**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 58 residents. The sample included 15 residents with eight residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure residents remained free from avoidable accidents and injuries. On 01/06/23 staff transferred Resident (R) 38 but failed to use appropriate gait belt technique. This failure resulted in a fall with a femur (thigh bone) fracture, which required surgical repair. The facility also failed to ensure adequate supervision during toileting for R10, who had a non-injury fall as a result. The facility further failed to ensure R14's bed was left in a safe position which placed R14 at increased risk for falls and related injury. Findings included: - R38's Electronic Medical Record (EMR), from the Diagnoses tab, documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), cerebral infarction (stroke-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and difficulty in walking. The Significant Change in Status Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of eleven, which indicated moderately impaired cognition. R38 required extensive assistance of one staff member for transfers and toileting. The MDS indicated R38 was unsteady moving from a seated position to a standing position and was only able to stabilize with human assistance. The Significant Change in Status MDS dated 01/12/23 documented a BIMS score of eight, which indicated moderately impaired cognition. The MDS documented R38 required total dependence on two staff members for transfers and extensive assistance of two staff for most other activities of daily living (ADL). R38's Falls Care Area Assessments CAA dated 01/11/23 recorded R38 was at risk for falls secondary to his recent fall with fracture, his medical diagnoses, and his medication regime. R38 was on several medications that could affect his strength and balance. The CAA recorded R38 had a fall on 01/06/23 during a transfer that resulted in a fracture to the left femoral neck and required surgical repair on 01/08/23. R38's historical Care Plan dated 03/28/22 documented R38 was at risk for falls. An intervention dated 02/28/22 directed staff R38 required extensive assistance with transfers. The care plan did not indicate how many staff or type of transfer. R38's current Care Plan dated 01/06/23 documented R38 was at risk for falls due to his personal history of falls, history of stroke compression fractures, and pain. The MDS recorded an intervention dated 01/09/23 which directed R38 had a fall with injury on 01/06/23 and staff received education on transfers with the use of the gait belt. R38's EMR recorded a note, under the Notes tab, dated 01/05/23 which recorded the interdisciplinary team (IDT) discussed R38 in IDT meeting regarding his fall risk. Staff planned to contact R38's representative about Hospice (end of life care) screening. R38 was on an antidepressant (medication which treats persistent feels of sadness). R38's Buspar (medication given to treat anxiety) was decreased. The note recorded R38 had several falls in December and had Covid (highly contagious respiratory virus) that month as well. R38's EMR recorded a note dated 01/06/23 at 06:00 PM, entered on 01/07/23 at 10:59 AM by Licensed Nurse (LN) G which documented at about 04:30 PM on 01/06/23 a Certified Nurse Aid reported to LN G that R38 fell mid-transfer. The note further documented while staff transferred R38 from his bed to his wheelchair, instead of sitting backwards into the wheelchair, he fell forward onto the ground. Staff initiated neurological assessments. R38 sat in his wheelchair while staff performed range of motion (ROM) and R38 denied pain at that time. The nurse felt R38's scalp and noted no new issues and the resident denied any pain during the assessment. Staff then assisted R38 to the dining room where he ate his normal amount of dinner. Upon reassessment, about an hour after the fall, R38 sat in his wheelchair with his bilateral feet propped up. He denied complaints of pain at that time. The note documented the on-call management staff were informed of the fall at 04:38 PM; the provider received notification at 04:51 PM; and R38's representative received notification at 05:15 PM. R38's EMR recorded a note dated 01/07/23 at 02:13 AM which documented staff notified R38's physician that R38 complained of hip pain post fall which occurred at around 04:30 PM the previous day. The physician ordered an x-ray to both R38's hips. R38's EMR recorded a note dated 01/07/23 at 08:27 AM which noted the x-ray results showed an acute, nondisplaced left femoral neck (where the femur shaft connects to the femur head which articulates to the hip joint) fracture. R38's physician gave orders to send R38 to the emergency room. R38's EMR recorded a note dated 01/10/23 at 06:04 PM, which recorded R38 readmitted to the facility after a fall which fractured his hip. The facility's staff members helped with transferring R38 from the gurney to his bed. He had a left hip incision that was 