Based on interview and record review, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1(#1) of 6 (#1, #2, #3, #R1, #R2, #R3) sampled residents. Findings: A review of Resident #1's medical records revealed an admission date of 08/14/2024 with diagnoses which included but were not limited to current episode depressed, severe, with psychotic features; major depressive disorder recurrent, severe with psychotic symptoms; persistent mood [affective] disorder, unspecified; borderline personality disorder; anxiety and bipolar disorder. A review of Resident #1's Pre admission Screening and Assessment Resident Review (PASARR), dated 08/12/2024, revealed a Level II determination that read, Individual meets state law criteria for intellectual/developmental disability . A review of Resident #1's MDS with an ARD (Assessment Reference date) date of 09/10/2024, section A1500 revealed the following: Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? The answer was coded 0 for no. A review of Resident #1's MDS with an ARD (Assessment Reference date) date of 11/07/2024, section A1500 revealed the following: Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? The answer was coded 0 for no. A review of Resident #1's MDS with an ARD (Assessment Reference date) date of 12/13/2024, section A1500 revealed the following: Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? The answer was coded 0 for no. On 07/01/2025 at 12:27 p.m., an interview and review of Resident #1's MDS for the above referenced ARD's was conducted with S5LPN (Licensed Practical Nurse). She confirmed that the PASARR was incorrectly coded and did not reflect that the resident was considered by the state level II PASARR process to have serious mental illness, and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to refer a resident with a diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 2 ( #2, #3) of 6 (#1, #2, #3, #R1, #R2, #R3) residents investigated for PASARR in a final sample of 6 residents. Findings: Review of Resident #2's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, major depressive disorder with severe psychotic symptoms, mood disorder, and generalized anxiety disorder. Review of Resident #2's Level I PASARR dated 04/15/2024 revealed section III, Question #1 Do you suspect the applicant has, or has the applicant ever been diagnosed as having a mental illness? Include mental disorders that may lead to chronic disability. If yes, please check the diagnosis below. No was indicated. Further review of Resident #2's records revealed no evidence that Level II PASARR had been submitted to the appropriate state-designated authority with those psychiatric diagnoses identified. Review of Resident #3's EHR revealed she was admitted to the facility on [DATE] and later received diagnoses on 06/30/2023 that included in part, Generalized Anxiety Disorder, Psychotic Disorder with Delusions, and Delirium. Review of Resident #3's Level I PASARR dated 01/24/2020 revealed section III Question #1 Do you suspect the applicant has, or has the applicant ever been diagnosed as having a mental illness? Include mental disorders that may lead to chronic disability. If yes, please check the diagnosis below. No was indicated. On 07/01/2025 at 10:45 a.m., a group interview was conducted with S1ADM (Administrator) and S4LPN (Licensed Practical Nurse, Admissions Nurse). S4LPN stated she was responsible for the PASARR's for residents at the facility. S4LPN reviewed both Resident #2 and Resident #3's EMR diagnosis list and confirmed the resident did have qualifying diagnoses that should have been indicated on the PASARR evaluation form. S4LPN then viewed the issue dates of both Residents' PASARR's and confirmed both resident's received these qualifying diagnoses after the PASARR issue date. S4LPN further confirmed that the Level I should have been resubmitted for review to indicate the newly qualifying diagnoses for a Level II determination and had not been.

Based on interviews and record reviews, the facility failed to ensure it employed a qualified social worker (SW) on a full-time basis. The facility had 130 licensed beds. Findings: On 06/30/2025 at 10:00 a.m., during an interview with S1ADM (Administrator), a request was made for the facility SW's credentials. On 06/30/2025 at 12:30 p.m., an interview was conducted with S3SS (Social Services). She confirmed she was SW for the facility. She stated she had a bachelor's degree in social work. At that time, a request for her credentials was made. She stated she would have to look for her diploma. S3SS stated she could provide her unofficial transcript. On 07/01/2025 at 8:50 a.m., during an interview with S3SS, she confirmed she did not have a copy of her diploma. A request for her transcript was made. On 07/01/2025 at 9:15 a.m., S3SS provided a copy of a receipt for a request for her diploma. A second request for her transcript was made. On 07/01/2025 at 11:25 a.m., an interview with S3SS was conducted. S3SS confirmed she did not have a copy of her transcript nor had received a copy of her diploma. On 07/01/2025 at 11:30 a.m., during an interview with S2AADM (Administrative Assistant), a request for S3SS's credentials was made. On 07/01/2025 at 11:45 a.m., an interview was conducted with S1ADM. He stated he was not able to locate S3SS's credentials. He confirmed the facility could not provide S3SS's qualifying credentials.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for Hospice care for 1 (Resident #83) out of 29 sampled residents. Findings: Review of Resident # 83's electronic health record revealed he was admitted to the facility on [DATE]. Further review of his record revealed a Physician's order dated 06/06/2024 for Admit to Hospice with terminal diagnosis of End Stage Neural Vascular Dementia. Review of Resident #83's Quarterly MDS assessment, with an ARD (Assessment Reference Date) of 09/09/2024, revealed: Section O for Special Treatments, Procedures, and Programs .K1. Hospice Care . B. While a Resident . Coded as No. On 09/25/2024 at 08:45 a.m., an interview and record review was conducted with S2LPN (Licensed Practical Nurse). She confirmed that Resident #83 was admitted to hospice care on 06/06/2024. She then reviewed Resident #83's Quarterly MDS, with ARD of 09/09/2024 and confirmed that hospice care was coded inaccurately as not receiving while a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refer a resident with a diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 ( #19) of 1 (#19) residents investigated for PASARR in a final sample of 29 residents. Findings: Review of Resident #19's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Major Depressive Disorder and Dementia; with Psychotic Disorder with Delusion added on 09/19/2023. Review of Resident #19's Level I PASARR dated 08/04/2023 revealed section III, Question #1 Do you suspect the applicant has, or has the applicant ever been diagnosed as having a mental illness? Include mental disorders that may lead to chronic disability. If yes, please check the diagnosis below. Answer checked was No. Further review of Resident #19's records revealed no evidence that Level II PASRR had been submitted to the appropriate state-designated authority with those psychiatric diagnoses identified. On 09/23/2024 at 12:45 p.m., an interview was conducted with S3LPN (Licensed Practical Nurse, Admissions Nurse). She reported she was responsible for the PASARR's for residents at the facility. S3LPN reviewed Resident #19's EMR diagnosis list and confirmed the resident did have a diagnosis of Major Depressive Disorder on 08/14/2024 and Psychotic Disorder on 09/19/2023. S3LPN then reviewed the Level I PASARR and confirmed the diagnosis of Major Depressive Disorder and Psychotic Disorder were not identified on the Level I screening. S3LPN also confirmed the Level I should have been resubmitted with the new diagnoses for a Level II determination and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide necessary care and services that is in accordance with professional standards of practice as evidenced by failing to ensure the resident's oxygen equipment was stored properly for 1 (#77) out of 2 (#77, #84) residents reviewed for respiratory care, with the potential to effect 14 residents receiving oxygen therapy. Findings: Review of the facility's policy titled Infection Control Oxygen Equipment Cleaning with a revision date of 06/2014, last review dated of 01/24/2024 revealed in part: 10. When not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date. Review of Resident #77's electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses, not limited to, Acute Respiratory Failure with Hypoxia, Vascular Dementia and Dyspnea. Review of Resident #77's Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating a moderately impaired mental status. Review of the physician's orders for Resident #77 revealed an order dated 07/26/2024 for Oxygen at 2 liters/nasal cannula (L/NC), as needed (PRN) for dyspnea. On 09/23/2024 at 9:07 a.m., an observation of Resident #77's oxygen tubing was laying over the oxygen concentrator machine, not in the bag that is hanging off side of machine. On 09/24/2024 at 8:10 a.m., a second observation was made of Resident #77's oxygen tubing laying over the concentrator, not in a storage bag. On 09/24/2024 at 8:30 a.m., an interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN confirmed the oxygen tubing for Resident #77's was laying over the top of the concentrator and should have been stored in the bag. She confirmed the resident's oxygen is PRN and was not used all the time, and unable recall the last time he had used the oxygen.

