**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, staff, and Physician Assistant (PA) interviews the facility failed to safely transfer a resident (Resident #3) from her bathroom to the recliner using the mechanical lift that resulted in the dislocation of the left shoulder which required treatment at a hospital. The facility also failed to safely transfer a resident (Resident #2) from her motorized wheelchair to the bed using the mechanical lift that resulted in a fracture to the right hip which required treatment at a hospital. This was for 2 of 6 residents reviewed for supervision to prevent accidents. Findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnosis that included osteoporosis, repeated falls, and pain to left arm. A care plan dated 12/28/22 revealed in part; Resident #3 had a focus area to maintain current level of physical mobility and ability to perform any assist with her self-care. Interventions read in part staff to assist with all transfers and to transfer with the stand up mechanical lift on days she ' s not able to assist staff with standing. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #3 cognition was severely impaired she exhibited no behaviors. She required extensive assistance with the help of two people with toilet use and total assistance with the help of two people with transfers. No limitations to mobility of upper or lower extremities. Resident #3 ' s incident report dated 01/24/23 at 6:40 PM that read in part that Resident #3 had a large area bruise on the left anterior thigh and complained of left shoulder pain. She was examined by the Physician Assistant (PA) which ordered an x-ray of her left shoulder. The x-ray revealed a dislocated left shoulder and Resident #3 was sent to the emergency room for further evaluation. An interview with Physician Assistant (PA) was conducted on 08/23/23 at 10:32 AM. He indicated staff called him to the Resident #3 ' s room on 01/24/23 due to a complaints of pain to her left shoulder. After assessing resident, he recommended Physical Therapy (PT) to assess her and to apply ice packs as needed. He further stated staff denied any injury or fall. PT recommended obtaining an x-ray for further evaluation which he ordered, and results revealed Resident #3 had a dislocated left shoulder. She was sent to the emergency room for further evaluation and treatment. A phone interview with Nurse #1 was conducted on 08/23/23 at 12:10 PM. She confirmed she did work on 01/24/23 from 6 AM-6 PM and was Resident #3 ' s nurse. She indicated she was told by Nursing Assistant (NA) #2 that Resident #3 had complained of left shoulder pain prior to breakfast and requested pain medication. She stated upon entering Resident #3 ' s room, she was sitting up in her recliner. She then administered the pain medication and assessed her shoulder. She indicated that she could wiggle her fingers, move her wrist in a circle, bent her arm at the elbow, and shrugged her shoulders without complaints of pain, however she was unable to lift her arm up. Resident #3 was unable to give a reason for the pain to her left shoulder. Nurse #1 then notified the Physician Assistant (PA) that was in the facility at the time. She also indicated NA #2 did not report any type of injury or fall. Nurse #1 verified she worked with Resident #3 on 01/23/23 and she did not complain of shoulder pain nor did staff report pain to shoulder or a bruise to her left thigh area. A phone interview with Nursing Assistant (NA) #3 was conducted on 08/23/23 at 12:10 PM. She stated she did work 6 AM-6 PM on 01/24/23 but she did not provide direct care to Resident #3. She indicated she did bring the resident her breakfast tray the morning of 01/24/23 and that she complained of left shoulder pain at that time. She further stated she notified the nurse of the residents ' complaints of pain. She also stated she did not assist NA #2 with any transfers with Resident #3 during her shift. A phone interview with Nursing Assistant (NA) #4 was conducted on 08/23/23 at 1:12 PM. She stated she did work 6 AM-6 PM on 01/24/23 but she did not provide direct care to Resident #3. She further stated she did not assist NA #2 with any transfers with Resident #3 during her shift. A phone interview with Nursing Assistant (NA) #5 was conducted on 08/23/23 at 1:21 PM. She stated she did work 6 AM-6 PM on 01/23/23 and she provided direct care to Resident #3. She indicated she did not see any skin discolorations, bruises, nor did Resident #3 complain of any new pain or discomfort during her shift. A phone interview with Nurse #3 was conducted on 08/23/23 at 1:49 PM. She stated she did work 6 PM-6AM on 01/24/23 but she did not provide direct care to Resident #3. She indicated she assisted Nurse #4 with performing an assessment on the resident and instructed her to