infection control practices for 1 of 2 residents reviewed for urinary catheters. The urinary catheter bag was on the floor.(Resident 54) Findings include: On 12/17/24 at 11:02 a.m., Resident 54 was observed to be sitting in her wheelchair with a urinary catheter drainage bag in a privacy bag placed under the wheelchair. The privacy bag was dragging the floor as the staff was pushing her in the wheelchair. On 12/17/24 11:13 a.m., Resident 54 was observed to be sitting in her wheelchair with a urinary catheter drainage bag in a privacy bag placed under the wheelchair. The privacy bag was dragging the floor as the staff was pushing her in the wheelchair. On 12/18/24 at 11:02 a.m., Resident 54's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease and neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord, or nerve problem). Resident 54's December 2024 Physician Order, indicated 16 French (size of catheter) catheter with a 10 milliliters balloon. Resident 54's care plan, dated 7/2/24, indicated she had a catheter for urinary retention and neuromuscular dysfunction of the bladder. The care plan lacked documentation of placement of catheter bag under wheel chair to assist with keeping drainage bag off the floor. During an interview on 12/20/24 at 11:55 a.m., CNA 1 indicated when drainage bag and cover were placed under the wheelchair, it should not touch or drag the floor. On 12/20/24 at 12:30 p.m., the Director of Nursing (DON) provided the facility's policy, Foley Catheter Care & Maintenance, dated 8/30/07, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .1. When in bed or wheel chair: .b. Place in catheter cover bag underneath wheelchair . c. Ensure bag or tubing is not touching floor . 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident's wheelchair was clean for 1 of 1 residents reviewed for feeding tubes. (Resident 19) Findings include: During a family interview on 2/20/24 at 11:39 a.m., Resident 19's wife indicated when she comes to visit, Resident 19 was always covered in sticky tube feeding solution. She indicated it's all over his clothes, his wheelchair, and on the bedroom floor. She wished the facility would be more careful to make sure the tube feeding did not get all over the place. During an observation at that time, a light-brown substance on various spots on the seat and the wheels of his wheelchair was observed. On 2/20/24 at 11:50 a.m., Resident 19's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction (stroke), dominant-sided hemiplegia, and acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). An Annual Minimum Data Set (MDS) assessment, dated 1/17/24, indicated the Resident 19 had impairment on one side for upper and lower extremities. He was dependent (helper does all of the effort and the resident does none of the effort to complete the activity) on staff with dressing and personal hygiene. A Brief Interview for Mental Status (BIMS) was not conducted because the resident was rarely/never understood. A physician's order, dated 1/15/24, indicated the resident was prescribed continuous administration of Jevity 1.2 (a nutritional tube feeding solution) at 50 milliliters per hour. On 2/22/24 at 3:04 p.m., Resident 19's wheelchair was observed with multiple light-brown substance spots on the seat and wheels. On 2/23/24 at 10:58 a.m., Resident 19's wheelchair was observed with multiple light-brown substance spots on the seat and wheels. During an interview on 2/23/24 at 2:30 p.m., the DON indicated Resident 19's wheelchair had splotches of brown substance on its wheels, seat, handles, and armrests and was in need of cleaning. She believed the substance was related to the placement of the tube feeding solution which had caused the spills. On 2/23/24 at 3:00 p.m., the Administrator provided the policy, Resident Rights, dated 11/17/17, and indicated it was the policy currently being used. A review of the policy indicated, . (i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment . The facility must provide -- (1) A safe clean comfortable, and homelike environment . 3.1-19(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure information regarding the administration of insulin was correctly entered in the Minimum Data Set assessment for 1 of 4 residents reviewed for unnecessary medications. (Resident 12) Finding includes: On 2/23/24 at 11:25 p.m., Resident 12's clinical record was reviewed. The diagnoses included, but were not limited to, chronic atrial fibrillation and diabetes. The Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated the resident had received 7 insulin injections within the past 7 days. A physician's order with a start date of 4/20/23 indicated the resident had been prescribed a 100 unit Humalog (insulin) solution injection on a sliding scale. The order was discontinued on 10/4/23. During an interview on 4/23/24 at 1:10 p.m., the MDS Coordinator indicated the MDS assessment information had been incorrectly entered, as the insulin order had been discontinued on 10/4/23. 3.1-31(d)