7 centimeters (cm) long, with a dressing in place. R38's ROM was limited due to the fracture. The unsigned Resident Incident Reporting Form documented an incident date of 01/06/23 at 04:30 PM. The form included the note entered on 01/07/23 at 10:59 AM by LN G. The form documented R38's vital signs and a pain score of zero. The form listed a staff witness of CNA T and an incident location of R38's room. The form listed the event type as a fall, found on floor. The following form sections were all noted as not applicable (N/A): Medications/Infusions; Adverse Clinical Event; Treatment/Procedure; Administrative; Abuse. The form noted it was completed by LN G and included notification times to R38's physician and representative. The form listed the incident had a severity rating of 3 which the form defined as an adverse event that did not result in death or serious disability and did not require medical intervention to prevent death or serious disability and directed to track and trend, but no root cause analysis was required. Under the severity ranking section the form documented fracture and No was entered. The form contained a section which directed For Falls also complete these sections. The form recorded yes to the query regarding if the resident's care plan was followed, if staff were transferring with the appropriate number of staff, if the resident's sued assistive devices and if the device was in sue at the time of the fall. The forms documented No to the question regarding if the residnet had a restraint or positioning device ordered and N/A regarding if the restraint/device was in use at the time of the incident. The form further recorded N/A to the query if counseling /education of staff was necessary. An undated Witness Statement from LN G recorded the same note entered on 01/07/23 at 10:59 AM. An undated Witness Statement from CNA T recorded CNA T was getting R38 up to take him to dinner on 01/06/23. R38 went forward and not backward, onto the floor and not into the chair. CNA T asked R38 if he was hurt and where, and R38 said no. CNA T let the nurse know about the fall. Upon request, the facility provided copies of the staff education on the use of gait belts with transfers which was provided after R38's fall and referenced in his plan of care. The education was provided to CNA T. CNA T signed and acknowledged the facility policy Use of Transfer Belt/gait Belt on 01/07/23. The facility provided a competency titled Competency Checklist-One-Person Transfer, signed by CNA T and Administrative Nurse E. The facility was unable to provide documentation of further education and/or ongoing monitoring related to the concern. The facility could not provide a completed investigation related to R38's fall on 01/06/23. On 03/07/23 at 11:51 AM R38 rested in bed. His wheelchair had anti-rollbacks in place and was next to his bed and his call light was in reach. On 03/09/23 at 08:05 AM CNA T stated that she only vaguely remembered the incident on 01/06/23 as it was a while ago. CNA T stated R38 required extensive assistance with transfers. CNA T stated she did use a gait belt when she transferred R38 on the day he fell, but when he started going forward, CNA T could not stop him from falling. She stated she could not remember if she had two hands or one hand on the gait belt or if she had applied the belt correctly. She said she was uncertain, but thought she stood beside or behind R38 during the transfer. On 03/09/23 at 08:12 AM Administrative Nurse E stated prior to his fall, R38 required extensive assistance from one staff with the use of a gait belt. Administrative Nurse E stated that unless the care plan directed the use of a mechanical lift, the staff would do a stand pivot with a gait belt for extensive assisted transfer. She said if she felt the resident was unsteady or too weak, she would get a second person to assist. Administrative Nurse E said the facility were doing a lot of training on gait belt use and positioning, and after the incident, gait belts were placed in all the rooms. On 03/09/23 at 08:17 AM Therapy Consultant JJ stated prior to R38's fall, R38 required minimum to moderate assistance with transfers. Consultant JJ stated therapy always recommended the use of a gait belt, for safety, with all stand pivot transfers. Consultant JJ confirmed R38 received therapy services after the fall, and stated R38 had returned to his previous level of function. On 03/09/23 at 10:58 AM Administrative Nurse D said extensive assistance of one staff would mean a stand pivot transfer. She said if a lift was needed, it was specified on the care plan. Administrative Nurse D stated that staff should always use a gait belt when performing a stand pivot transfer with the residents. Administrative Nurse D stated when R38 fell, CNA T used a gait belt but did not use it correctly. Administrative Nurse D said CNA T held the gait belt overhand from the top; so, when R38 lost his balance, CNA T could not support R38's weight and he fell