Based on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. a thick layer of debris on the deep fryer cooking oil collection area; 2. expired foods from the kitchen walk in cooler, and dry storage area; 3. opened food items not labeled with the date and time; and 4. sticky residue with food debris on the cart used to bring food items from one part of the kitchen to another. This deficient practice had the potential to affect the 87 residents who consumed food from the kitchen. Findings: On 09/23/2024 at 8:33 a.m., a tour of the facility's kitchen was conducted with S1DS (Dietary Supervisor), who stated that she was responsible for the day's management of the kitchen. On 09/23/2024 at 8:39 a.m., an observation of the deep fryer was conducted with S1DS that revealed the cooking oil collection area had a thick layer of debris. S1DS stated the deep fryer was last used on 09/17/2024 and confirmed that is was not cleaned after it was used and should have been. On 09/23/2024 at 8:48 a.m., an observation of the walk in cooler was conducted with S1DS and revealed the following: 1. (7) unopened squeeze bottle containers of strawberry jam with an expiration date of 09/22/2024 2. large opened container of caesar dressing with an expiration date of 06/14/2024 3. large opened container of mayonnaise tarter dressing with an expiration date of 04/14/2024 4. opened gallon of milk with an expiration date of 09/18/2024 5. large container of cherries with the opened date of 06/24/2024 Further observation of the cooler revealed the following items were opened but were not labeled with the date and time they were opened: 1. large bag of garlic bread toast 2. large bag of hot dog buns 3. large container of sour cream S1DS confirmed the food items were expired and should have been removed from the walk in cooler and discarded. She also confirmed the food items listed above were opened, and not labeled with the date and time they were opened, and should have been. On 09/23/2024 at 9:09 a.m., an observation of the dry storage room was conducted with S1DS and revealed the following: 1. plastic gallon bag with an opened bag of blueberry muffin mix dated 08/03/2024 2. (2) plastic gallon bags with opened bags of white frosting mix, one dated 08/02/2024, and one dated 02/05/2024 3. plastic gallon bag with an opened bag of cheese cake mix dated 08/28/2023, with an expiration date of 02/21/2024 S1DS confirmed the food items were expired and should have been discarded. On 09/23/2024 at 12:48 p.m., an observation of the food service line was conducted. Food trays were placed on a cart for tray distribution. Further observation of the cart revealed multiple areas of a sticky residue and food debris on both sides and front of the cart. At 12:49 p.m., an interview and cart observation was conducted with S1DS, who stated that the carts were to be cleaned after each use and confirmed the cart was not cleaned from previous use and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately code the resident's MDS (Minimum Data Set) assessment for 1 (#104) out of 37 sampled residents. This deficient practice had the potential to affect a census of 103. Findings: Review of Resident 104's medical record revealed he was admitted on [DATE] and discharged on 09/29/2023. Resident #104's nursing progress noted dated 09/29/2023 at 10:41 a.m., indicated he had discharged to his home. Review of the facility's Detail Admission/Discharge Report dated 07/01/2023 through 10/23/2023 revealed on 09/29/2023 Resident's discharge location was home. Review of Resident 104's Discharge MDS with an ARD (Assessment Reference Date) of 09/29/2023 revealed a planned discharge, return not anticipated assessment was completed. Section A-Identification Information, A2100 Discharge Status was coded 03, indicating acute hospital. On 10/24/2023 at 3:50 p.m., an interview and record review was conducted with S5ALPN (Assessment Licensed Practical Nurse). She confirmed that Resident #104 was discharged from the facility on 09/29/2023 to his home. S5ALPN reviewed Resident #104's Discharge MDS with an ARD of 09/29/2023 and confirmed his discharge status indicated he was discharged to an acute hospital instead of the community (private home).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards for 1 (#76) of 37 sampled residents. This deficient practice was evident when facility staff failed to ensure respiratory suction equipment was properly stored for Resident #76. Findings: On 10/24/2023 at 1:15 p.m. and on 10/25/2023 at 12:00 p.m., a request was made for S2DON (Director of Nursing) to provide the facility's policy regarding proper storage of respiratory suction equipment. By time of exit on 10/26/2023, the facility failed to provide the requested policy. Review of Resident #76's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dysphagia, Functional Quadriplegia, and Generalized Muscle Weakness. Review of the resident's MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 1 indicating his cognition was severely impaired. Review of resident's comprehensive care plan revealed no plan for the use of suction or respiratory equipment. On 10/23/2023 at 12:06 p.m., an observation was made in Resident #76's room. A suction machine was located on her bedside table with the yanker (suction mouth piece) not bagged, open to air lying on the base of the suction machine which had a thick layer of dust. On 10/24/2023 at 1:05 p.m., a second observation was made in Resident #76's room. Again, the suction machine was located on her bedside table with the yanker (suction mouth piece) not bagged, open to air lying on the base of the suction machine which had a thick layer of dust. On 10/24/2023 at 1:10 p.m., an observation and interview was conducted with S4LPN (Licensed Practical Nurse). She confirmed the yanker mouth piece was not bagged and was lying on the dust lined base. She confirmed the yanker should not be open to air and should be stored in a bag when not in use. She confirmed that Resident #76 was unable to move herself or the suction machine.

Based on observations and interviews, the facility failed to ensure the residents had a safe, clean, comfortable homelike environment by failing to maintain a clean environment in resident bathrooms for 5 (Resident #35, Resident #61, Resident #74, Resident #91, Resident #93) out of 37 sampled residents. This deficient practice had the potential to affect a total census of 103. Findings: Resident #35 On 10/23/2023 at 12:34 p.m., an observation was made of Resident #34's bathroom. The bathroom toilets seat, rim, and inside/outside of bowl was soiled with thick black and brown substances. On the inside of the toilet bowl, at the water line, there was a ring of black mildew. On 10/24/2023 at 8:40 a.m., a second observation was made of Resident #34's bathroom. The bathroom toilet seat, rim, and inside/outside of bowl was soiled with thick black and brown substances. On the inside of the toilet bowl, at the water line, there was black mildew. Resident #61 On 10/23/2023 12:10 p.m., an observation was made of Resident #61's bathroom. On the inside of the toilet bowl, at the water line, there was a ring black mildew. On 10/24/2023 8:39 a.m., a second observation was made of Resident #61's bathroom toilet. On the inside of the toilet bowl, at the water line, the black mildew ring remained. Resident #74 On 10/23/2023 at 11:54 a.m., an observation was made of Resident #74's bathroom. On the inside of the toilet bowl, at the water line, there was a ring black mildew. On 10/24/2023 at 8:37 a.m., a second observation was made of Resident #74's bathroom. On the inside of the toilet bowl, at the water line, the ring black mildew remained. Resident #91 On 10/23/2023 at 12:40 p.m., an observation was made of Resident #91's bathroom. On the inside of the toilet bowl, at the water line, there was a ring black mildew. On 10/24/2023 at 8:43 a.m., a second observation was made of Resident #91's bathroom. On the inside of the toilet bowl, at the water line, the ring black mildew remained. Resident #93 On 10/23/2023 at 11:49 a.m., an observation was made of Resident #93's bathroom. On the inside of bathroom toilet bowl, it was heavily soiled with black mildew, 3-4 inches in width around water line. There was 1 full, tied bag of trash on floor and the trash can was full with discarded trash. The bathroom had foul odor. On 10/24/2023 at 8:35 a.m., a second observation was made of Resident #93's bathroom. On the inside of bathroom toilet bowl, it was heavily soiled with black mildew, 3-4 inches in width around water line. There was 1 full, tied bag of trash on floor and the trash can was full with discarded trash. The bathroom had foul odor. On 10/24/2023 at 8:45 a.m., observations and an interview was conducted with S4HSK (Housekeeper). She confirmed that during the resident room cleaning process; the resident bathroom toilets should be cleaned daily and the trash should be emptied and taken out of the room daily. She also confirmed that when cleaning the resident bathroom toilets, the housekeeper should clean both inside and outside the toilet bowl and the toilet seat. She confirmed that Resident #35's, Resident #61's, Resident #74's, Resident #91's and Resident #93's bathrooms and bathroom toilets were soiled and should not be. She confirmed that no toilets should have mildew or any dried substances on them and there should be no trash bags left on resident bathroom floors. On 10/24/2023 at 2:30 p.m., an interview was conducted with S3HSK (Housekeeping Supervisor). He confirmed that during the residents room cleaning process; the residents bathroom toilets, inside and outside of the bowl, should be cleaned daily and the trash should be taken out daily. He confirmed that Resident #35's, Resident #61's, Resident #74's, Resident #91's and Resident #93's bathrooms and bathroom toilets were soiled and should not be. He confirmed that if the resident bathrooms and bathroom toilet had been cleaned daily, they would not have mildew or trash on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interviews, staff failed to implement its policy for incident invesitgation and reporting when staff failed to immediately report alleged staff-to-resident verbal and physical abuse to administrative staff for 1 resident (#3) out of a total of 5 (#1-#5) sampled residents Findings: Review of the facility's policy titled Review of the facility's policy titled Incident Investigation and Reporting (LA ONLY) Policy revealed the following: Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse . (State Survey Agency) .To ensure reporting reasonable suspicion of crimes against a resident within prescribed timeframes. Relevant terms: Verbal Abuse: The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents ., regardless of their age, ability to comprehend, or disability. Physical Abuse: This includes but is not limited to hitting, slapping, kicking. It also includes controlling behavior through corporal punishment . 3. Abuse .are crimes and shall be reported to proper authorities as such. In the event of any incident involving an allegation or suspicion of .abuse, .each occurrence will be reported immediately to the Administrator of the facility . Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety and Depression. Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/05/2022 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 04, indicating the resident was severely cognitively impaired. Review of a written statement by S4Dietary dated 12/19/2022 revealed, in part: She (S5LPN) told the lady (Resident #3) f*** you and she told her she didn't care who she told, and the nurse start turning her in her wheel chair and told her she didn't care who in the f*** she told. And then she stepped on the resident's foot and cursed her again. Review of a written statement by S6CNA read: As I was getting the cart and coming out the door Resident #3 was in the way so asked her to move for me to come out and she wouldn't. Then the nurse move her and turn her around a couple of times; signed and no date present. Review of a written statement by S5LPN read: On 12/18/2022 at approx. 6:45p resident #3 was sitting in middle of hallway. While CNA was attempting to push meal cart out of DR. This nurse redirected resident. Resident #3 refused to move so this nurse moved resident. Resident's hands were on wheels so we went in a circle. Resident #3 was parked near nursing cart. CNA proceeded to push med (medication) cart out of room. Resident #3 sat in hall near nursing cart. On 1/25/2023 at 1:20 p.m., a phone interview was conducted with S6CNA. S6CNA reported she was working the evening shift on 12/18/2022 and was asked to return the dining meal cart. S6CNA reported she walked out and returned the cart to the kitchen and that's when S4Dietary asked her if she had seen S5LPN cuss out Resident #3 and step on the resident's bare foot. S6CNA reported she had not informed her supervisor of the abuse allegations made towards S5LPN and stated It was none of my business. On 1/25/2023 at 1:52 p.m., an interview was conducted with S4Dietary who reported she remembered working on 12/18/2022 and an incident involving S5LPN and Resident #3. S4Dietary reported she had finished her work in the kitchen and was waiting for the last dining meal cart to be returned from the secure unit. S4Dietary reported she was walking to the unit when one of the CNAs (S6CNA) was coming out the unit with the dining meal cart leaving a little crack in the door. S4Dietary reported she had stood there and watched S5LPN because S5LPN was cussing at Resident #3 and telling the resident I don't give a f*** who you tell and then swung her in the wheelchair. S4Dietary continued to watch S5LPN and reported witnessing S5LPN point her finger in Resident #3's face stating go tell your people that; I don't give a f*** who you tell. S4Dietary reported that Resident #3 wasn't wearing any socks or shoes when she saw S5LPN step on Resident #3's bare foot. S4Dietary further explained she had asked S6CNA if she had seen S5LPN twist Resident #3 around in the wheelchair and then asked for S5LPN name. S4Dietary confirmed she had not reported the alleged verbal and physical abuse immediately and should have. On 1/25/2023 at 4:23 p.m., a joint interview was conducted with S2DON (Director of Nursing) and S3CRN (Corporate Registered Nurse). S2DON reported S4Dietary had informed her of the alleged abuse on 12/19/2022 involving Resident #3 being cussed at and foot stepped on by S5LPN during the evening shift on 12/18/2022. S3CRN reported all staff were educated that any allegations of abuse were to be reported immediately. S2DON and S3CRN confirmed S4Dietary had not reported the allegations immediately and should have.