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed. (Resident B) Finding includes: On 8/2/23 at 11:00 a.m., the clinical record for Resident B was reviewed. The diagnoses included, but were not limited to, cerebral vascular accident (CVA) and hypertension. A review of the admission home health orders, dated 6/29/23, included, but were not limited to: - Chlorthalidone (a diuretic medication) 25 mg (milligrams), give one half tablet daily, dated 6/29/23. A review of the signed orders physician's orders included, but were not limited to: Chlorthalidone 25 mg, one tablet daily, initiated 7/19/23 Resident B's MAR (Medication Administration Record), dated 7/1/2023 through 7/31/2023, indicated Resident B received Chlorthalidone 25 mg daily while in the facility. On 8/2/23 at 12:56 p.m., the DON (Director of Nursing) indicated Resident B was to receive Chlorthalidone 25 mg, one half tablet daily. After Resident B was discharged to home, it was discovered Resident B was given a whole tablet of Chlorthalidone 25 mg daily. She indicated when the nursing staff received the orders from the home health agency, they entered it into the computer and sent it to the physician for verification. The DON indicated the staff should have reviewed the medications put into the computer, but they did not. On 8/2/23 at 1:35 p.m., the DON provided the facility Physician Order Transcription Policy, revised 6/15/10, and indicated it was the policy currently in use. The policy indicated if orders were entered directly into the PCC (point click care software) just add the new orders. This Federal tag relates to Complaint IN00414135. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure an accurate record of dispensing for a narcotic pain medication. The nurse failed to have a second nurse verify a narcotic pain medication was disposed before preparing and administering a second dose of the medication. (Resident B, LPN 1) Finding includes: During an interview on 2/15/23 at 9:50 a.m., the Administrator indicated an investigation was completed when LPN 1 (Licensed Practical Nurse) dropped an oxycodone (narcotic pain medication) 5 mg (milligram) tablet on the floor. She prepared another dose for Resident B without having a second nurse verify the first pill was wasted. The clinical record for Resident B was reviewed on 2/15/23 at 10:04 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease and pain. An admission MDS (Minimum Data Set) assessment, dated 1/27/23, indicated Resident B was cognitively intact. Physician's orders included, but was not limited to, oxycodone 5 mg by mouth every 8 hours as needed for pain, initiated 1/20/23. The February 2023 Medication Administration Record indicated Resident B was assessed for effectiveness of oxycodone 5 mg, on 2/7/23 at 12:42 p.m. and 9:50 p.m. The Controlled Medication Record Sheet, dated 2/7/23, indicated LPN 1 administered oxycodone 5 mg to Resident B on 2/7/23 at 11:00 a.m., 6:30 p.m. The Drug Diversion Investigation Worksheet: Reasonable suspicion of a Crime, dated 2/9/23 at 2:04 p.m., indicated medication was signed out as administered but Resident B stated she did not receive the medication. During an interview on 2/15/23 at 10:58 a.m. LPN 1 indicated she gave oxycodone 5 mg to Resident B two times, on 2/7/23 at 11:00 a.m. and 6:30 p.m. She prepared one oxycodone 5 mg tablet for the 6:30 p.m. dose but dropped it on the floor. She prepared a second dose of oxycodone 5 mg and administered it to Resident B. She wrote dropped on the controlled medication record sheet but did not have a second nurse verify the oxycodone tablet was wasted. She should have had a second nurse verify the oxycodone tablet was wasted before she administered the second oxycodone tablet to Resident B. On 2/15/23 at 1:00 p.m., the Administrator provided a copy of a facility policy, titled Counting and Disposing of Schedule 2 Narcotics, dated 1/29/16, and indicated this was the current policy used by the facility. A review of the policy indicated if a dose of scheduled 2 narcotic is removed from the container but refused by the resident or not given for any reason, it will be destroyed in the presence of 2 licensed nurses. The disposal will be documented on the narcotic count sheet and or drug disposition record. 3.1-25(s)(8)