notify the Director of Nursing (DON) due to a large, bruised area to Resident #3 ' s left thigh area. Nurse #4 was unavailable for interview. According to Nurse #4 ' s statement dated 01/24/23 during 6 PM-6AM shift she indicated she received report from Nurse #1 that Resident #3 had complained of left shoulder pain during her shift. She indicated that the Physician Assistant (PA) and Physical Therapy (PT) had evaluated Resident #3 and an x-ray had been ordered. She stated the Nursing Assistant (NA) notified her of a large bruised are to the residents left thigh area. She performed an assessment and noted the bruise/hematoma to her left thigh, resident denied pain at the time. X-ray results revealed Resident #3 had a dislocated left shoulder and was sent to the emergency room for evaluation and treatment. An interview with the Director of Nursing (DON) was conducted on 08/23/23 at 2:12 PM. She stated she received a call from Nurse #4 on 01/24/23 informing her the x-ray results revealed a dislocated shoulder and she reported a bruised area to Resident #3 ' s left leg. She also stated that she was being sent to the emergency room for evaluation and treatment. She returned to work on the morning of 01/25/23 and performed an investigation of the dislocated shoulder and bruised leg. She indicated Nursing Assistant (NA) #2 was Resident #3 ' s direct care NA for 01/24/23 from 6 AM-6 PM. She had a phone interview with NA #2 which stated that when she went in to provide AM care to Resident #3, she had complained of shoulder pain. She indicated NA #2 then explained that during a transfer using the stand-up mechanical lift that the residents ' legs gave out and she lowered her to floor. She then stated NA #2 indicated a short girl with black hair assisted her in getting Resident #3 off the floor but was unable to provide a name. No employee ' s that worked on 01/24/23 matched the description that NA #2 gave. She verified NA #2 stated she did not have assistance by another staff member while utilizing the mechanical lift. The DON then stated that NA #2 had not reported the fall to the nurse and that her description of a staff member that assisted her with getting Resident #3 from the floor did not match anyone that had worked on 01/24/23. She further stated mechanical lifts require 2 person staff assistance. She indicated all nursing staff had received training on using the mechanical lift. She further stated NA #2 should have asked for assistance before transferring Resident #3 alone. A phone interview with Nursing Assistant (NA) #2 was conducted on 08/23/23 at 2:45 PM. She stated she did work 6 AM-6 PM on 01/24/23 and she provided direct care to Resident #3. She also stated that when she went in to provide AM care to Resident #3, she had complained of left arm pain. She indicated that during a transfer using the stand-up mechanical lift the morning of 01/24/23 the residents ' legs gave out and she lowered her to floor, she did not have another staff member in the room with her during the transfer. NA #2 stated a short girl with black hair assisted her in getting Resident #3 off the floor, but she did not know the girl ' s name. She further stated Resident #3 had no difficulty holding the handles during the transfer and did not complain of pain. NA #2 indicated she did not observe any bruising to residents left thigh area when providing incontinence care but that she did not remove her pants, only enough to put the incontinence brief on. 2. Resident #2 was readmitted to the facility on [DATE] with diagnosis that included orthopedic aftercare after right hip fracture due to a fall, osteoarthritis, and spondylosis with myelopathy of the cervical region. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #2 was cognitively intact. She required extensive assistance with the help of two people with bed mobility, transfers, and activities of daily living. Impaired mobility to both sides of upper and lower extremities and as having no falls. A care plan dated 04/07/23 revealed in part; Resident #2 had a focus area of impaired functional status related to no functional use of her legs. Interventions included in part; to transfer with the total mechanical lift. She also had a focus area of at risk for falls related to no functional use of her legs. Interventions included in part; staff will assist me during transfers from surface to surface as needed. Resident #2 ' s incident report dated 04/10/23 at 1:10 PM completed by Nurse #1 read in part that Resident #2 was being transferred to the emergency room for possible right hip fracture due to a fall. Resident complained of back pain and right hip pain, and her right leg was rotated outward. Resident #2 ' s fall scene investigation report dated 04/13/23 read in part that she fell from the mechanical lift during a transfer