forward. Administrative Nurse D said the facility response to the incident was education specific to the involved CNA. She stated the facility further ensured all residents had gait belt available in the rooms. Administrative Nurse D stated the facility conducted several huddles and conducted in-person demonstrations and return demonstration on the use of gait belts, but the facility did not do formal education or competency checks with all relevant staff. Administrative Nurse D confirmed that no formal investigation, which included a root cause analysis and facility actions, was completed for R38's fall; she stated it would be a good idea to have all the efforts conducted by the facility documented. Review of the facility competency checklist titled Certified Nurse Aide Clinical Skill Competency Checklist effective 10/31/17 revealed a clinical competency that required demonstration of proper technique for gait belt use, and a pivot transfer using gait belt. Review of the undated facility Competency Checklist-One-Person Transfer revealed the following steps: Apply gait belt and stand facing the resident with feet shoulder width apart. Have resident place hands on staff member's shoulders and the staff would grasp the belt firmly at each side of the resident. The undated facility policy Use of Transfer Belt/Gait Belt directed staff to wrap the gait belt around the elder's waist and buckle it securely in the front. Stand in front of the elder with the staff member's knees bent, feet apart and back straight. Position one hand on either side of the gait belt with an underhand grip and assist elder to move forward. The facility failed to ensure staff used appropriate gait belt transfer technique during a staff assisted transfer for R38, who required extensive staff assistance. As a result of this failure, R38 fell and sustained a fracture which required hospitalization and surgical intervention. -The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), difficulty walking, heart failure, retention of urine, and a history of falling with fractures (broken bone). R10's Quarterly Minimum Data Set (MDS) dated 01/21/23 noted a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. The MDS indicated he required extensive two-person assistance for bed mobility and transfers. The MDS noted he required extensive assistance from one staff for personal hygiene and toileting. The MDS indicated no falls since last assessment. R10's admission MDS dated 07/29/22 indicated he required supervision and physical assistance from one staff member for all transfers and toileting. The MDS indicated he had a fracture related to a fall prior to admission to the facility. A review of R10's Communication Care Area Assessment (CAA) completed 08/08/22 indicated he had difficulty understanding and being understood by others due to his cognitive loss. The CAA identified risk factors for falls, self-care deficits, weight loss, and decline in mood related to his communication concerns. R10's Activities of Daily Living (ADLs) CAA completed 08/08/22 indicated risk factors for falls, self-care deficits, weight loss, and decline in mood related to his medical diagnoses. The MDS indicated he had impaired balance and transitions during transfers, functional impairment in activity, and decreased safety awareness. R10 was not triggered for a Falls CAA. A review of R10's Baseline Care Plan initiated 07/25/22 indicated he was a fall risk. The plan indicated he required assistance from two staff for bed mobility, transfers, grooming, and toileting (07/25/22). A review of R10's current Care Plan revised 09/08/22 revealed he had a non-injury fall on 08/08/22 and instructed staff to educate him on using his call light. This entry was created on 03/08/23 and back dated to start on 08/08/22. A review of R10's EMR under Progress Notes revealed on 08/08/22 at 08:00PM R10 was found on the floor of his room after attempting to self-transfer to his wheelchair. The note indicated R9 was using his walker at the time of the fall. The note indicated that staff assisted him to the restroom and left him alone. The note revealed R10 stated I don't know why she had to leave I was not going to be long. A review of the Fall Investigation under Witness Statements indicated direct care staff last saw R10 in his restroom at 07:45PM. The investigation noted Resident should be reminded to use his call button after using the bathroom use. The investigation revealed that R10 had was confused and trying to get to his wheelchair after using the restroom. On 03/06/23 R10 slept in his bed. R10's bed was in the low position. R10's urinary catheter (tube inserted into the bladder to drain urine) collection bag was visible from the hallway without a privacy bag. The bottom of R10's collection bag was on the floor. R10's wheelchair sat in the corner of the room. His unbagged nasal cannula and oxygen tubing hung over the oxygen cannister. On 03/09/23 at 09:38AM, Certified Nurse's Aide (CNA) M stated that R10 should be