Based on observation, interview, and record review, the facility failed to assess and monitor a resident for 72 hours after a fall for 1 of 3 residents reviewed for accidents. (Resident 10) Finding includes: During an interview on 1/12/23 at 10:30 a.m., Resident 10's family member indicated about a month ago Resident 10 fell and hit her head. On 1/13/23 at 10:51 a.m., Resident 10 was observed to be sitting up in her bed with her feet resting in her wheelchair. On 1/17/23 at 11:35 a.m., Resident 10 was observed to be sitting in her bed with her shoes on. On 1/17/23 at 10:44 a.m., Resident 10's clinical record was reviewed. The diagnoses included, but were not limited to, vascular dementia, Alzheimer's disease, repeated falls, and anxiety. The Significant Change Minimum Data Set (MDS) assessment, dated 12/13/22, indicated Resident 10 had severe impaired cognition and had one fall with no injury. The Nursing-Occurrence Initial Assessment, dated 12/18/22 at 3:04 a.m., indicated Resident 10 was found lying on the floor next to her bed. She indicated she was trying to empty her trash and slid off her bed onto the floor hitting her head. She had a small abrasion to her right eyebrow. The Nursing-Occurrence Follow-Up Assessment, dated 12/22/22 at 1:15 a.m., indicated neurological and head to toe assessments were completed. The clinical record lacked Nursing-Occurrence Follow-Up documentation being completed every shift for 12/19/22, 12/20/22, or 12/21/22. The December 2022 progress notes lacked documentation of fall follow up. The Neurological Checklist dated 12/18/22 through 12/26/22 lacked documentation of vital signs and neurological assessments being completed on 12/18/22 at 1:15 p.m., 12/18/22 at 3:15 p.m., 12/18/22 at 5:15 p.m., 12/18/22 at 9:15 p.m., 12/19/22 at 1:15 a.m., 12/19/22 at 5:15 a.m., 12/20/22 at 9:15 a.m., and 12/20/22 at 5:15 p.m. During an interview on 1/18/23 at 11:07 a.m., the Director of Nursing (DON) indicated a fall with injury was followed-up every shift for 72 hour on a Nursing-Occurrence Follow-up. During an interview on 1/18/23 at 11:32 a.m., the DON indicated Resident 10's clinical record lacked documentation of 72 hour fall follow-up. During an interview on 1/18/23 at 12:15 p.m., the DON indicated the Neurological Checklist lacked documentation on 12/18/22 at 1:15 p.m., 12/18/22 at 3:15 p.m., 12/18/22 at 5:15 p.m., 12/18/22 at 9:15 p.m., 12/19/22 at 1:15 a.m., 12/19/22 at 5:15 a.m., 12/20/22 at 9:15 a.m., and 12/20/22 at 5:15 p.m. On 1/18/23 at 12:45 p.m., the DON provided the facility's policy, Fall Management Procedure dated 3/18/22, and indicated this was the policy currently being used by the facility. A review of the policy did not provide how often fall follow-up should be completed. 3.1-37(a)

2. On 1/12/23 from 9:30 a.m. until 12:07 p.m., Resident 9 was observed lying on his back in his bed with the head of his bed raised at an approximate angle of 45 degrees. His lower body was in full contact with the mattress. During an interview at 11:47 a.m., the resident indicated he had been lying in the same position as long as he could recall. He wished to reposition off of his bottom, but when he tried to do so himself he slid on the wound on his left buttock. He would have used his call light button, but staff took too long to get to him. On 1/13/22 from 9:40 a.m. until 12:16 p.m., Resident 9 was observed lying on his back in his bed with the head of the bed raised at an approximate angle of 45 degrees. His lower body was in full contact with the mattress. Certified Nurse Aide (CNA) 2 was observed entering the room at 10:40 a.m. to attend to the resident's roommate until 10:45 a.m. There was no interaction between CNA 2 and Resident 9. During an interview at 10:48 a.m., the resident indicated staff repositioned him that morning around 8:30 a.m. but had not come in to do so for a long time. He could not wait for them because of the pain he had in his left hip and he tried to move himself in the bed, sliding on the wound on his left buttock. He believed the dressing they put on his wound came off whenever he moved himself in bed. On 1/17/23 from 9:10 a.m. until 11:20 a.m., Resident 9 was observed lying on his back in his bed with the head of the bed raised at an approximate angle of 45 degrees. His lower body was in full contact with the mattress. On 1/17/23 at 11:32 a.m., the Director of Nursing (DON) was observed performing a dressing change for a pressure ulcer on the left buttock of the resident. There was no prior dressing on the wound to remove during the observation. The skin at the resident's coccyx (a small triangular bone at the base of the spinal column) area was intact and appeared reddened in color. During an interview at that time, the DON indicated the previous dressing may have come off when the resident attempted to reposition himself. During an interview on 1/18/23 at 10:43 a.m., CNA 1 indicated staff were to encourage or assist residents at risk for pressure sores every 2 to 3 hours. They documented this was done each shift, but not necessarily each individual time the resident was repositioned. During an interview on 1/18/23 at 11:52 p.m., The DON indicated the resident was able to move himself in his bed and did not always wait or call for assistance to be repositioned. Residents at risk for pressure ulcers were to be repositioned every 2 to 3 hours. On 1/17/23 at 11:50 a.m., Resident 9's clinical record was reviewed. