Licensure Reference Number 175 NAC 12.006.09(J)(i)(1) Based on observation, interview, and record review the facility failed to evaluate and implement interventions to prevent significant weight loss for 1 (Resident 37) of 1 resident sampled. The facility census was 86. The Findings are: Record Review of Resident 37's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 06-28-2024 revealed an admission date of 06-25-2024 following hospitalization for surgery of a diaphragmatic Hernia with Obstruction (is a protrusion of abdominal contents into the thoracic cavity due to a defect within the diaphragm), other diagnosis included Gastro Esophageal Reflux Disease (GERD, is a long-term condition that occurs when stomach acid flows back up into the esophagus), Barrett's Esophagus (is a condition in which the flat pink lining of the swallowing tube that connects the mouth to the stomach (esophagus) becomes damaged by acid reflux, which causes the lining to thicken and become red) with dysphagia (difficulty swallowing). The MDS also indicated Resident 37 had a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) score of 15 and required set up assistance from staff for oral and personal hygiene, partial assistance for dressing, substantial assistance with bed mobility and was dependent on staff for bathing and transfers. The MDS also revealed Resident 14 weighed 120 pounds. An interview conducted with Resident 37 on 08-07-2024 at 11:54 AM revealed Resident 37 thought they had lost weight but did not know how much. Record Review of Resident 37's Electronic Health Record (EHR, is a digital version of a patient's paper chart) under weights and vitals revealed the following weights: -06-26-2024 weight 120.6 pounds taken on a wheelchair scale. -06-28-2024 weight 120.4 pounds taken on a wheelchair scale. -07-01-2024 weight 120.1 pounds taken on a wheelchair scale. -07-22-2024 weight 114.0 pounds taken on a wheelchair scale, a loss of 6.6 pounds or 5.47% compared to the weight on 6-26-2024. Record Review of Resident 37's Dietary Progress Notes (DPN) revealed on 07-08-2024 Registered Dietician (RD) had identified a current body weight of 120.1 and a Body Mass Index (BMI, is a calculation that estimates body fat and a person's relative weight for their height) of 20.6. The DPN dated 07-08-2024 further identified nutritional supplements had not been ordered, but since Resident 37 was at the low end of a healthy BMI the RD identified Resident 37 could benefit from added calories and recommended a Magic Cup (a nutritional supplement) twice a day at lunch and dinner. According to the DPN dated 07-08-2024, the RD would continue to follow Resident 37 for weight trends, orders/supplements, and to evaluate for further recommendations as needed. Record Review of an email from the facility RD to the facility Director of Nursing (DON) and the DFS on 07-08-2024 revealed a recommendation from the RD to add a Magic Cup to Resident 37's lunch and supper trays. Record Review of progress notes, assessments and care plan in Resident 37's EHR revealed no additional nutritional evaluation related to the significant weight loss on 7-22-2024. An observation conducted during the interview with Resident 37 on 08-07-2024 at 11:54 AM revealed Resident 37 had been served a lunch tray without a Magic cup or other nutritional supplement. An interview with the facility RD on 08-08-2024 at 10:30 AM revealed the RD was at the facility on 07-31-2024 and had not noticed and had not been notified of a weight loss of 6.6 pounds for Resident 37. The RD confirmed during the interview Resident 37 had unplanned weight loss was 5% of Resident 37's body weight within 30 days which was clinically significant. The RD also confirmed Resident 37's physician had not been updated on the significant weight loss and on 07-08-2024 a Magic Cup with lunch and dinner had been recommended. An observation on 08-08-2024 at 12:24 PM of Resident 37 eating lunch revealed the absence of a Magic Cup on the lunch meal tray, Further observation on 08-08-2024 at 12:24 PM revealed Resident 37's dietary slip on the tray did not direct the staff to