Based on record review and interview, the facility failed to conduct Quality Assessment and Assurance meetings at least quarterly. Findings: A review of the facility's Quality Assessment and Assurance committee's agenda revealed meeting dates of 3/29/2022 for the first quarter, 5/14/2022 and 6/28/2022 for the second quarter. There was no documented evidence the committee had met for the third quarter as of this date. During an interview on 10/26/2022 at 4:47 p.m., S1ADM (Administrator), confirmed the last committee meeting was held on 6/28/2022.

Based on policy review, record review and interviews, the facility failed to implement their policies and procedures as evidenced by failing to ensure COVID-19 vaccination status of staff was tracked and documentation maintained for 2 (S7CNA and S10LPN) of 137 staff listed on the facility's COVID-19 Staff Vaccination Status for Providers. This deficient practice had the potential to affect the 94 residents who resided in the facility. Findings: Review of policy: Mandatory COVID-19 Vaccination Policy and Procedure revealed the following, in part: Scope = This mandatory COVID-19 Vaccination Policy applies to all staff of the facility. All staff, covered by this policy, are required to be fully vaccinated as a term and condition of employment at this facility. New Staff have at a minimum the first dose in a vaccine series if applicable completed prior to working in the facility with 30 days to complete the series of have an approved exemption request in order to be eligible for employment. Staff are to be considered fully vaccinated two weeks after completing primary vaccination with a COVID-19 vaccine, with, if applicable, at least the minimum recommended interval between doses. For example, this includes two weeks after a second dose in a two-dose series, such as the Pfizer or Moderna vaccines Vaccination Status and Acceptable Forms of Proof of Vaccination listed in-part: Documentation of COVID-19 Vaccination Status shall be confidential and maintained in the Employee Health Folder. A listing of employees to include their vaccination status and exemption status shall be tracked and securely maintained by the Infection Preventionist. Review of the facility's COVID-19 Staff Vaccination Status for Providers form, provided by S1Administrator (ADM), revealed a list of 137 total staff. The form also listed 11 staff partially vaccinated, 108 staff completely vaccinated, no staff pending any exemption, 18 staff granted a non-medical exemption, no staff with a temporary delay or newly hired and no staff not vaccinated without exemption or delay. Surveyor requested a list of the facility's current employees from the human resources list to determine the date of hire for the staff listed as partially vaccinated. Review of two forms provided by S1ADM and human resources labeled as: Employee Information Report and Credentials (S1ADM's Name) COVID Vaccination Status revealed the following, in part, for 2 (S7CNA and S10LPN) of the 11 staff listed as Partially Vaccinated: S7CNA with a date of hire (DOH) of 05/25/2022, was listed as an active employee with dose 1 of Pfizer dated 02/02/2022. S10LPN with a DOH of 03/02/2022, was listed as an active employee with dose 1 of Pfizer dated 12/06/2021. Interview and review of record with S1ADM on 10/25/2022 at 2:20 p.m. revealed the following in-part: S7CNA had a hire date of 05/25/2022, was listed as an active employee with dose 1 of Pfizer dated 02/02/2022. She was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Review of the personnel record with S1ADM revealed S7CNA last worked 11 p.m. to 7 a.m. 10/20/2022. Further review revealed S7's personnel record also contained forms signed and dated 05/27/2022 by S7CNA which included: A document that S7CNA was planning on filing and approved exemption reason and had the needed information to do so on 05/27/2022. A Signed COVID-19 Vaccine Declination due to personal choice. A copy of her COVID-19 Vaccination card with only one dose of Pfizer vaccine administered on 02/02/2022. A Medical Record Checklist signed and dated 05/27/22 which indicated her COVID-19 Vaccination card was provided to the facility. S1ADM verified the above findings and said the facility hired her to work on 05/27/2022, had no exemption for COVID-19 vaccination and allowed her to work in the facility with her latest date of work on 10/20/2022. On 10/25/2022 at 4:10 p.m., S1ADM and S2DON (Director of Nurses) verified the latest COVID -19 Staff Vaccination for Providers form included 11 staff who were listed as partially vaccinated. They were asked for and confirmed that the facility had no exemption, temporary delay, requested or pending exemption for any of the 11 Partially Vaccinated staff listed on the form. S10LPN was present, working and interviewed on 10/25/2022 at 4:25 p.m. She said she was fully vaccinated with 2 doses of Pfizer. She provided her vaccination card and it documented she received her Pfizer vaccination doses dated 12/06/2021 and 01/13/2022. S10LPN said she had provided a copy of her COVID-19 vaccination card to the facility.