from her electric wheelchair to the bed. The report included contributing factors observed at time of fall were staff/equipment error and that the mechanical lift pad caught the arm of her wheelchair. The report summary revealed staff member transferred resident using total lift without having a second clinical staff member present. Discharge summary dated [DATE] read in part that Resident #2 presented to the emergency department related a mechanical lift fall with osteoporotic bone disease. The fall resulted in a right hip fracture that required a surgical right hip partial repair on 04/11/23. Investigation report revealed Resident #2 had a fall from a mechanical lift during a transfer. The Physician Assistant (PA) was in facility at the time of the incident and assessed resident promptly. Emergency Medical Assistants (EMS) was called, and resident was transferred to the hospital and admitted for a right hip fracture. Nursing Assistant (NA) #1 was written up for failure to follow policy and training to have a second staff member present at the time of lifts. After a detailed fall investigation and witness statements, it was determined that there was no failure through inattentiveness, intentional or reckless behavior, or carelessness to provide resident services. All care staff immediately in serviced in safe operation of equipment and following established safety operating policy. An interview with Nursing Assistants (NA) #1 was conducted on 08/22/23 at 2:41 PM. She indicated Resident #2 was in her electronic wheelchair and requested to be put in bed because she needed to use the bed pan. She stated Resident #2 required the use of a mechanical lift for all transfers and when she retrieved the lift, she did not see another staff member to assist her. She proceeded to Resident #2 ' s room and applied the lift pad to the mechanical lift, assuring the clasps were securely locked into place. NA #1 then stated when she went to lift her up in the lift, she double checked that the clasps were in place and proceeded to raise her approximately two feet from her chair. She indicated she then went around to the back of the lift to turn it around to get to the bed when Resident #2 stated she was falling. She stated before she could get around the lift to assist, Resident #2 slid out of the lift pad landing on the floor in front of her wheelchair. NA #1 then went to get assistance from the nurse. NA #1 further stated that she does not know what could have happened and indicated the lift pad may have got caught on the wheelchair. An interview with the Director of Nursing (DON) was conducted on 08/22/23 at 3:07 PM. She stated she was called to Resident #2 ' s room due to a fall from the mechanical lift. Upon entering the room, Resident #2 was on the floor and at that time denied pain or discomfort. She assisted Resident #2 onto her back, and she then complained of back pain. Resident #2 agreed to go to the emergency room for evaluation. She indicated she questioned Nursing Assistant (NA) #1 in reference to what had occurred, and she stated she did not know what could have happened that caused the fall with Resident #2. She indicated the lift pad may have got caught on the wheelchair handle. She stated she had NA #1 perform a reenactment of the incident and reeducated her regarding safe transfers and facility policy guidelines. She revealed that Resident #2 obtained a right hip fracture due to the fall from the mechanical lift. An interview with Physician Assistant (PA) was conducted on 08/23/23 at 10:32 AM. He indicated staff called him to the Resident #2 ' s room on 04/10/23 due to a fall from the mechanical lift. Upon entering the room Resident #2 was lying on the floor with complaints of pain to the back of her head and right hip. He indicated Resident #2 was stable and comfortable while awaiting Emergency Medical Services (EMS). He further indicated staff should follow the facility protocol and the resident care plan when utilizing mechanical lifts to help prevent accidents and injuries. An interview with Resident #2 was conducted on 08/23/23 at 10:54 AM. She indicated that she did remember the fall on 04/10/23 and that it was just an accident. She indicated normally there were two staff members who assisted her with transfers using a mechanical lift. She recalled Nursing Assistant (NA) #1 transferred her from her wheelchair to the bed by herself. She stated during the transfer she told NA #1 that she felt like she was sliding out of the sling, but NA #1 was unable to get around the lift before she fell out. She further stated she doesn ' t know how she fell, maybe she was off center in the sling because she knew the clasps were fastened and locked into place. Resident #2 indicated the NA left the room to get help. She was sent to the emergency room for