give a Magic cup with lunch. A follow up interview was conducted with Resident 37 on 08-08-2024 at 12:24 PM. During the interview Resident 37 reported (gender) had received a frozen nutritional supplement for a couple of days and then it stopped. An interview with the Director of Food Service (DFS) on 08-08-2024 at 12:44 PM confirmed the Magic cup was not on the dietary slip for Resident 37. During the interview the DFS reported they were not aware the Magic cup was recommended for Resident 37. An interview with Licensed Practical Nurse (LPN) K on 08-08-2024 1:48 PM revealed LPN K was passing medication for Resident 37 and confirmed (gender) had not provided a Magic Cup at lunch. An interview with Registered Nurse (RN) J on 08-08-2024 at 1:50 PM confirmed (gender) had not provided a Magic Cup for Resident 37 at lunch. Record Review of the Facility Policy Hydration and Nutrition dated 08-24-2023 revealed the following: - Policy-each resident receives a sufficient amount of food and fluids to maintain acceptable parameters of nutritional and hydration status. Under the section Procedure: -1. A physician order is obtained for all regular and therapeutic diets, including those with modified textures. -2. A minimum of three meals are provided each day. If a meal or particular food is refused, the resident is offered a substitute of a similar nutritive value. -3. Snacks are given between meals and at bedtime according to resident desire and/or need. -4. Fluid is available to residents at all times. -5. The resident is positioned properly to consume meals and snacks. -6. An ongoing assessment of the ability to consume and assimilate food and fluid is conducted by nursing personnel and all concerns are reported to the nurse, to include -Positioning needs, -Environmental and social considerations -Ability of resident to feed self -Ability of resident to chew, drink and swallow -Amount of food lost in spillage -Nutritional balance or imbalance of intake -Weight loss or gain -Signs of dehydration -7. Consultation with dietary and therapy personnel is performed on admission and as needed. -8. The facility will document intake percentages. -9. The physician is notified of any concerns. The facility was not able to provide additional information related to the evaluation of Resident 37's significant weight loss prior to exiting the facility on 08-13-2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** D. Record Review of Resident 17's weights revealed the following: -6/23/2022 10:42 101.8 Lbs -6/12/2022 13:32 101.8 Lbs -6/2/2022 06:16 101.8 Lbs -4/26/2022 09:45 108.8 Lbs -4/12/2022 07:08 107.8 Lbs -4/2/2022 16:27 108.2 Lbs -3/29/2022 10:08 106.7 Lbs -3/27/2022 20:29 106.7 Lbs -3/23/2022 06:57 108.8 Lbs -3/15/2022 06:17 107.6 Lbs -3/13/2022 18:51 107.6 Lbs -2/28/2022 12:07 105.6 Lbs -2/14/2022 17:07 104.0 Lbs -2/8/2022 17:39 104.2 Lbs -2/6/2022 13:39 104.2 Lbs -2/4/2022 08:40 103.2 Lbs -1/25/2022 17:30 95.6 Lbs -1/23/2022 13:13 95.6 Lbs -1/18/2022 14:47 96.0 Lbs -1/9/2022 13:48 100.4 Lbs -1/9/2022 13:34 100.4 Lbs -1/4/2022 12:19 98.2 Lbs -The documented weight of 108.8 on 04/26/22 to a weight of 101.8 on 06/02/22 indicated a 6.43% weight loss. Review of Weight Change Note on 6/23/2022 at 20:18 revealed Resident 17 is at 101.8# with weight gain from 99.8#. Would continue regimen and monitor for stable weight. Interview conducted with the (Director of Nursing) DON on 07/05/22 at 09:00 AM which confirmed a significant weight loss of 6.43% from 4/26-6/02/22. Licensure Reference Number 175 NAC 12-006.09D8 and 12-006.09D9 Based on observations, interviews and record reviews, the facility failed to evaluate and implement interventions to prevent significant weight loss for 5 of 8 residents reviewed (Resident 7, 9, 17, 50, 65) and failed to ensure water was within reach for Resident 9 and 19. The facility census was 91. Findings are: A. Review of Resident 65's Diagnosis list revealed Resident 65 has the following diagnoses: - Hemiplegia (weakness of one side of the body) related to CVA (stroke) - Dysphagia (difficulty with swallowing) Review of the facility weight documentation revealed, on 