Based on record review and interview, the facility failed to implement a process to ensure 100% of the facility's staff were fully vaccinated as evidenced by 6 (S7 - S12) of 137 staff being listed as partially vaccinated and not having the required documentation for a non-medical or other accepted exemption/delay. This deficient practice had the potential to affect the 94 residents who resided in the facility. Findings: Review of policy: Mandatory COVID-19 Vaccination Policy and Procedure revealed the following, in part: Scope = This mandatory COVID-19 Vaccination Policy applies to all staff of the facility. All staff, covered by this policy, are required to be fully vaccinated as a term and condition of employment at this facility. New Staff have at a minimum the first dose in a vaccine series if applicable completed prior to working in the facility with 30 days to complete the series of have an approved exemption request in order to be eligible for employment. Staff are to be considered fully vaccinated two weeks after completing primary vaccination with a COVID-19 vaccine, with, if applicable, at least the minimum recommended interval between doses. For example, this includes two weeks after a second dose in a two-dose series, such as the Pfizer or Moderna vaccines Review of the facility's COVID-19 Staff Vaccination Status for Providers form, provided by S1Administrator (ADM), revealed a list of 137 total staff. The form also listed 11 staff partially vaccinated, 108 staff completely vaccinated, no staff pending any exemption, 18 staff granted a non-medical exemption, no staff with a temporary delay or newly hired and no staff not vaccinated without exemption or delay. On 10/25/2022 at 4:10 p.m., S1ADM and S2DON (Director of Nurses) verified the latest COVID -19 Staff Vaccination for Providers form included 11 staff who were listed as partially vaccinated. They were asked for and confirmed that the facility had no exemption, temporary delay, requested or pending exemption for any of the 11 Partially Vaccinated staff listed on the form. Surveyor requested a list of the facility's current employees from the human resources list to determine the date of hire for the staff listed as partially vaccinated. Review of two forms provided by S1ADM and human resources labeled as: Employee Information Report and Credentials (S1ADM's Name) COVID Vaccination Status revealed the following, in part, for 6 (S7 - S12) of the 11 staff listed as Partially Vaccinated: S7CNA with a date of hire (DOH) of 05/25/2022, was listed as an active employee with dose 1 of Pfizer dated 02/02/2022. S8NAT (Nurse Assistant in Training) with a DOH of 01/19/2022, was listed as an active employee with dose 1 of Pfizer dated 01/11/2022. S9CNA with a DOH of 05/28/2021, was listed as an active employee with dose 1 of Moderna dated 07/09/2021. S10LPN with a DOH of 03/02/2022, was listed as an active employee with dose 1 of Pfizer dated 12/06/2021. S11CNA with a DOH of 06/13/2019, was listed as an active employee with unvaccinated listed and pending dose 1 only, dated 01/06/2022. S12LPN with a DOH on 06/15/2021, was listed as an active employee with dose 1 of Pfizer dated 04/08/2022. With this information as documented above, the facility's staff vaccination percentage = 92%, less than the required 100%. On 10/25/2022 at 4:45 p.m., S1ADM and S2DON were informed the facility's COVID-19 Staff Vaccination Status (percent of vaccinated staff) was not the required 100 % as evidenced with the provided documents. The two staff provided no additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident's family and/or responsible party as well as the resident's physician of significant weight loss for 3 (#40,#59 and #74) out of 6 final sample residents with a significant weight loss. The total census was 94. This deficient practice had the potential to affect a census of 94 residents. Findings: Review of the facility policy titled, Change in Resident Medical Status read in part, a significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting 2. Impacts more than one area of the resident's health status; A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is . 2. A significant change in the resident's physical, mental, or psychosocial status; (that is a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications . Resident #40: Review of Resident 40's medical record revealed she was admitted to the facility on [DATE]. Her current diagnoses were the following in part, Dementia, Unspecified Protein-Calorie Malnutrition, Gastro-esophageal reflux disease and Dysphagia. Her BIMS (Brief Interview for Mental Status) score was 3 meaning she had impaired cognition. Review of the resident's weights from April 2022 through October 2022 revealed the following weights: 4/04/22 - 138.6 pounds; 5/02/22 - 140.2 pounds; 6/03/22 to138.8 pounds; 7/05/22 - 135 pounds; 8/16/22 - 130.4 pounds; 9/09/22 - 129.4 pounds; and 10/06/22 - 122.8 pounds. This resulted in a 5.10% weight loss in one month from 9/9/22 to10/6/22 and 11.56% loss in six months from 4/4/22 to 10/6/22. Resident #59: Review of Resident 59's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included in part, Muscle Wasting and Atrophy, Major Depressive Disorder, Type 2 Diabetes Mellitus and Dysphagia. Her BIMS (Brief Interview of Mental Status) was 11, indicating the resident's cognition was moderately intact. Review of the resident's weights from April 2022 - October 2022 revealed the following weights: 4/1/22 - 171 pounds; 5/9/22 - 171.4 pounds; 6/2/22 - 168.2 pounds; 7/6/22 - 168.6 pounds; 8/1/22 - 162.2 pounds; 9/8/22-157 pounds; 10/4/22-143 pounds. This resulted in an 8.92% weight loss in one month (9/8-10/4//22) and 16.37% weight loss over six months from 4/1/22-10/4/22. Resident #74: Review of Resident 74's medical records revealed she was admitted to the facility on [DATE]. Her current diagnoses were the following in part, Alzheimer's Disease, Dementia, Deficiencies of Vitamins and Dysphagia. Her BIMS score was 6, indicating severe cognitive impairment. Review of the resident's weights from September 2022 through October 2022 revealed the following weights: 9/09/2022 - 125.4 pounds and 10/04/2022 - 118.4 pounds. This resulted in a 5.58% weight loss in one month. The facility was made aware of Residents #40, #59, and #74 weight loss on 10/24/22. Review of Resident #40, #59 and #74's medical records on 10/26/22 revealed no documented evidence that the residents' family and/or responsible party were notified of their weight loss. An interview was conducted on 10/26/22 at 4:30 p.m. with S3ADON. S3ADON stated that she was responsible for contacting the resident's family and/or responsible party when there was a change in the resident's weight and the nurses were responsible for making sure that the physician was made aware of any dietician recommendations. She stated that the process was to notify the resident's family and/or responsible party by phone. S3ADON confirmed that she did not notify Resident #40, #59 or #74's family and/or their responsible party nor had their physician been notified that there was significant change in the their weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #61 A review of a document, provided by the facility, for CMS 802 titled Matrix for Providers indicated resident #61 had Physical Restraints. A review of Resident #61's clinical record indicated diagnoses that included Osteoporosis, Congestive Heart failure, muscle weakness, and abnormal mobility. Her current physician orders and plan of care failed to provide documented evidence of restraint usage for bed rails. A review of resident #61's electronic clinical record for a Significant Change Minimum Data Set (MDS) Assessment with an assessment reference date (ARD) of 07/18/2022, revealed, in part: Section G for Functional Status . Bed Mobility . Extensive one-person assistance. Section N for Medications . Medications Received. Indicate the number of Days the resident received the following medications during the last 7 day E. Anticoagulants . Coded for 7 days. Section P for Restraint Physical Restraints .Used in bed .A. bed rail 1. Used less than daily A review of resident #61's electronic medication administration record for July 2022 revealed no anticoagulants administered during the 7 day lookback period of ARD 7/18/2022. An observation of resident #61's bed on 10/25/2022 revealed partial bed rails located on the upper half of her bed. The partial side rails did not interfere with her freedom of movement. On 10/25/2022 at 9:28 a.m., an interview was conducted with S13MDS. She verbalized resident #61's bed rails were utilized for positioning and bed mobility, did not restrict her freedom of movement, and were not considered a restraint. She confirmed her Significant Change MDS with ARD of 7/18/22 was incorrectly coded for restraints regarding bed rail usage. S13MDS reviewed resident #61's medication administration record for July 2022 and confirmed residents anticoagulant was discontinued prior to the 7-day look back period of the MDS and should not have been coded as receiving anticoagulants for 7 days. On 10/25/2022 at 10:18 a.m. an interview was conducted with S2DON (Director of Nursing) who confirmed the facility is restraint free and no residents should be documented as having a restraint for bed rails. Based on record review and interview, the facility failed to ensure staff who have the skills and qualifications to assess relevant care areas and who were knowledgeable about the resident ' s status, needs, strengths and areas of decline, accurately completed the resident assessment for 3 (#61, #86, #91) of 44 final sampled residents. Findings: Resident #86 Review of the resident's electronic health record revealed she was admitted to the facility on [DATE] and had diagnoses including unspecified Dementia with behavioral disturbance and Bipolar Disorder. Review of the resident's current physician orders for October 2022 revealed an order dated 9/16/22 Seroquel 25mg tablet give 1 per peg (percutaneous endoscopic gastrostomy) q hs (every night) target behavior withdrawn. Review of the resident's MAR (Medication Administration Record) for September - October 2022 revealed Seroquel was administered on 9/16/22 through 9/30/22. Further review revealed the resident continued to receive Seroquel through October 2022. Review of section N - Medications of the resident's Significant Change MDS (Minimum Data Set) assessment dated [DATE] revealed: No - Antipsychotics were not received. On 10/25/22 at 03:15 p.m., an interview and review of Resident #86's medical record was conducted with S15MDS. She confirmed Resident #86 was prescribed Seroquel, an antipsychotic medication, on 9/16/22. S15MDS reviewed Resident #86's September MAR and Significant Change MDS assessment dated [DATE]. She