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, anxiety disorder, insomnia, and muscle weakness. The Quarterly MDS assessment, dated 11/16/22, indicated the resident was cognitively intact, at risk for developing pressure ulcers, and required the extensive physical assistance of 1 person for bed mobility. A pressure injury assessment, dated 1/5/23, indicated the resident had developed a stage 2 pressure ulcer measuring 1.8 cm long by 1.2 cm wide, and 0.1 cm deep on his left buttock while a resident of the facility. A physician's order, dated 1/5/23 indicated the resident's wound was to be treated every 2 days by cleaning the left buttock with normal saline, applying collagen powder and covering with mepitel one (a see thru dressing). A skin risk care plan, initiated on 5/10/22 indicated, Document encouraged/assisted to turn/reposition every 2-3 hr to prevent pressure injuries. On 1/18/23 at 12:35 p.m., the DON provided the policy, Skin Management Program, dated 8/14/14, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . E. REPOSITIONING FOR THE PREVENTION OF PRESSURE ULCERS: . II . In general, every 2 hours will be the minimum for repositioning the resident. III . If the resident is not responding as expected to the repositioning schedule, reconsider the frequency and method of repositioning. IV. Lift - don't drag the resident when repositioning. 3.1-40(a)(1) Based on observation, interview, and record review, the facility failed to ensure treatment was provided to prevent the development of pressure ulcers which resulted in the development of a facility acquired stage 2 pressure ulcer (Resident 9) and an unstageable and infected pressure ulcer (Resident 7) for 2 of 5 residents reviewed for pressure ulcers. Findings include: 1. During an interview on 1/12/23 at 11:52 a.m., Resident 7 was sitting in his wheelchair and indicated he had recently developed a pressure ulcer on his bottom. He indicated the staff wanted him to lay in the bed to get him off of his bottom, however, lying in the bed hurt his right leg which he could not move or bear any weight. Since he had no side rails, he could not easily move around in bed. He further indicated staff did not reposition him every 2 to 3 hours, rather in bed or up in his wheelchair. No side rails were observed to the resident's bed. On 1/13/23 at 10:17 a.m., Resident 7's clinical record was reviewed. The diagnoses included, but were not limited to, neuromuscular dysfunction of bladder, difficulty in walking, muscle weakness, incomplete paraplegia, arthropathy (joint disease), and peripheral vascular disease. On 1/7/23 the resident weighed 244 pounds, and was 6 foot and 2 inches tall. A Quarterly MDS (Minimum Data Set) assessment, dated 11/7/22, indicated the resident had moderately impaired cognition, the resident required limited assistance of one staff with transfers, and he had lower extremity impairment on both sides. During the assessment look-behind period, the MDS indicated the resident was unsteady and only able to stabilize with human assistance with surface-to-surface transfers, and when moving on and off of the toilet. The resident's wound assessments indicated the following: - On 12/21/22, the resident developed an in-house stage 2 pressure ulcer which resulted from shearing. The wound measured 8 centimeters (cm) in length, 5 cm. in width, and had a depth of 0.1 cm. The assessment identified the resident was chairfast (the ability to walk was severely limited or non-existent) and he could not bear own weight and/or must be assisted into chair or wheelchair. The resident required moderate to maximum assistance in moving, complete lifting without sliding against sheets was impossible, and he frequently slid down in the bed or chair and required frequent repositioning with maximum assistance. - On 12/27/22, the wound measured 9.5 cm in length, 6.5 cm in width, and had a depth of 0.1 cm. The wound was now a stage 3, with 25% slough, and had a foul odor. - On 1/3/23, the wound measured 13 cm in length, 6.5 cm in width, and had a depth of 0.1 cm. - On 1/10/23, the wound measured 11 cm in length, 5 cm in width, and had a depth of 0 cm. The wound was now unstageable, with 100% slough. - On 1/17/23, the wound measured 10 cm in length, 6 cm in width, and had a depth of 0.1 cm. - On 1/17/23, the resident developed 3 new, in-house, pressure ulcers on his left upper thigh. The first fluid-filled blister measured 2 cm in length, 2 cm. in width, and had no depth. The second fluid-filled blister measured 1 cm in length, 1 cm in width, and had no depth. The third fluid-filled