03/17/2022 Resident 65 weighed 162 lbs. and on 06/15/2022 Resident 65 weight was down to 136 pounds which is a 16 percent loss in 3 months. Review of Resident 65's physician orders revealed Resident 65 was placed on hospice services on 6/17/2022. Review of Resident 65's care plan dated 3/2/2022 revealed Resident 65 required extensive assist with meals. Observation on 6/22/2022 at 7:35 AM revealed Resident 65 in the facility dining room. Resident 65 was leaning to the left and having difficulty cutting pancakes with a knife and fork. No staff assisted Resident 65 to cut pancakes or assisted Resident 65 to eat. Resident 65 continued to attempt for 5 minutes to cut the pancake and eat. Resident 65 was unable to eat independently and dropped food on Resident 65's shirt while attempting to eat with right hand fingers. At 7:45 AM Resident 65 stopped attempting to eat and pushed the plate away. Resident 65 tried to eat oatmeal with a fork. No assistance was provided by the staff. Observation of Resident 65 on 06/22/22 at 12:34 PM revealed Resident 65 in the main facility dining room. Resident 65's plate was placed on the table in front of Resident 65. Resident 65 attempted to feed self. Staff were in the dining room assisting other residents. Resident 65 had a difficult time holding a regular fork. Resident 65 held fork by index finger and thumb at the top of the fork and attempted to stab at food. No staff in the dining area attempted to assist the resident during the entire meal service and no adaptive utensils were offered. Review of Resident 65's Nutrition/Dietary Note dated 5/9/2022 revealed Resident 65 was at 149 pounds with weight loss from 162.1 pounds in 1 month. The Dietician recommended adding 240 milliliters (ml- a unit of measure) Osmolyte 1.5 four times a day (QID) with 200ml H20 QID. Observation on 6/22/2022 at 9:31 AM revealed Registered Nurse (RN)-T gathered supplies for Resident 65's Tube feeding including a bottle of Osmolyte 1.5 237 ml. RN T revealed since Resident 65 ate over 50% of the breakfast meal as documented in Resident 65's intake sheet RN T will only give 100ml of osmolyte and the water flush. RN T accessed Resident 65's G-tube (Gastric Tube: a tube placed through the abdominal wall into the stomach to provide nutrition) and poured part of the bottle of osmolyte into tube without measuring. Review of Resident 65's Order Summary Report dated June 22,2022 revealed an order dated 5/16/2022 for Osmolyte 1.5 250 ml 4 times daily. Interview on 06/23/22 at 1:49 PM with the facility contracted Dietician revealed the osmolyte was to be given without being dependent on meal intake. Review of Resident 65's Medication Administration Record (MAR) revealed an order dated 5/16/2022 for Osmolyte 1.5 250 ml per G-tube four times a day for Supplement Caloric undernutrition. Review of Resident 65's MAR revealed for the month of May 2022 after the order was received on 5/16/2022 the resident did not receive any tube feeding 6 times, a reduced amount 6 times, several times the amount given was 237 ml instead of the ordered 250 ml. Review of Resident 65's MAR revealed for the month of June 2022 the resident did not receive a tube feeding 6 times, a reduced amount 7 times, and 237 ml documented instead of the 250 ml ordered Review of Resident 65's weight log revealed, on 05/25/2022, the resident weighed 142 pounds and on 06/15/2022, the resident weighed 136 pounds which is a 4.23 percent loss in less than 30 days. Review of Resident 65's progress note revealed no further review of Resident 65's continued weight loss was documented by the facility Dietician. Interview on 06/23/22 at 1:49 PM with the facility Dietician revealed the Dietician reviews weights from home and does not observe resident to make recommendations. Review of Resident 65's medical record revealed Resident 65 was placed on hospice care on 6/17/2022 and Resident 65 has not been weighed since 6/15/2022, therefore no available data to determine any further weight loss. Interview on 7/6/2022 at 11:58 AM with the Director of Nursing revealed Resident 65 should have been receiving the full amount