monitored during personal hygiene and toileting. She stated that residents should be supervised to prevent falls and injuries from occurring. She stated that R10 was a fall risk and should no be left alone during toileting. She stated that other fall prevention intervention includes call light placement, frequent checks, and ensuring the residents needs are met. On 03/06/23 at 10:03AM, Licensed Nurse (LN) G stated that residents identified with fall risk should be closely supervised during ADL care. She stated staff should never leave a resident alone when toileting. She stated that the direct care staff have access to the resident's care plan and should know the level of assistance and supervision required for each resident. On 03/09/23 at 10:21AM, Administrative Nurse D stated staff should never leave residents at risk for falling alone during toileting. She stated that they should ensure each resident's call light is within reach. She stated that R10 had encourage resident to use call light added to his care plan after the fall occurred. The undated facility policy Accident Prevention directed all staff members of the facility would ensure the each elder's environment remained as free from accident hazards as possible and each elder would receive adequate supervision and assistive devices to prevent accidents. The facility failed to provide supervision for R10 resulting in a non-injury fall after toileting. This deficient practice placed R10 at risk for preventable falls and injuries. - The electronic medical record (EMR) for R14 documented diagnoses of hypertension (elevated blood pressure), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), and contracture of the lower leg muscle (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity). The Annual Minimum Data Set (MDS) dated 04/20/22 documented R14 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R14 required extensive assistance of one or more staff for activities of daily living (ADLs)supervision and assist of one staff for eating. R14 had functional limitation in range of motion (ROM) in both upper and lower extremities on both sides. R14 required the use of a wheelchair for mobility. R14 had no history of falls since the prior assessment. The Quarterly MDS dated 12/24/22 documented R14 had a BIMS score of 15 which indicated an intact cognition. R14 required extensive assistance of two or more staff for bed mobility R14 had functional limitation (ROM) in both upper and lower extremities on both sides. R14 required the use of a wheelchair for mobility. The MDS recorded R14 had no history of falls since the last assessment. The Care Area Assessment (CAA) for falls was not triggered. The ADL CAA dated 05/05/22 documented this care area triggered secondary to assistance required in ADLs, impaired balance and transition status and functional ability, during transfers, and functional impairment in activity. Contributing factors include generalized weakness, and decreased safety awareness. Risk factors include further ADL decline, falls, incontinence, skin breakdown, and pain. The Falls Care Plan initiated 0521/21 documented R14 was at risk for falls and used a Hoyer lift (an assistive device used to allow a person to be lifted and transferred with a minimum of physical effort) for transfers. Staff was to observe R14 for the need of physical or occupational therapy. Staff was to observe him for changes in his condition that may warrant increased supervision/assistance and notify the physician. The care plan lacked evidence R14 had a preference for the bed in a high position. R14's clinical record lacked evidence of safety education related to his bed height. On 03/06/23 at 11:47 AM R14 laid in his bed, the bed height was at a height approximately three feet from the floor, R14's head and upper torso was leaned over to the left side. On 03/07/23 at 08:44 AM R14 laid on his back in bed, with a neck pillow around neck, his bed height was at hip height (approximately 36 inches/ three feet). On 03/07/23 at 12:03 PM R14 laid in bed, his upper torso was leaning to the left, support pillow around his neck, call light in reach, bed level elevated. On 03/07/23 at 01:56 PM R14 laid in bed with his torso leaning to the left side of his bed. R14 stated he was having pain, he turned on his call light and an aide came into room and asked him if he needed anything. R14 told the aide he was having some pain and the aide exited the room before repositioning R14. On 03/07/23 03:35 PM R14 was bent over in bed holding a drink. R14'sneck pillow on but head bent completely to left and body tilting to the left. R14's pancake call light was out of reach on residents lap area, with bedside table pulled close obstructing his reach. R14's drink (Styrofoam cup with lid and straw). R14 asked this writer to take drink as he was holding the drink in his left hand and unable to reach the table to set drink down. With the health facility surveyor (HFS) intervention R14 activated call light and staff responded