confirmed antipsychotic medication was administered to the resident on 9/16/22 through 9/30/22. She confirmed the MDS assessment was coded as the resident did not receive any antipsychotic medication. S15MDS confirmed the assessment was not accurate and that the assessment should have been coded yes for receiving an antipsychotic. Resident #91 Resident #91 was admitted to the facility on [DATE]. His diagnoses included the following in part, Heart Failure, Essential Hypertension, Peripheral Vascular Disease and Mood Disorder. Review of Resident #91's October 2022 physician orders revealed an order for Quetiapine (Seroquel), an antipsychotic, 25mg (milligram)-give ½ tab (12.5mg) by every night. Review of Resident #91's quarterly MDS (Minimum Data Set) dated 9/26/22 under the medication received section revealed that zero was entered for the number of days that the resident received an antipsychotic medication. Review of Resident #91's October 2022 MAR (Medication Administration Record) revealed that the resident received Seroquel daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #14 Review of physician orders revealed resident #14 had an order dated 9/29/22, with a start date of 9/30/22 for an H&H (Hemoglobin and Hematocrit) and Chemistry 8 every 2 weeks and an order dated 10/12/14 for a Chemistry 18/CBC/HGA1C. Review of the medical record revealed the lab results dated September 30, 2022 for a Chemistry, HCT, & HGB and results for a Chemistry completed October 21, 2022. No results or evidence that the labs ordered for 2 week intervals nor the HGA1C, Chemistry 18, and CBC that was ordered for October 12,2022 were ever completed. On 10/26/22 at 1:18 p.m., an interview was conducted with S4LPN. At this time S4LPN reviewed the Resident #14's record and confirmed there were no results or evidence the labs were completed as ordered for October 2022. Based on observations, interviews and records reviewed, the facility failed to develop and implement the comprehensive person centered care plan as evidenced by: 1. failing to develop a care plan for a resident receiving an antipsychotic medication (#86); 2. failing to care plan resident #4 for her dentures; and 3. failing to follow physican orders for 2 (#14 and #36) residents in a final sample of 44 residents. Findings: 1. Resident #86 Review of the resident's electronic health record revealed she was admitted to the facility on [DATE] and had diagnoses including unspecified Dementia with behavioral disturbance and Bipolar Disorder. Review of the resident's current physician orders for October 2022 revealed: order dated 9/16/22 Seroquel 25mg tablet give 1 per peg (percutaneous endoscopic gastrostomy) q hs (every night) target behavior withdrawn. Review of the resident's MAR (Medication Administration Record) for September - October 2022 revealed Seroquel was administered on 9/16/22 thorough October 2022. Review of the resident's care plan revealed she was not care planned for use of an antipsychotic with individualized approaches to care, including non-pharmacological interventions. On 10/26/22 at 09:00 a.m., an interview and review of Resident #86's medical record was conducted with S15MDS. She confirmed the resident received antipsychotic medication as ordered in September and October 2022. S15MDS reviewed the resident's care plan and stated that the resident was not care planned for antipsychotic use and should have been. On 10/26/22 at 04:23 p.m., S2DON confirmed staff failed to develop care plan interventions for the use of antipsychotic medication administered to Resident #86. 2. Resident #4 Record review revealed Resident #4 was admitted to the facility on [DATE], her BIMS (Brief Interview for Mental Status) score was 8, meaning her cognition was moderately impaired. On 10/24/22 at12:19 p.m., an observation revealed Resident #4 had upper dentures and was missing her bottom dentures. At that time she stated she came to the facility with both of her dentures and lost her lower dentures. On 10/25/22 at 10:40 a.m., S18LPN confirmed Resident #4 had a full set of dentures on admit. On 10/25/22 at 10:45 a.m., S19CNA confirmed Resident#4 had upper and lower dentures when she was admitted to the facility but had miss placed her lower dentures. Record review of Resident #4's Care Plan revealed the resident was not care plan for her upper and lower dentures. 10/26/22 09:29 a.m., S13LPN, MDS nurse reviewed Resident #4's care plan and stated the resident was not care planned for dentures. She stated if the resident had dentures she should have a care plan for the dentures. 3. Resident #36 Record review revealed Resident #36 was admitted to the facility on [DATE] to the Alzheimer's unit. Her diagnosis were Cognitive communication deficit, Muscle wasting, Psychotic disorder, Anxiety, Alzheimer's disease, and Dementia. Record review of Resident #36's Physicians Orders dated October 2022 read in part, Chem (Chemistry)-18, CBC (Complete Blood Count), Fasting Lipid Panel, TSH (Thyroid Stimulating Hormone), Urinalysis Yearly (May). Record review of Resident #36's laboratory results revealed on 07/25/22 a CBC and CMP (Comprehensive Metabolic Panel) was resulted. There was no Fasting Lipid Panel, TSH, or Urinalysis drawn. On 10/26/22 at 11:06 a.m., an interview with S2DON revealed she did not have a Chem-18, CBC, Fasting Lipid Panel or TSH, drawn in May 2022 as the physician ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #47's medical records revealed he was admitted to the facility on [DATE]. Review of the resident's Significant Change MDS (Minimum Data Set) assessment, dated 9/15/22, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 7, indicating his cognition was moderately intact. Review of the facility's care plan review form titled Conferences held for all OBRA (Omnibus Budget Reconciliation Act) required assessments: admission, quarterly, annual, planned discharge, significant change, and resident/resident representative request. Review of the document titled, Care Plan Review revealed that Resident #47 last attended a meeting on 8/12/21. On 10/24/22 at 10:36 a.m., during an interview with Resident #47, the resident stated that he was not sure what a care plan meeting was and that he had not been invited to attend a meeting. On 10/26/22 at 09:07 a.m., an interview was conducted with S14SSD about documentation of Resident #47's care plan meeting notes. S14SSD replied I can't find them. S14SSD was asked when was the last time the resident was invited to or attended a care plan meeting. S14SSD replied that she was not sure of when the last time a care plan meeting was held for the resident. She stated that she reviewed the resident's chart and the last documented care plan meeting was in 2021. S14SSD stated that care plan meetings should be conducted quarterly and documented. She then confirmed she failed to conduct care plan meetings for Resident #47 as required. On 10/26/22 at 10:20 a.m., S2DON stated that the facility does not have a policy for care plan meetings and reviews. She stated that care plan meetings should be held as indicated on the Care Plan Review form. Based on record review and interview, the facility failed to: 1. ensure the resident's care plan was accurately updated to reflect the resident's current use of anticoagulant, a blood thinner medication, for 1 (#91) out of 5 (#36, #50, #86, #91 and # 92) residents investigated for unnecessary medication review; and 2. failed to facilitate the resident's and if applicable, the resident representatives' participation in the care planning process for 1 (#47) of 1 residents investigated for care planning. Findings: 1. Resident #91 was admitted to the facility on [DATE]. His diagnoses included the following in part, Heart Failure, Essential Hypertension, Peripheral Vascular Disease, and Other Symptoms and Signs involving the Circulation and Respiratory Systems. Review of Resident #91's MAR (Medication Administration Record) revealed an order for Xarelto (a blood thinner) 2.5mg tablet-take one tablet by mouth twice a day. Review of Resident #91's care plan revealed that the resident was care planned for Potential for injury related to history of Plavix and Aspirin use. Further review of the resident's care plan revealed it was not updated to reflect that the resident was no longer on Plavix and his anticoagulant medication was changed to Xarelto. On 10/26/22 at 9:10 a.m., an interview and a record review was conducted with S15MDS (Minimum Data Set). S15MDS stated that she was responsible for updating the residents' care plans when needed. A review of Resident #91's physician orders was conducted and S15MDS confirmed that the resident was on Xarelto. A review of Resident #91's care plan was also conducted and S15MDS confirmed that the resident's care plan was not updated to reflect that the resident was no longer on Plavix and was taking Xarelto.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the resident's environment was free of hazards as evidenced by: 1. staff failing to follow the facility's smoking policy by allowing residents to keep cigarettes and lighters in their rooms for 3 (#38, #47, #84) of 4 (#38, #47, #84, #447); and 2. failing to reassess residents for smoking in the observation period of each MDS per the facility's policy for 3 (#38, #47, #84) of 4 (#38, #47, #84, #447) residents investigated for smoking out of a total of 8 smokers residing in the facility. 