hitting her head, back pain and a possible fractured right hip. She revealed that she underwent a repair of the right hip due to a fracture she obtained during the fall. An interview with the Director of Nursing (DON) was conducted on 08/23/23 at 2:12 PM. She stated the mechanical lift required 2 person staff assistance. The DON indicated the facility implemented a corrective action plan on 04/10/23 to prevent a reoccurrence. She indicated all nursing staff had received training on 04/11/23 using the mechanical lift. She further stated Nursing Assistant (NA) #1 should have asked for assistance before transferring Resident #2 alone. Corrective action for the involved resident dated 04/11/23 read as follows: Resident #2 was assessed for potential injuries by the licensed nurse. Resident #2 was sent to the hospital for an evaluation and treatment. Employee providing care received disciplinary action. Corrective action for other potentially affected residents dated 04/11/23 read as follows: Audit of all current residents was conducted by the Director of Nursing (DON) regarding transfer status. All current residents identified as being transferred using a mechanical lift were audited to make sure the transfer status was accurate in the chart and care plan by the Minimum Data Set (MDS) nurse. Systemic Changes and Education initiated on 04/11/23 read as follows: All current nursing staff were educated by the Staff Development Coordinator (SDC) regarding the mechanical lift policy which requires two staff members be present for each transfer on 04/11/23. Any licensed or nursing staff that cannot be reached within the initial reeducation time frame will not take an assignment until they have received this reeducation. Agency licensed nurses or nursing staff and newly hired licensed nurses or nursing staff will have this education during their orientation. Quality Assurance (QA) Plan initiated on 04/11/23 read as follows: The Director of Nursing (DON), Staff Development Coordinator (SDC) or Registered Nurse Supervisor will randomly audit a mechanical lift transfer 3 times per week for 3 months. Reports would be presented to QA committee by the DON to ensure corrective action was appropriate. Compliance would be monitored, and ongoing auditing program would be reviewed at monthly QA meetings for the timeframe of the monitoring period or as it is amended by the committee. The April monthly QA meeting was attended by the Medical Director (MD), Administrator, DON, MDS Nurse, Social Worker (SW), medical records, Chief Executive Officer (CEO), Director of Rehab, and the Dietary Manager. The May monthly QA meeting was attended by the Medical Director (MD), Administrator, DON, SDC, MDS Nurse, Social Worker (SW), medical records, and Director of Rehab. The June monthly QA meeting was attended by the Medical Director (MD), Administrator, DON, SDC, MDS Nurse, Social Worker (SW), medical records, Chief Executive Officer (CEO), Director of Rehab, Dietary Manager, and Resident Care Coordinator. The plan alleged compliance on 04/12/23. Review of the facility plan of correction revealed evidence of 100% auditing of staff using correct transfer techniques for residents requiring a mechanical lift, evidence of 100% all staff interviewing and observation of utilizing mechanical lifts completed on 08/08/23. The facility provided evidence of 100% staff education on correct transfer techniques for residents requiring a mechanical lift completed on 04/12/23. The facility also provided evidence of a QA audits of observations for correct transfer techniques for residents requiring a mechanical lift completed on 08/08/23. Residents deemed alert and oriented revealed no current concerns related to staff using correct transfer techniques requiring a mechanical lift to include having two staff members present. Observations revealed two staff were transferring a resident with a mechanical lift as specified on the care plan. The facility ' s date of compliance was validated as 04/12/23. The facility ' s date of compliance was validated on 08/23/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, Physician Assistant (PA) interview and Responsible Party (RP) interview and record review the facility failed to identify the root cause and implement effective interventions to prevent multiple falls (Resident #32). In addition, the facility failed to identify the root cause for multiple falls (Resident #18) and failed to safely utilize a total body (hydraulic lift utilizing a body sling) lift while attempting to transfer a resident resulting in a fall without injuries (Resident #29). This was for 3 of 3 residents reviewed for accidents. The findings included: 1. Resident #32 was admitted on [DATE] with cumulative diagnoses of Dementia, osteoporosis, a history of a femur fracture and a