blister measured 1.6 cm in length, 2.3 cm in width, and had no depth. The resident's progress notes indicated the following: - On 12/21/22 at 3:25 p.m., the resident developed an in-house pressure ulcer to his right buttocks. The facility was to obtain a slider sheet since the resident frequently needed to be pulled up higher in the bed due to sliding down in the bed. - On 12/28/22 at 4:37 p.m., a new order for Clindamycin 300 milligrams (mg) was placed due to the buttocks wound. - On 1/3/23 at 10:51 a.m., the resident's pressure ulcer was not healing. - On 1/10/23 at 10:09 a.m., the resident's pressure ulcer was not healing. The resident's physician orders indicated the following: - On 12/21/22 at 1:30 p.m., the pressure wound treatment was to clean buttocks with normal saline, apply collagen powder, and cover with Mepilex (foam dressing that absorbs exudate and maintains a moist wound environment) every 2 days. The order was discontinued on 1/3/23. - On 12/28/22 at 1:15 p.m., the resident was ordered Clindamycin (an antibiotic medication) 300 mg, three times a day, for 7 days, for the buttocks wound. - On 1/3/23 11:15 a.m., the pressure wound treatment was to clean buttocks with normal saline, apply Exufiber (an absorbent sterile dressing), cover with dry dressing, and change every 2 days. - On 1/18/23 at 11:15 a.m., the pressure wound treatment was changed add collagen powder to the Exufiber dressing changes. The order was now for daily dressing changes. The resident's care plan's indicated the following: - On 10/10/22, the resident was identified to be at risk for pressure ulcers. He required up to extensive assistance with bed mobility due to weakness related to his diagnosis of incomplete paralysis of lower limbs. An intervention included for staff to document any encouraged/assisted to turn/reposition every 2-3 hour to prevent pressure ulcers. - On 10/11/22, the resident was identified to be at risk for falls. He required up to extensive staff assistance with transfers related to his diagnosis of incomplete paralysis of bilateral lower extremities (BLE). The interventions did not identify how the resident should be transferred. - On 10/11/22 the resident was identified as needing assistance with ADLs (activities of daily living). He required up to total assistance with ADL's (including bed mobility and transfers) due to his diagnosis of incomplete paralysis of BLE and muscle weakness. The interventions did not identify how the resident should be transferred. - On 12/21/22, the resident developed a pressure ulcer on his right buttocks. He needed to be pulled up in the bed often from sliding down, and he could not lift body weight to assist staff. The resident was encouraged to turn and reposition every 2 hours. The resident's December through January turn sheets indicated staff documented on turning/repositioning every shift (three times a day). There was no other documentation related to staff turning or repositioning the resident. During an observation on 1/18/23 at 10:15 a.m., CNA (Certified Nurse Aide) 1 and BNA (Basic Nurse Aide) 1 were observed mid transfer of the resident from his bed. The CNAs instructed the resident to help with the transfer, however, the resident was screaming loudly in pain and indicated he could not help with the transfer. After a rapid drop to the bed, the resident was observed laying with half of his bottom off of the side of the bed, he was breathing heavily, and showed signs of distress. His pants were below his briefs, exposing his supra pubic catheter and tubing, 3 dark purple fluid-filled blisters to his upper thigh, and his catheter site entrance had bright red blood around the naval tubing. The CNAs indicated they needed extra help, and CNA 1 was observed to leave the room to get additional staff. The resident indicated he could not do the transfer because he could not use his legs. BNA 1 indicated she did not know what caused the blisters and thought it might have been due to his catheter tubing position on his leg. On 1/18/23 at 10:21 a.m., a large, irregular-shaped, tunneling wound with slough (necrotic tissue that needs to be removed from the wound for healing to take place) was observed on the resident's right buttock. The left buttock was observed to be reddened. RN 1 indicated the wound was not improving. During an interview on 1/18/23 at 11:23 a.m., CNA 1 indicated she did not know if he was normally a manual transfer because she did not normally work that hall. He should be turned or repositioned every 2 hours. During an interview on 1/18/23 at 12:08 p.m., the resident indicated frustration with how staff transfer him. Last night he was dropped in his bed during a manual transfer. He indicated that staff would sometimes use the mechanical lift with him, but not often. He would like to try a slide-board for transfers since he could not use his legs. During an interview on 1/18/23 at 10:38 a.m. the Director of Nursing (DON) indicated she was the wound nurse for the facility. The resident's buttocks wound now had tunneling and it developed due to shearing when staff transferred him. She was still investigating the incident related to the resident's transfer last night.