in less than one minute. The staff member canceled the call light and went and got another staff to come assist with repositioning. Bed in high height. On 03/08/23 at 09:26 AM R14 sat in his bed with the head of the bed elevated, neck pillow around neck. R14's bed was at a medium high position (about three feet). On 03/09/23 at 09:48 AM Certified Nurse Aide (CNA) M stated a resident who was a fall risk should have their bed in low position. CNA M stated R14 did prefer to have his bed at a higher level most of the time. On 03/09/23 at 10:31 AM Licensed Nurse (LN) G stated beds should be kept in a low position if a resident was a fall risk. R14 had been educated by staff of the increased risk of falls due to the bed being at a higher height. On 03/09/23 at 10:45 AM Administrative Nurse D stated R14 was particular about the height of his bed. Administrative Nurse D stated R14 preferred his bed at a higher height so he would be able to view his television better. Administrative Nurse D stated R14 was educated on the risk of having his bed at the higher height but acknowledged this was not reflected in R14's plan of care or medical record. The undated facility policy Accident Prevention directed all staff members of the facility would ensure the each elder's environment remained as free from accident hazards as possible and each elder would receive adequate supervision and assistive devices to prevent accidents. The facility failed to ensure that R14's bed was maintained at a safe level while R14 occupied the bed. This placed R14 at risk for increased falls and/or possible further injury.

The facility identified a census of 58 residents. The sample included 15 residents with four residents reviewed for nutrition. Based on observation, record review, and interview, the facility failed to identify and respond to weight loss for Resident (R)14 to prevent further loss. The facility failed to ensure R14 had the required built-up eating utensils and staff assistance during meals and failed to involve the registered dietician (RD) and R14's physician to evaluate and initiate interventions to prevent further loss. This deficient practice resulted in a significant weight loss of 12.59 percent (%) over six months (August 2022 to February 2023) for R14 and placed this resident at risk for other adverse effects. Findings included: - The Electronic Medical Record (EMR) for R14 documented diagnoses of hypertension (elevated blood pressure), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), and contracture of the lower leg muscle (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity). The Annual Minimum Data Set (MDS) dated 04/20/22 documented R14 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R14 required supervision and assistance of one staff for eating. R14 had functional limitation in range of motion (ROM) in both upper and lower extremities, required the use of a wheelchair for mobility, and had no weight loss in the last month or last six months. The Quarterly MDS dated 12/24/22 documented R14 had a BIMS score of 15, which indicated intact cognition. R14 required limited assistance of one staff for eating. R14 had functional limitation (ROM) in both upper and lower extremities and required the use of a wheelchair for mobility. The MDS inaccurately recorded R14 had no history of weight gain or weight loss during the last six months. The Pressure Ulcer Care Area Assessment (CAA) dated 05/05/22 documented R14 was a risk for pressure ulcer development due to ADL/functional/mobility impairment. The physician was to be notified of any abnormal findings. The dietician was to monitor food and fluid intake and implement dietary interventions, as necessary. The Nutritional Status Care Plan dated 05/21/22 documented R14 was at risk for alteration in nutritional status and directed staff to weigh R14 routinely though did not direct any specific frequency . The dietician was to visit annually and as needed. The Assistive Dining Care Plan dated 12/22/22 documented R14 required built-up utensils while dining due to tremors (involuntary shaking or movement, ranging from slight to severe, and commonly affecting hands, legs, face, head, or vocal cords). R14 required restorative dining services with verbal cues for use of built-up utensils and verbal cue for meal completion. Under the Orders tab documented an order for R14 dated 05/21/21 to obtain weights monthly and as needed. Upon review of R14's recorded weights from 05/01/22 to 03/01/23: R14's weight on 05/01/22 was 184 pounds (lbs.). R14's weight on 08/01/22 at 08:16 AM was 189 lbs. R14's weight on 10/17/22 was 178.4 lbs. R14's weight on 12/01/22 was 163.2 lbs. R14's weight on 02/03/23 was 165.6 lbs., which indicated a 12.59 percent in six months. R14's weight on 03/01/23 was 161.8 lbs., representing an additional 3.8 lbs. loss. The EMR for R14 lacked evidence of notes from the registered dietician and the physician during the months of August 2022 to December 2022 to address R14's significant