3. failing to have an appropriate care plan intervention for 1 (#36) of 9 (#36, #38, #47, #74, #84, #86, #92, #445, #447) investigated for falls. Findings: 1. Review of the facility's policy titled, Smoking Policies and Regulations read in part: Cigarette lighters and matches are not permitted in a resident's room and will be kept at the nurses stations. The facility will provide matches and will light cigarettes upon request in designated areas set aside for smoking . Adherence to these policies and procedures will be strictly enforced. Resident #47 Review of the resident's Significant Change MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 7, indicating his cognition was moderately intact. Review of the resident's printed care plan revealed in part: Resident uses tobacco .cigarettes and lighters are kept at nursing station. On 10/24/22 at 09:58 a.m., Resident #47 was observed in the doorway of his room fumbling with smoking apron. A pack of cigarettes was observed in his shirt pocket. The resident stated he was going into the smoking room to smoke and was allowed to keep his cigarettes and lighter on his person and inside his room. On 10/24/22 at 10:41 a.m., an interview was conducted with Resident #47 inside his room. The resident was observed sitting on his bed. He was asked if he had cigarettes and a lighter. The resident then obtained a pack of cigarettes and lighter from inside his baseball style cap observed in his wheelchair next to his bed. Observations of the resident's room revealed an ashtray on top of a mini-fridge containing 3 loose cigarettes with burnt ends. On 10/26/22 at 07:39 a.m., S16LPN stated she was assigned to care for Resident #47. She stated that Resident #47 was cognitive and allowed to keep his cigarettes and lighter on him at all times and inside his room. On 10/26/22 at 08:20 a.m., Resident #47 was observed inside his room transferring himself from his wheelchair to his bed. A pack of cigarettes was observed inside his shirt pocket. Resident #47 pulled out a lighter from his shirt pocket. Resident #84 Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 15, indicating she was cognitively intact. On 10/26/22 at 12:25 p.m., an observation was made of Resident #84 sitting in her room. The resident stated she is a smoker and stated she keeps her cigarettes and lighter in her room inside her bedside drawer. Her cigarettes and lighter were observed in the drawer. Resident #38 Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 15, indicating she was cognitively intact. On 10/26/22 at 12:31 p.m., an observation was made of Resident #38 lying in bed, reading book. She confirmed she was a smoker and keeps her cigarettes and lighter inside her room. A pack of cigarettes and lighter was observed at her bedside in a zippered pouch. On 10/26/2022 at 3:20 p.m., in an another interview, S16LPN stated that Residents #47, #84, and #38 were safe smokers and allowed to keep cigarettes and lighters inside their rooms. On 10/26/22 at 04:27 p.m., S2DON reviewed the facility's policy and confirmed that all residents in the facility who smoke whether safe or unsafe smokers were not allowed to keep cigarettes and lighters in their room. She stated that the facility's administration had been trying to get residents and staff to comply with the smoking policy. 2. Review of the facility's policy titled, Smoking Policies and Regulations read in part: Smokers will be screened on admission/readmission, and in the observation period of each MDS .Adherence to these policies and procedures will be strictly enforced. Resident #47 Review of Resident #47's medical records revealed he was admitted to the facility on [DATE]. The resident's electronic care plan read in part, potential for injury related to smoking .complete smoker's high risk on admit and quarterly. Resident #84 Review of the resident's medical record revealed she was admitted to the facility on [DATE]. The resident's care plan read in part, resident has potential for injury related to smoking .complete smokers high risk on admit and quarterly. Resident #38 Review of the resident's medical record revealed she was admitted to the facility on [DATE]. The resident's care plan read in part, Resident has potential for injury related to smoking .complete smokers high risk on admit and quarterly. On 10/25/22 at 09:04 a.m., S15MDS stated that she was not responsible for completing smoking assessments and that she was not sure who was responsible for doing it. A review of Resident #47's electronic record conducted with S15MDS revealed no documentation of smoking assessments anywhere in the resident's record. On 10/25/22 at 09:13 a.m., S2DON stated that S14SSD was responsible for completing resident smoking assessments. On 10/25/22 at 09:15 a.m., S14SSD who stated that she has never done smoking assessments and was not sure who was responsible for completing them. On 10/25/22 at 09:23 a.m., S2DON stated that she was wrong and that S13MDS and S15MDS were responsible for completing resident smoking assessments upon admission, quarterly, annually and during significant change MDS assessments. On 10/25/22 at 09:28 a.m., an interview was conducted with S13MDS who stated she was not sure who was responsible for completing smoking assessments. She stated that residents are assessed for smoking upon admission to determine if safe or unsafe, but not reassessed periodically thereafter. She further stated that she not sure if anyone was responsible for periodic assessments. S13MDS stated that it was likely that the residents who smoke had not been reassessed for smoking since their admission smoking assessment. S13MDS further stated that she could not find evidence of any smoking assessments in the medical records for Resident #47. On 10/26/22 at 3:10 p.m., a follow-up interview was conducted with S15MDS. She confirmed that Residents #84 and #38 were both smokers and that she could not find any of their smoking assessments. She stated that smoking assessments should be done on admit, quarterly, and yearly. When asked if the residents' assessments should have been completed, she replied yes. On 10/26/22 at 04:27 p.m., S2DON stated if there was no documentation found in the residents' records or anywhere in the facility, that it was not done. She reviewed the facility's smoking policy and stated that the MDS nurses failed to complete resident smoking assessments per the facility's policy. 3. Record review revealed Resident #36 was admitted to the facility on [DATE] to the Alzheimer's unit. Her current diagnosis were, Unsteadiness on feet, Cognitive Communication Deficit, Muscle wasting and atrophy, Psychotic disorder, anxiety, Alzheimer's Disease, and Dementia. She had a BIMS (Brief Interview for Mental Status) of 3 meaning she has severe Cognitive Impairment. Record review of Resident #36's Incident Accident reports revealed the following, On 08/15/22 resident was found on the floor. An unobserved fall. Complained of pain to neck, back and pelvic area. Sent to emergency room for evaluation. Record review of Resident #36 Care Plan read in part, Risk for falls related to Dementia Process. On 08/15/22 Resident Fell. Intervention was to send to emergency room for Evaluation and treatment. On 10/26/22 at 9:37 a.m., review of Resident #36 care plan with S13MDS confirmed that on 08/15/2022 she fell and was sent emergency room for an intervention. She stated sending the resident to the emergency was not an appropriate intervention to prevent further falls.

Based on record review and interview, the facility failed to be administered in a manner to efficiently and effectively use its resources to maintain the highest practicable physical well-being of its residents by failing to have a functional system to assess significant weight changes. The facility failed to assess weights and intervene when significant and severe weight loss occurred for 5 (#4, #36, #40, #59, #74) of 5 (#4, #36, #40, #59, #74) residents investigated for nutritional status. This deficient practice has the likelihood for the facility's 94 residents, who require weekly and/or monthly weights, to experience undetected, significant weight loss. Findings: Record review of Resident #4's electronic weight history read, 09/09/2022 169.4 lbs. 10/04/2022 156.8 lbs. Resident #4 had a -7.44% severe weight loss in one month from 09/09/2022 to 10/04/2022. Record review of Resident #36's electronic weight history read, 04/04/2022 134.2 lbs. 05/02/2022 133.8 lbs. 06/03/2022 128 lbs. 07/05/2022 128.8 lbs. 08/16/2022 120 lbs. 09/09/2022 117.4 lbs. 10/06/2022 118.4 lbs. Resident #36 had a -13.01% severe weight loss in 6 months from 04/04/2022 to 10/06/2022. Record review of Resident #40 electronic weight history read, 11/06/21 146.6 lbs. 12/23/21 143.8 lbs. 01/07/22 140 lbs. 02/01/22 135 lbs. 03/04/22 141.4 lbs. 04/04/22 138.6 lbs. 05/02/22 140.2 lbs. 06/03/22 138.8 lbs. 07/05/22 135 lbs. 08/16/22 130.4 lbs. 09/09/22 129.4 lbs. 10/06/22 122.8 lbs. Resident #40 had a 5.10% severe weight loss in one month from 09/09/2022 to 10/06/2022. She had a -11.56 % severe weight loss in 6 months from 04/04/2022 to 10/06/2022. Record review of Resident #74 electronic weight history read, 09/09/2022 125.4 lbs. 10/04/2022 118.4 lbs. Resident #74 had a -5.58% severe weight loss in 1 month from 09/09/2022 to 10/04/2022. The facility's Weight Team, consisting of S3ADON (Assistant Director of Nursing), S20FSS (Food Service Supervisor)/DM (Dietary Manager), and S22RD (Registered Dietician), did not identify declining resident weights. On 110/25/2022 at 3:29 p.m., S3ADON stated that her computer system, which reported weight loss did not pull all residents who had actual significant and severe weight loss. On 10/26/2022 at 11:39 p.m., S20FSS stated that he monitored resident's weights and did not notice the severe weight loss for residents #4, #36, #40, #59, and #74. The facility's Registered Dietician, had access to all resident weights, and failed to provide recommendations for residents who had severe weight loss. On 10/26/22 at 01:49 p.m., an interview was conducted with S3ADON. She stated the reports for weights would have been looked at on 10/04/22. She recalculated resident weights, ran another report, and stated that the system is still not working. After reviewing the report, Resident #59 was still not showing up as having a weight change. She stated that she had to get with the administrator to contact support to see what's going on with the system because she thought it was working. She stated that there was no other way to check to see if any resident had a significant weight loss without manually calculating weights for each resident since the system was not working properly. On 10/26/22 at 5:42 p.m., an interview with S1ADM (Administrator), and S2DON (Director of Nursing) confirmed S3ADON (Assistant Director of Nursing), S20FSS (Food Service Supervisor) and S22RD (Registered Dietician) where on the Weight Team and S3ADON and S20FSS should have been monitoring the residents' weights monthly and reporting weight losses and/or gains to the S22RD in order for her to assess and provide interventions for the weight loss or gain. S1ADM confirmed S3ADON and S20FSS should have been aware of the weight loss and brought this to management's attention to resolve the problem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #59 Review of the resident's medical record revealed she was admitted to the facility on [DATE] and had diagnoses including need for assistance with personal care, Muscle Wasting and Atrophy, Major Depressive Disorder, lack of coordination, Type 2 Diabetes Mellitus, Dysphagia following other non-traumatic intracranial hemorrhage, and Aphasia. Review of the resident's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 11, indicating the resident's cognition was moderately intact. Review of the resident's weights April 2022-October 2022 revealed: 10/4/22 143 pounds, BMI (Body Mass Index) 21.74 No weight documented for September 8/1/22 162.2 pounds BMI 24.66 7/6/22 168.6 pounds 6/2/22 168.2 pounds 5/9/22 171.4 pounds 4/1/22 171 pounds On 04/01/2022, the resident weighed 171 lbs. On 10/04/2022, the resident weighed 143 pounds which was a -16.37 % severe weight loss