history of falls. Her annual Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment, extensive assistance with transfers and she was coded as have two falls with minor injuries since the previous MDS assessment. She was also coded for a prognosis of less than six months and hospice services. Resident #32 was care planned for falls initially on 6/30/21 and last revised on 7/30/22. Interventions included in part frequent checks, encourage her to stay in the common area for closer staff supervision, routine toileting and staff were not to lock her wheelchair brakes. Review of Resident #32's electronic care guide utilized by the aides included the same interventions as her comprehensive care plan. Resident #32's fall incident reports read the following: *4/14/22 at 5:15 PM, Resident #32 fell from her wheelchair and on the floor in the hallway. She sustained a laceration to her forehead and sent to the hospital for an evaluation. Her CT Scan was negative for head or spine injuries and she returned to the facility with steri-strips to her forehead laceration. The intervention read to encourage her to stay in the common area for closer staff supervision. There was no documented evidence of the facility completing a root cause analysis. *5/8/22 at 4:00 PM, Resident #32 was on the floor in the Dining Room with her wheelchair behind her. She sustained a skin tear to her left hand. The intervention read to remind staff to provide routine toileting. There was no documented evidence of the facility completing a root cause analysis. *6/6/22 at 8:20 PM, Resident was observed lying on the floor with her back close to the bed. She sustained a skin tear to her left forearm, left wrist, right shin and a raised area to her right forehead with an abrasion. Neurological checks initiated and steri-strips were applied to her skin tears. The intervention read for staff to provide routine rounds for safety. There was no documented evidence of the facility completing a root cause analysis. Review of the nursing notes read the skin tear to her right shin appeared red on 6/14/22 at 8:50 PM and a nursing note dated 6/16/22 at 10:19 PM read the area to her right shin had increased redness, slough with moderate exudate. The Physician was notified and orders were given on 6/17/22 for a wound consult. A nursing note dated 6/20/22 at 11:15 PM read there was edema to her right shin, ankle and foot with foul smelling drainage. A nursing note dated 6/21/22 at 1:42 PM read Resident #32 was seen by the wound consultant and new orders were given for wound care and an antibiotic. A nursing note dated 6/29/22 at 10:22 AM read the wound consultant assessed the area and noted improvement with no evidence of an infection and the wound consult dated 7/5/22 indicated the area to her right shin was healed. *7/30/22 at 4:00 PM, Resident #32 was observed on the floor in front of her wheelchair with her wheelchair brakes locked. Location was not documented and she did not sustain any injuries. Staff were in-serviced not to lock Resident #32's wheelchair brakes while she was up in her wheelchair. There was no documented evidence of the facility completing a root cause analysis. An observation was completed on 8/8/22 at 10:36 AM. Resident #32 was sitting in a high back wheelchair at Nurses Station #1. She was trying to propel herself but was not able to make any significant progress. The wheelchair brakes were unlocked and Nurse #4 was standing beside her. Review of another fall incident report dated 8/8/22 read the following: *8/8/22 at 5:30 PM, Resident #32 was sitting in her wheelchair at Nursing Station #1. She was observed leaning forward and Nurse #4 asked her to lean back. Nurse #4 continued charting when she heard a noise. She looked up and did not see Resident #32. She found her lying on the floor on her stomach in front of the wheelchair. Resident #32 had a lump to the left side of her forehead and was sent out to the hospital for an evaluation. The intervention read to place Resident #32 in bed after being up for 2 or more hours unless there was an activity to keep her preoccupied. A nursing note dated 8/8/22 at 10:00 PM read Resident #32 returned to the facility and her CT scan was negative for head or spine injuries. She returned with a large hematoma covering the entire left side of her forehead from above her left eye up to her scalp. There was no documented evidence of the facility completing a root cause analysis. An interview was completed on 8/9/22 at 2:05 PM with Nurse #4, She stated the fall dated 7/30/22 occurred at NS #1 when an agency aide placed her at Nurses Station #1 and locked her wheelchair brakes. She stated the agency aides were not familiar with interventions put in place to prevent Resident #29 from falling. A telephone interview was completed on 8/9/22 at 3:00 PM