of Osmolyte regardless of amount eaten, the resident should have been assisted with meals and the G-tube orders were not followed. B. Review of the Resident 50's NUTRITION: Assessment/Nutritional Data Collection Dated 5/11/2022 revealed Resident 50's weight is 192.2 pounds, estimated needs determined and met. Diet order consistent with nutrition needs. Will monitor for changes in weight, renal status, and tolerance to diet order. Review of an Alert Note dated 6/1/2022 revealed Resident 50 was admitted on [DATE] with bladder neck obstruction. Resident 50's current weight 219.4 pounds. Will discontinue from Risk Assessment Review (RAR) meeting. Review of Resident 50's weight log revealed Resident 50 gained 17 pounds to 219.4 pounds in the first 5 days in the facility and then lost 49.6 pound to 169.8 pounds in the next in 21 days. This is an overall weight loss of 23.6 pounds in 30 days or over 10% loss. No documentation was found in the Electronic Medical Record (EMR) that this weight loss was identified or reviewed. Review of Resident 50's progress notes revealed No Dietary notes related to weight loss on 6/2/2022. No further dietary assessments were found in the medical record. Interview on 06/23/22 at 02:55 PM with the Dietician revealed the Dietician looks up weights from home and, relies on calls from the facility with weight loss concerns and provides recommendations. The Dietician comes into the facility for quarterly reviews. The facility did not notify the Dietician of the weight loss. The Dietician revealed Resident 50 has not been assessed since the initial admission nutrition assessment. On 7/6/2022 interview with the Director of Nursing revealed Resident 50's weight loss was not identified and investigated. C. Review of Resident 7's Nutrition/Dietary Note dated 2/6/2022 revealed Resident 7 is at 145# (pounds) with weight loss from 184# over 5 months. Would continue regimen and monitor for supportive nutrition. On 12/07/2021, the resident weighed 145 lbs. On 06/02/2022, the resident weighed 130 pounds which is a 10.34% Loss. Review of Resident 7's Alert Note dated 3/30/2022 revealed the facility staff questioned the accuracy of Resident 7's weight. It revealed a 20-pound weight loss. Nursing staff were instructed to re-weigh Resident 7 the following day. Review of Resident 7's weight log revealed no additional weight was obtained until 6 days later and results revealed Resident 7's weight to be 129.8# on 4/5/2022 compared to weight on 3/29/2022 of 126.8. No documentation was found in the medical record to show the weight loss of 15 pounds in 23 days was reported to the facility dietician. Interview on 06/23/22 at 2:52 PM with the Dietician revealed Resident 7's weight fluctuates, and Resident 7 has been off and on supplements and diuretics. The Dietician has not reviewed Resident 7's weight since 2/6/2022 and was not aware of the further weight loss. There was no dietary assessment after 2/6/2022. The Dietician agreed Resident 7's weight loss was significant and should have been addressed. E. Observation on 6/21/22 at 10:00 AM revealed Resident 9 in bed being assisted to eat a regular consistency diet by Nursing Assistant [NA] U. The resident did not exhibit any signs of coughing or choking. The resident was able to grasp the glass of water and drink independently. Observation on 6/21/22 at 1:19 PM revealed Resident 9 seated at a table in the dining area with a regular consistency diet plate of food. Resident 9 ate the food independently with some spilling onto the clothing and occasionally coughed throughout the breakfast meal. The resident was able to grasp the glass of water and drink independently. NA C stopped and encouraged the resident to slow down and take smaller bites of food. The staff member did not sit down or assist Resident 9 with eating. Record review of Resident 9's admission Minimum Data Set [MDS] [ a mandatory comprehensive assessment tool used for care planning] dated 12/21/21 revealed that Resident 9 was admitted to the facility on [DATE]. The resident had a Brief Inventory of Mental status [BIMS] score of 10 which indicated moderate