in 6 months. Review of the S22RD's (Registered Dietitian) notes for the past year revealed one note, dated 10/24/22, that revealed in part: PO (oral) intake ~25-100% of meals recorded looking back 14 days .weight changes -11.84% in ~64 days. -15.18% in ~90 days, -16.57% in ~148 days. Review of the resident's nutritional care plan revealed interventions that included: determine food preferences, observe weight as ordered, refer to RD (Registered Dietitian) for evaluation and recommendation as needed, supplements as ordered. Further review revealed no interventions and no documentation regarding the resident's nutritional status in regards to her significant weight loss. Review of the resident's Dietary Notes for the past year of the resident's stay revealed no documentation of dietary assessments or assessment of food prefrences. Review of the resident's physician orders for October 2022 revealed an order dated 5/12/21 Diet Regular LCS, NAS (low concentrated sweets, no added salt). Further review revealed no further orders for nutritional supplements, weights or nutritional interventions addressing the resident's weight loss. Review of the resident's MAR (Medication Administration Record) September 2022-October 2022 revealed no nutritional supplements were administered. On 10/26/22 at 10:07 a.m., S13MDS stated that there were no dietary notes in Resident #59's medical record for the last year. On 10/26/22 at 11:24 a.m., an interview and observation of Resident #59 was conducted. The resident was wearing jeans that fit a little baggy. Resident #59 stated that she had desired to lose weight and was much smaller now than she was before. When asked what she did to lose the weight, the resident stated that she ate less during meals or skipped some meals. She further stated that it seemed like none of the staff noticed she lost weight because none of them commented about it. She stated that she did not tell the staff about her desire to lose weight and that no one asked her about it or counseled her about it. Resident #59 stated that no one from the Dietary Department nor S22RD spoke to her about her weight loss or had ever spoken to her about her food preferences. On 10/26/22 at 11:44 a.m., an interview was conducted with S16LPN and S23CNA who stated that the resident did not have any visible weight loss that they had noticed. S16LPN stated she had not noticed a difference in the way the resident's clothes fit and there were no changes in the resident's appetite that she noticed. S16LPN stated that the CNAs (Certified Nursing Assistants) did not report any issues to her and no other staff reported to her the resident wasn't eating enough. S23CNA and S16LPN stated that no one reported to them that Resident #59 had a significant weight loss. S16LPN stated resident #59 is not on any nutritional supplements. S16LPN and S23CNA stated that the resident had never told them that she was intentionally losing weight or expressed desired weight loss. S16LPN stated the resident has never had any weight issues since her admission to the the facility. On 10/26/22 at 12:06 p.m., F20FSS stated he was responsible for assessing residents' food preferences and dietary needs upon admission and when their required assessments were due- quarterly and annually. S20FSS stated that he would provide copies of dietary and food preference assessments for Resident #59. On 10/26/22 at 12:18 p.m., S20FSS returned without documentation of Resident #59's dietary assessments. S20FSS stated that he was not made aware that Resident #59 had any weight loss. On 10/26/22 at 12:21 p.m., an interview and review of Resident #59's medical record was conducted with S3ADON, who stated that she played an active part in obtaining residents' weights. She further stated that she was solely responsible for tracking residents' weights and weight comparisons. She stated that if a weight change was identified she was responsible for notifying S22RD of the weight change. She stated that S22RD came into the facility three times a month to assess residents. On the 10th day of each month or the week of the 10th of each month, S22RD assessed significant weight changes. She reviewed Resident #59's weight history and confirmed there was no weight documented for September 2022. S3ADON stated that she ran a weight report on 10/11/22 and had not noticed Resident #59's weight loss because the resident's name did not show up on the weight change report. The facility's electronic health record system was down the week of 10/10/22, so S22RD had to come back to the facility later in the month to complete her assessments. She stated she did not notice Resident #59 had a weight loss until S22RD entered her note on 10/24/22. She stated she was not sure if the physician reviewed S22RD's dietary recommendations yet and was not sure when the physician was due to return to the facility to review them. She stated that had she caught Resident #59's weight loss sooner, she would have notified S22RD as soon as possible. She reviewed S22RD's note and the calculations of the resident's weight loss and confirmed the resident's weight loss was significant. She reviewed the resident's physician's orders and confirmed the order for Resident #59's supplement had not been entered. She confirmed there were no dietary notes for the resident for the last year. On 10/26/22 at 01:28 p.m., S3ADON provided copy of her weight change report dated 10/11/22 and Resident #59's September 2022 weight that she had handwritten on a log as 195 w/ chair - 38. S3ADON stated that the resident's weight minus 38 which was the weight of the wheelchair which equaled 157 pounds. A comparison of the September 2022 with the October 2022 weight revealed: On 09/08/2022, the resident weighed 157 lbs. On 10/04/2022, the resident weighed 143 pounds which is a -8.92 % loss in 1 month. On 10/26/22 at 01:49 p.m., a follow-up interview was conducted with S3ADON who confirmed the resident had a significant weight loss of greater than 5% in one month that was missed because the resident's September weight had not been entered into the resident's record. She stated the reports for weights would have been looked at on 10/04/22. She recalculated and ran another report and stated that the system is still not working. After reviewing the report, the resident was still not showing up as having a weight change. She stated that she had to get with the administrator to contact support to see what's going on with the system because she thought it was working. She stated that there was no other way to check to see if any resident had a significant weight loss without manually calculating weights for each resident since the system was not working properly. On 10/26/22 at 04:20 p.m., S2DON stated that due to the facility's issues with the electronic health record system, the resident's significant weight loss was not identified by staff timely. On 10/26/22 at 04:30 p.m., a phone interview and record review was conducted with S22RD who stated that she had access to the resident's record remotely. She was asked if she attended or participated in the facility's weight committee meetings. S22RD stated she had no idea if they have weight team meetings and that she didn't have time to wait for weight team meetings with her workload. She stated she reviewed Resident #59 for weight changes on 10/20/22 when she ran the weight change report. When she ran the report on 10/20/22 she saw that the resident had a 15.1% weight loss in 90 days. She stated that the weight loss was considered severe. She had not received any notification from S20FSS nor S3ADON that the resident had a significant weight loss prior to 10/20/22. She then wrote her recommendations on 10/24/22 (20 days after the last weight was obtained on 10/4/22) when she reviewed the resident's record. When asked why the resident lost weight, she stated that it was due to decreased oral intake per the resident's record. When asked if she spoke to the resident on 10/24/22 when she made her recommendations, she replied no. She stated that she had not spoken to the resident and had only reviewed her record and was unsure of any other reason she may have lost weight. S22RD stated that her latest weight report noted the weight for May 2022 and she was not aware of what the resident's weight was in April. Therefore, she was not able to assess the 6 month weight loss. She further stated that she did not have a weight recorded for September 2022 to do a 1 month weight comparison. S22RD stated she was not aware that Resident #59 had an 8.92 % weight loss in one month from September 2022-October 2022. She stated that an 8.92% weight loss in 1 month was significant and had it been caught by S20FSS or S3ADON, she would have put in recommendations/interventions sooner. Based on observation, record review, and interview, the facility failed to maintain acceptable parameters of nutritional status by failing to have a functional system to assess significant weight changes. The facility failed to assess weights and intervene when significant and severe weight loss occurred for 5 (#4, #36, #40, #59, #74) of 5 (#4, #36, #40, #59, #74) residents investigated for nutritional status. This deficient practice has the likelihood for the facility's 94 residents, who require weekly and/or monthly weights, to experience undetected, significant weight loss. Findings: Record review of the facility's Policy titled Weight Evaluation read in part, Accurate .weights are determined for all residents. Weights are monitored to identify significant changes or residents with nutrition problems. Procedure: 1. A designated Weight Team is established which consists of at least two designated nurse aides and DON or Nurse Designee who will weigh residents on admission and each month and/or each week as needed. Members of the weight team are trained in the correct method for weighing residents accurately 4. All residents will be routinely weighed each month .6. Any variation from the DBW (Desirable Body Weight) is addressed in the medical record and if determined as a legitimate Need by the interdisciplinary team, is identified on the care plan as appropriate .9. As the weight team takes weights the nurse is present and monitors accuracy by comparing the current weight with prior weights. If there is a weight difference of three or more pounds the resident must be promptly reweighed and the weight verified. Once the team nurse verifies the weight, it is recorded in the medical record as soon as possible. All weights recorded are considered accurate. 10. The schedule for weights is developed by the weight team nurse, to include monthly weights . 