weight loss. A Clinical Note dated 01/12/23 at 10:35 AM documented R14 was discussed in a weekly risk meeting. The note recorded R14's weight had been trending down and R14 had a rehospitalization and COVID (a respiratory disease) since August. R14 had no recent falls. A Nursing Clinical Note for R14 dated 02/09/23 at 08:21 PM documented the resident was reviewed during the weekly interdisciplinary team (IDT) meeting. Resident declined hospice, had not falls, and had a significant weight change of -14.13 percent, 23.4 pounds in 180 days contributed to a hospital visit in the fall of 2022. No interventions needed per registered dietician. A Written Physician Order dated 02/09/23 for R14 documented the resident had a significant weight change of 14.13% in 180 days. No new interventions were initiated. A Dietary Clinical Note dated 02/10/23 at 01:42 PM for R14 documented R14's current body weight was 165.6 pounds, and he did have a significant weight loss over 180 days (-14%). Weight was currently stable for the last 30 days. Per risk meeting discussion, resident had a hospital stay in the fall of 2022 that most likely contributed to his weight loss (constipation, possible impacted stool that was relieved). R14 was on a regular diet with regular textures and thin liquids. Per available chart data oral intakes were fair with average of 50 to 100% at meals. R14 did participate in restorative dining. Nutrition related medications reviewed, and no supplements were currently ordered. Oral intakes were adequate, weight stable for last 30 days, no new nutritional recommendations, and R14 was to continue current plan of care. The registered dietician would monitor and was available, as needed. Review of R14's meal intake over the last three months documented R14's oral food intake was 50 to 100%. On 03/07/22 at 01:22 PM R14 sat up in his bed with the bedside table across his bed with a Styrofoam food container with his lunch in it and plastic eating utensils. There were no staff present supervising or cueing. On 03/08/23 at 09:29 AM R14 was eating breakfast in his room with the head of his bed elevated, and a neck pillow present around his neck. A Styrofoam container and plastic utensils were noted on his bedside table and there were no staff supervising or cueing. On 03/09/23 at 08:55 AM Consultant HH stated R14 had been evaluated by the therapy department quarterly, before the MDS was completed, to determine what type of adaptive devices or services were needed. R14 required the use of built-up utensils and restorative dining during meals. The dietary staff were responsible for ensuring R14 had the appropriate utensils and plate, per the dietary orders. The dietary staff had a card in the kitchen for each resident that documented what diet the resident was on, along with any specialty utensils or plate needed. On 03/09/23 at 09:40 AM Certified Nurse Aide (CNA) M stated the CNAs were responsible for obtaining the resident weights and then the weights were turned in to the nurse for review. On 03/09/23 at 10:31 AM Licensed Nurse (LN) G stated R14 should have the built-up utensils while eating. LN G stated the dietary staff should provide R14 with his adaptive utensils at meals. On 03/09/23 at 10:45 AM Administrative Nurse D stated the registered dietician came to the facility every couple of weeks to review the resident's weights and food intake. Administrative Nurse D stated she had been reviewing a lot of the residents EMR and had noted R14 had shown a significant weight loss several months ago. Administrative Nurse D stated she was unable to say what had been done for R14 prior to her joining the facility in December 2022. Administrative Nurse D stated R14 had been evaluated by the registered dietician and by the physician, but no new orders had been initiated by either. The undated facility policy Monitoring Weights directed all elders of the facility would be evaluated for weight stabilization for timely identification of weight loss and treatment would be provided when possible and accepted by the elder and/or surrogate decision maker to prevent weight loss unless the eider's physician has indicated a planned weight loss program. The policy defined significant weight loss as: three pounds in one week, 5% loss in 30 days, 7.5% loss in 90 days, or 10% loss in 180 days. The policy directed the physician, elder and/or surrogate decision maker would be notified immediately (within twenty-four (24) hours) of any elder meeting the definition of significant weight loss in this policy. The facility failed to identify and address R14's weight loss before a significant loss occurred. The facility failed to ensure R14 had the ordered built-up eating utensils and restorative dining during meals and failed to ensure the registered dietician and physician addressed R14's weight loss in a timely manner. This deficient practice resulted in a significant weight loss for R14 and placed this resident at risk for other adverse effects and health concerns.