cognitive impairment, was independent with eating, had a weight of 165 and Diagnoses that included Dementia and Parkinsons Disease. The resident had no swallowing difficulties at the time of admission. Record review of a Transfer to the Hospital Summary Progress Note dated 2/8/22 revealed that Resident 9 was sent to the hospital and admitted for weakness on the right side. The Resident was admitted to the hospital for possible Cerebral vascular Accident and possible Aspiration Pneumonia. The resident returned to the facility on 2/11/22 per the Census Report in Resident 9's Electronic Medical Record [EMR]. Record review of Resident 9's most recent MDS dated [DATE] revealed a BIMS score of 6 which indicated severe cognitive impairment. The resident required extensive assist with eating and had a weight of 140. These indicated that Resident 9 had a decline in cognition, weight and in the ability to eat since admission to the nursing facility on 12/21/22. Record review of Resident 9's weight records since admission revealed the following weights over time from 6/23/22 to the admission date of 12/17/22: -6/23/2022 131.4 Lbs -6/14/2022 125.2 Lbs -4/6/2022 140.2 Lbs -3/15/2022 140.2 Lbs -3/2/2022 138.1 Lbs -1/30/2022 145.4 Lbs -1/25/2022 145.2 Lbs -1/18/2022 144.6 Lbs -1/6/2022 152.4 Lbs -12/22/2021 165.0 Lbs -12/17/2021 164.2 Lbs Record review of the weight records for Resident 9 revealed that on 12/17/2021 Resident 9 weighed 164 lbs. On 06/14/2022, Resident 9 weighed 125 pounds which was a -23.78 % weight loss over 6 months. Record review of a Progress Health Note dated 6/23/22 for Resident 9 revealed the following: - 6/23/2022 13:46 Health Status Note reweighed wheelchair; only 87 not 98lbs. So re weight on resident this am; incorrect. WEIGHT is 131.4. Record review of Resident 9's current weights as of 6/23/22 revealed the following: On 12/17/2021, the resident weighed 164 lbs. On 06/23/2022, the resident weighed 131 pounds which is a -20.12 % loss over 6 months. Record review of Resident 9's Nutrition Resident at Risk [NAR/ RAR] Progress Notes revealed the following information: - 3/11/2022 13:08 written by Licensed Practical Nurse [LPN] K: RAR meeting held. Resident readmitted on 2/11 for stroke. Resident is on puree soft with nectar thick liquids. Current weight 138.1. Resident is working with PT/OT to improve current ADLs and mobility. - 2/6/2022 16:28 Nutrition/Dietary Note written by the Registered Dietician: Resident is at 145.4# with weight loss x 1 month from 164.2#. No skin breakdown noted. Rx Vitamin C, Colace, Lisinopril, Zinc. Dx Parkinsons, HLD, Dementia. Diet order remains appropriate. Receives Regular. Will continue to follow. Record review of Resident 9's Nutrition Assessment completed 1/16/22 by the Registered Dietician revealed the following: - Resident is a 145.4# with weight loss from 164.2#. Skin tx to right posterior knee. Rx Vitamin C, Colace, Zinc. Dx Parkinsons, HLD, Dysphagia, HTN, GERD. Estimated needs determined and met. Receives Regular Diet. Will monitor for stable weight. Would add 60ml Med Pass Supplement BID and d/c zinc and vitamin c. Will monitor. Record review of Resident 9's EMR revealed no other nutritional assessments had been completed between 2/6/22 and 6/23/22 by the Registered Dietician to address Resident 9's continued weight loss. On 6/23/22, the RD completed a Nutritional Assessment for Resident 9 after the start of the annual survey which revealed: Resident is at 131.2# with weight loss noted from 164.2#. hospitalized in February. Weight appears to have been previously in the range of 150#. Loss to 140#, now reweigh of 131.2#. Intake inadequate to maintain weight; however, kcal exceed needs. Previously tried med pass supplement but will request 60ml Med Pass Supplement BID and if resident accepts, will increase. Would also d/c Zinc and add MVI w/Minerals. Review of nutritional history, intake and progression of disease, unless intake improves, weight loss will likely continue regardless of increased kcal. Will follow for supportive nutrition. Record review of Resident 9's Physician Orders revealed no orders for Med Pass