11. All unplanned weight deviations plus or minus 5% or more per month, or 10% of body weight over a six month period or with insidious weight loss, require completion of a weight evaluation by the facility weight evaluation team .12. The Director of Food and Nutrition Services (Dietary Manager) refers newly identified residents with significant weight loss to the RD (Registered Dietician). 13. The weight team nurse and Director of Food and Nutrition Services are responsible for monitoring resident weight histories to determine a significant weight loss. This review is done each time a resident is weighed. If the resident has a history of gradual weight loss that is not significant, this is addressed in the medical record. 14. Documentation regarding weight status is documented in the medical record by nursing and the Director of Food and Nutrition Services and RD (Registered Dietician). Review of the facility's policy titled, Dietary Services read in part: Food likes, dislikes, and eating habits are assessed by the Nursing and Dietary Departments. This information is recorded in the resident's Medical Record. Resident #4 Review of the clinical record for Resident #4 revealed she was admitted to the facility on [DATE] to the Alzheimer's Unit. Her diagnoses were, Dementia, Urinary Tract Infection, and Gastro-esophageal reflux disease. Review of the MDS (Minimal Data Set), dated 09/16/2022, revealed a BIMS (Brief Interview for Mental Status) score of 8, meaning she had moderate cognitive impairment. Record review of Resident #40's Electronic weight history read, 09/09/2022 169.4 lbs. 10/04/2022 156.8 lbs. Resident #4 had a 7.44% severe weight loss in one month from 09/09/2022 to 10/04/2022. Record review of S22RD (Registered Dietician)'s Notes for Resident #4, read in part, 3/29/22 NAS (No Added Salt) /Regular diet. PO (by mouth) Intake 75-100% of meals, admitted to Memory Unit. No RD changes at this time. Continue POC (Plan of Care). Further review of S22RD's notes revealed no documentation for Resident #4 after 3/29/22. Record review of Resident #4's clinical record from 01/2022 to 10/26/22 revealed no documentation from S20FSS (Food Service Supervisor). On 10/25/22 at 10:55 a.m., S18LPN reviewed Resident #4's electronic weights and confirmed the resident had lost 7.44 % of body weight in one month. On 10/25/22 at 3:49 p.m., S3ADON reviewed Resident #4's electronic weight record and confirmed the resident had lost 7.44% in one month. She stated when she ran the weight reports the computer should have flagged the resident for weight loss. She stated that she was not aware that the resident had weight loss. Resident #36 Review of the clinical record revealed Resident #36 was admitted on [DATE] to the Alzheimer's unit with diagnoses in part, Cognitive communication deficit, Psychotic disorder, Alzheimer's disease, Dementia, Muscle wasting, and Urinary Tract Infection. Review of the resident's MDS, dated [DATE], revealed a BIMS Score was 3 meaning severe cognitive impairment. Record review of Resident #36's Electronic weight history read, 04/04/2022 134.2 lbs. 05/02/2022 133.8 lbs. 06/03/2022 128 lbs. 07/05/2022 128.8 lbs. 08/16/2022 120 lbs. 09/09/2022 117.4 lbs. 10/06/2022 118.4 lbs. Resident #36 had a 13.01% severe weight loss in 6 months from 04/04/2022 to 10/06/2022. Record review of S22RD's Notes read in part, 10/24/22 (18 days after the last weight was obtained) Weight Changes -11.51 % in 157 Days. Staff continue to encourage intake of meals. Record review of Resident #36's Care Plan, dated 05/13/2021, read in part, Potential for weight loss. Resident is on a therapeutic Diet: Regular: Observe weight as ordered, Refer to RD (Registered Dietician) for Evaluation and recommendation as needed. Further review revealed no new interventions when weight loss occurred. Review of Resident #36's record from 01/2022 to 10/26/2022 revealed no documentation by S20FSS. On 10/25/22 at 4:01 p.m., S3ADON reviewed Resident #36's electronic weights and stated the resident had lost 13% body weight in 6 months. She stated when she ran the 1 month and 6 month weight reports, the computer did not pick up Resident #36's 13% weight loss in 6 months. Resident #40 Review of the clinical record revealed Resident #40 was admitted on [DATE] to the Alzheimer's Unit, with diagnoses in part as follows: Dementia, Unspecified Protein-Calorie Malnutrition, Gastro-esophageal reflux disease, Dysphagia, Constipation, and Diarrhea. Review of Resident #40's MDS, dated [DATE], revealed a BIMS score of 3, which indicated severe impaired cognition. Record review of Resident #40 Electronic weight history read, 11/06/21 146.6 lbs. 12/23/21 143.8 lbs. 01/07/22 140 lbs. 02/01/22 135 lbs. 03/04/22 141.4 lbs. 04/04/22 138.6 lbs. 05/02/22 140.2 lbs. 06/03/22 138.8 lbs. 07/05/22 135 lbs. 08/16/22 130.4 lbs. 09/09/22 129.4 lbs. 10/06/22 122.8 lbs. Resident #40 had a 5.10% severe weight loss in one month from 09/09/2022 to 10/06/2022. She had a 11.56 % severe weight loss in 6 months from 04/04/2022 to 10/06/2022. Review of S22RD's notes, dated 10/24/2022, read in part, Weight change: -10% in 27 Days. -11.53% in 125Days. -12.41% 157 Days. Rec: Increase House Supplement to 240cc TID (three times a day) for Sign (significant) weight change. RD review and recommendation was 18 days after the last recorded weight on 10/6/22. Record review of Resident #40's Care Plan read in part, Resident needs assist with eating. Resident eats in Unit dining room and occasionally needs to be fed d/t (due to) occasional tiredness in the morning. Further review revealed no new interventions with the continued weight loss. Review of Resident #40's record from 01/2022 to 10/26/2022 revealed no documentation from S20FSS. On 10/25/22 at 3:57 p.m., S3ADON reviewed Resident #40's electronic weights and confirmed the resident lost 5.10% weight in one month and 11.56 % weight in 6 months She stated she ran the weight report on 10/11/2022 for a one month report and six month report and the computer did not pick up the weight loss. Resident #74 Review of the clinical record revealed Resident #74 was admitted on [DATE] to the Alzheimer's unit with diagnoses as follows: Alzheimer's disease, Dementia, Deficiencies of Vitamins, Chronic Obstructive Pulmonary Disease, Constipation, Dysphagia, and Pain. Review of the resident's MDS, dated [DATE], revealed a BIMS score of 6 which indicated severe cognitive impairment. Record review of Resident #74 electronic weight history read, 09/09/2022 125.4 lbs. 10/04/2022 118.4 lbs. Resident #74 had a 5.58% severe weight loss in 1 month from 09/09/2022 to 10/04/2022. Review of S22RD's Notes read in part, 04/12/22 Mech (mechanical) soft/Puree meat diet. MD ordered a house supplement due to sign (significant) weight loss from Hospital. Further review revealed no other RD notes. On 10/26/22 at 4:28 p.m., an interview withS22RD revealed she visited the nursing home on [DATE] and did not look at Resident #74 for weight loss. Record review of Resident #74's Care Plan read in part, Resident has a potential for weight loss due to disease process. On mechanical soft diet with pureed meats Further review revealed no changes in the care plan when weight loss occurred. Review of Resident #74's record from 01/2022 to 10/26/22 revealed no documentation from S20FSS. On 10/25/22 at 3:57 p.m., S3ADON reviewed Resident #74's electronic weights and stated the resident had lost 5.58 % body weight in one month. She stated she ran the weight report on 10/11/2022 and the computer did not pick up the weight loss. On 10/25/22 at 3:29 p.m., an interview with S3ADON revealed she was in charge of the resident's monthly weights. She stated all the residents in the facility were weighed monthly. On the 4th of every month she went to the units to ensure all residents were weighed accurately by the CNAs (Certified Nursing Assistants). She stated that she put weights into the computer, and was able to tell at that time if the residents had weight loss. She stated that she ran weight reports for one month and six months and the computer calculated the weight loss or gain and printed out a list. She stated she brought the residents with weight loss or gain to the attention of the Registered Dietician. She stated the Food Services Supervisor should be reviewing the residents' weights and if he noticed a weight loss or gain, he should have brought it to the attention of the registered dietician. On 10/26/22 at 9:11 a.m., S20CNA confirmed that S3ADON supervised and assisted CNAs with obtaining accurate resident weights. On 10/26/22 at 11:39 a.m., an interview with S20FSS (Food Service Supervisor) confirmed that he was part of the Weight Team. He stated S3ADON weighed the residents and put the results in the computer. He stated the RD assessed the residents' weights with him. He stated he reviewed weights for new admissions, hospital returns, and quarterly. He monitored residents' weights monthly to ensure there was no weight loss. He stated the Weight Team had meetings once a month. S20FSS stated he was not aware Resident #40 had a 5.10 % weight loss in one month or 11.56% in 6 months. He was not aware Resident #4 had a 7.44% weight loss in 1 month, was not aware Resident #74 had a 5.58% weight loss in 1 month, or that Resident #36 had a 13.01% weight loss in 6 months. He stated he did not run the weight report. He stated he looked at the weights in the computer and should have recognized the weight losses when reviewing the weights monthly. He stated he was behind on all of his quarterly assessments and had not done any quarterly assessments for Resident #4, #36, #40 and #74 this year. On 10/26/22 at 4:28 p.m., a phone interview with S22RD confirmed she went to the facility 3 times a month to assess the residents. She stated S20FSS and S3ADON left her a log of residents to be seen. She stated the facility's computer had an algorithm that calculated weight gain and loss. She stated, if the residents had a weight gain or loss within 31 days or 6 months, this program should have picked them up. She stated that on 10/20/22 she pulled a weight report for 6 months, from 4/2022 to 10/20/2022. She stated Resident #74 had a -11.5 % weight loss in 157 days, and Resident #40 had a 5.1% loss in 27 days and -12.41 % in 157 days. She stated she did not see Resident #4 or Resident #36 on 10/24/2022, when she visited the facility. She stated if a resident had a significant weight loss for 6 months or for 1 month, they should have an intervention done to prevent further weight loss. She stated she did not get any reports of resident weight loss from the S3ADON or S20FSS that Residents #4, #36, #40 and #74 had lost any weight. She stated she did not attend any weight loss meetings at the facility on a monthly bases. She stated if the facility had a Weight Team, and had meetings, she was not aware of them. She stated the facility's computer algorithm should have picked up if residents had weight gain or loss at 31 days and within 6 months.