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and respond to an assessed weight loss and failed to implement interventions for 1 of 1 resident reviewed for nutrition. (Resident 217) Finding includes: During an interview on 1/12/23 at 1:59 p.m., Resident 217 indicated she had lost weight since her admission to the facility but she hadn't had much of an appetite since being in the hospital and hadn't been eating very much. She did drink an Ensure at times. Resident 217's clinical record was reviewed on 1/17/23 at 2:00 p.m. The diagnoses included, but were not limited to, diverticulitis of the small intestine with perforation and abscess without bleeding and ileostomy (an opening in the abdominal wall). The resident admitted to the facility on [DATE]. Physician orders, dated 1/18/23, for Resident 217 indicated, . Diet: regular, low fiber and Ensure 257 ml [milliliters] with meals for poor appetite. The start date of the Ensure was 1/7/2023 . A care plan, initiated on 1/4/23, with a target date of 4/4/23, for Resident 217 indicated, . FOCUS: Nutritional risk. I am at nutritional risk related to: BMI [body mass index], I do not drink a minimum of 1500 ml fluids daily. Potential for weight fluctuations related to fluid shifts. I eat only 2 meals a day most of time at home. I am particular about what I eat. Varied intakes of meals. Edema in lower extremities. Potential for weight fluctuations related to fluid shifts . GOAL: I will consume meals of foods and beverages that I select to maintain weight. I will have no significant weight loss of 5% or greater in 1 month . INTERVENTIONS: . Diet is served as ordered, snacks are available to me between meals upon request, offer replacement for foods not consumed . monitor weights and intakes . oral pharmaceutical supplements as ordered . provide with bedtime snack . monitor labs . notify physician and resident representative of significant weight changes . Resident 217's weights indicated the following: - On 1/4/23, the resident weighed 162 pounds. - On 1/12/23, the resident weighed 140 pounds. - On 1/15/23, the resident weighed 139.2 pounds. This was an assessed 14.07% severe weight loss in 11 days. The Dietary Full Review, dated, 1/11/23 at 3:59 p.m., for Resident 217 indicated . Does resident receive dietary provided nutritional supplements, No . Weight changes . new admission and no weight trend identified yet . Goal: I will have no significant weight loss of 5% or greater in 1 month . Recommendations, No . The clinical record for Resident 217 lacked documentation of an assessment or implementation of a nutritional intervention after the residents was noted to have a significant weight loss since admission. During an observation on 1/17/23 at 12:27 p.m., Resident 217 was observed to have a bowl of mashed potatoes and gravy and a bowl of yogurt. Resident indicated at that time she couldn't eat anything else on the menu that day and no one had offered her a substitute. She thought she might try a hamburger. During an interview on 1/17/23 at 12:30 p.m., Licensed Practical Nurse (LPN) 1 indicated she would order Resident 217 a hamburger. During an interview on 1/17/23 at 2:31 p.m., Resident 217 indicated she ate 3/4 of the hamburger and it was really good. During an interview on 1/18/23 at 10:10 a.m., the Dietician indicated she relies on the facility to let her know when a resident has lost weight because she doesn't look at the weights everyday. The Interdisciplinary Team (IDT) should have met on 1/13/2023, and would have discussed Resident 217's weight loss but they did not meet that day due to the Department of Health being in the facility. The resident was ordered Ensure on 1/7/23, and she does drink it. During an interview on 1/18/23 at 10:25 a.m., the Director of Nursing (DON) indicated they weigh new admissions weekly for four weeks to establish a baseline. After 1 month they will address any weight loss in the IDT meeting. They run a report once a month before the meeting. Resident 217 would not have triggered in the weekly meeting because it had not been a month since she had been admitted . On 1/18/23 at 10:34 a.m., the Director of Nursing provided the facility's policy, Weight Management Program dated, 12/13/19, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . A. New Admissions will be weighed weekly X 4 weeks to establish a baseline weight . G. Resident experiencing unplanned weight change will be assessed for interventions . 3.1-46(a)(1)