supplement given to Resident 9 prior to 6/30/22. Record review of Resident 9's Physician Orders dated 6/30/22 revealed an order for 2 Cal Med Pass[ a nutritional supplement high in calories to help people gain weight] Supplement 60 milliliter's [ml] to be give 2 times per day. Interview on 06/23/22 at 08:16 AM with the Director of Nursing [DON] confirmed that Resident 9 had a significant weight loss and that no supplements or other interventions were implemented to prevent further weight loss. The DON confirmed that Resident 9 was reviewed for weight loss by the NAR team and that the RD had not been to the facility to assess the resident and the continued weight loss since a nutrition note was written on February 6th of 2022. The DON confirmed that there were no NAR notes documented after 3/17/22 for Resident 9 when the resident was identified with stable weight at 140 pounds and was discontinued from the NAR/ RAR meetings. Interview on 06/23/22 at 1:31 PM with the RD confirmed that Resident 9 had not been assessed for continued weight loss since February of 2022 and that supplements were started for one day but then stopped. The RD was unsure of why the supplements had been stopped. The RD stated that nutritional assessments are completed by offsite review by looking at lab values and the NAR notes which would include any weight changes or loss. The RD stated that Resident 9's labs had been reviewed offsite in March of 2022 and were within normal limits at that time. The RD confirmed that the last time Resident 9 was assessed by the RD was February 6th, 2022. The RD stated [gender] was just made aware of Resident 9's weight loss on 6/23/22. Interview on 7/6/22 at 2:23 PM with the DON revealed that the resident had undergone several weeks of speech therapy in March and April after he came back from the hospital and that the Med Pass was discontinued in February 2022 due to refusals. On April 1st 2022, after speech therapy had worked with Resident 9, the diet order was changed from thickened liquids and puree to thin liquids and regular consistency. The DON confirmed that Resident 9 should have been reassessed by the RD after the speech therapy and the diet change and this was not done. F. Record review of Resident 9's MDS dated [DATE] revealed that Resident 9 required extensive assist with eating. Observations of Resident 9 on 6/21/22 at 10:00 AM, 11:06 AM and 3:30 PM and on 6/22/22 at 6:15 AM and 9:05 AM, 9:30 AM and 2:55 PM revealed Resident 9 seated in a wheelchair in room with a water pitcher on a bedside table that was located across the room and not within the residents reach. Interview with the Director of Nursing on 6/22/22 at 2:55 PM confirmed that Resident 9's water pitcher was not in reach of the resident and should be. The DON confirmed that Resident 9 was able to grasp a glass of water and drink independently. G. Record review of Resident 19's MDS dated [DATE] revealed that Resident 19 required supervision with eating. Observations of Resident 19 on 6/21/22 at 9:10 AM, 11:10 AM and 3:30 PM, on 6/22/22 at 6:25 AM, and 9:00 AM and on 6/23/22 at 7:05 AM revealed Resident 19 seated in a wheelchair in room with a water pitcher on a bedside table that was located across the room and not within the residents reach. Interview with the Medication Aide [MA] S on 6/23/22 at 7:07 AM confirmed that Resident 19's water pitcher was not in reach of the resident and should be. MA S confirmed that Resident 19 was able to grasp a glass of water and drink independently. Record review of a facility policy entitled Hydration and Nutrition effective 7/14/21 revealed: - Residents are to be offered sufficient fluid intakes to maintain hydration and health. - 4. Fluid is available to residents at all times. A hydration cart may be utilized. - 5. The resident is positioned properly to consume meals and snacks. Assistance is provided as needed. - 6. An ongoing assessment of the ability to consume and assimilate food and fluids is conducted by nursing personnel and all concerns are reported to the nurse to include weight loss or gain, signs of dehydration. - 8. The facility will document the intake percentages. H. Record review of Resident 9 and 19's Electronic Medical record [EMR] revealed no documentation of fluid intake percentages or fluids consumed. Interview on 06/23/22 at 02:11 PM with the Registered Dietician confirmed that residents should have water in reach in their rooms and that fluid intakes are not recorded unless ordered by the physician.

LICENSURE REFERENCE NUMBER 175 Chapter 12-006.02 Based on observations, record review and interview, the administrative and consultant staff failed to ensure the facility resources were utilized in a manner to ensure provision of care and services for residents. This deficient practice provided the potential to affect all residents of the facility. The facility census was 91. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance which required an extended survey related to substandard quality of care. The following issues related to systems failure and or failure to follow standards of care resulted in patterns of failure in the facility related to weight loss and hydration needs. Review of the facility roster matrix (a report indicating care concerns for each resident) developed from the MDS (Minimum Data Set: a federally mandated tool used for care planning) provided on entrance to the facility for annual survey revealed no residents identified for significant weight loss. Observations, record review and interviews through the initial phase of the survey identified 8 residents as having a potential significant weight loss. After moving into the investigative stage of the survey 6 were identified for Nutrition/hydration deficiencies related to lack of identification of the significant weight loss and monitoring interventions for reversing weight loss. Interview on 06/23/22 at 1:49 PM with the facility Dietician revealed the Dietician reviews weights from home and does not observe residents except for at the quarterly reviews. Interview with the administrator on 7/7/2022 at 9:10 AM revealed the facility does not have someone designated to review all resident weights monthly to identify significant weight loss and the facility should utilize the contracted Dietician more frequently.

Licensure Reference Number 175 NAC12-006.07 Based on interviews and record reviews, the facility failed to ensure the quality assurance program addressed concerns related to deficient practice cited on the annual and extended survey. The facility census was 91. Findings are: Annual survey completed on 7/7/2022 revealed deficient practice at the following areas: F558- Accommodation of needs F561-Self Determination F584-Safe/Clean/ homelike environment F623-Notice requirements before transfer/discharge F625-Notice of Bed Hold Policy before transfer F684-Quality of Care F689-Free of accident hazards F690-Bowel/Bladder Incontinence, catheter care F692-Nutrition/hydration maintenance F695-Respiratory care F726-Competent Nurse staff F809-Frequency of meals F812-Food storage and kitchen sanitation F835-Administration F867-QApi/QAA improvement activities F880-Infection Prevention and Control F886-Covid 19 staff testing F923-Ventilation F947 -Required In-service training for Nurse aides The Director of Nursing provided the Performance Improvement Plans (PIP) for nursing. Review of the facility PIP revealed the facility had plans to include Infection Surveillance, ADL assistance, Room moves, Wounds, low risk bowel and bladder incontinence, and Antipsychotic use in the PIP. Review of the facility [NAME] reports (a federal report listing facility deficiency history) revealed repeat tags from the previous 3 annual surveys include: 584- safe clean comfortable/homelike environment 623- Notice before transfer 625- Bed hold policy 684-Quality of Care 880- Infection Control 812- Food Procurement, store/prepare/serve Sanitary 867-QAA/QAPI Activities Interview on 7/7/2022 at 9:10 AM with the facility Administrator revealed the facility QAPI committee had not identified the cited deficient practice except for F809 regarding the extended meal serving times. A performance improvement plan had been developed but had not been put in place.