with agency Nursing Assistant (NA) #5. She stated she did not recall being assigned Resident #32 on 7/30/22 but did recall leaving early at 2:00 PM that day and rolling Resident #32 up to Nurses Station #1 as she was leaving. She stated she did not recall locking her wheelchair brakes but confirmed an in-service about it on 8/1/22. An interview was completed on 8/10/22 at 8:20 AM with the Administrator. He stated the managers discussed any falls from the day/night before every Monday through Friday and discussed weekend falls on Mondays. He stated at that time, the Director of Nursing (DON) put interventions in place and the MDS Nurse revised the care plan. He stated the facility also reviewed resident falls during the Resident at Risk (RAR) monthly meeting and included the Director of Nursing, Nurse Managers, the MDS Nurse and himself. He stated the RAR meetings were weekly up until recently but offered no explanation as to why the weekly meetings were discontinued. The Administrator stated they were resuming the weekly RAR meetings weekly on 9/5/22. The Administrator was unable to answer how agency staff were educated about how to care for the residents, he stated he was not sure if there was any sort of orientation and deferred the question to the interim DON. A telephone interview was completed on 8/10/22 at 9:30 AM with the previous DON. She stated her last day at the facility was 7/28/22. She stated all managers met Monday through Friday and discussed all resident falls. She stated the facility could not provide 24 hour/7 days a week supervision but they did the best they could. She stated staffing was a challenge but it was a challenge everywhere in healthcare. An observation was completed on 8/10/22 at 10:00 AM of Resident #32. She was in her room sitting up in a recliner. Observed was a large dark blue and purple discoloration to the entire left side of her forehead and around her left eye. An interview was completed on 8/10/22 at 12:10 PM with Nurse #4. She stated Resident #9 was at Nursing Station #1 on 8/8/22 while she was charting. She stated she and other staff had to keep reminding Resident #32 to not lean forward but rather lean back in her wheelchair. Nurse #4 stated she continued charting when she heard a bump and found Resident #32 on the floor in front of her wheelchair. She stated her wheelchair brakes were not locked at the time of the fall and she sustained a bump to her left forehead. Nurse #4 stated she notified the hospice nurse and the Physician and orders were given to send her to the hospital for an evaluation. Nurse #4 stated she left for the day around 7:00 PM and did not receive Resident #32 when she returned from the hospital but was surprised at the bruising the next day. An interview was completed on 8/10/22 at 12:16 PM with the PA. He stated he would like to know more details involving the circumstances prior to a resident fall for example what medications were administered prior or when was the last time the resident was toileting, etc. to identify a trend or pattern. The PA stated it seemed that the staff were in the resident's rooms too long and if there was only two aides on the floor and the nurse was passing medications, there was a lack of enough staff to oversee residents' safety. An interview was completed on 8/10/22 at 1:20 PM with the Activity Director (AD). She stated once Resident #29 was up and after lunch, she was taken to the afternoon activities but she did not actively participate and would get fidgety and roll herself out of the activity. A telephone interview was attempted on 8/10/22 at 2:15 PM with Resident #29's hospice nurse. There was no return telephone call. An interview was completed on 8/10/22 at 2:30 PM with the Rehabilitation Manger (RM). She stated Resident #29 was a hospice resident and in order to evaluate and treat Resident #29, hospice would need to approve it and she stated that seldom if ever happened. The RM stated resident falls were discussed in the morning meeting and she would offer ideas or suggestions but she was not a part of the RAR meetings. A telephone interview was completed on 8/10/22 at 4:55 PM with Resident #32's RP. She stated she was concerned about her falls and afraid a fall could result in a serious injury or worse for Resident #32. The RP stated she was not sure if the facility was doing all they could to monitor Resident #32 for safety. An interview was completed on 8/10/22 at 5:04 PM with the interim DON. She stated the facility should resume the weekly RAR meetings to better identify the root cause of a fall and to help identify trends or patterns timely. She also stated it was her expectation that the facility identify the root cause for each fall and implement effective interventions to lessen the number of falls that had occurred with Resident #32. 2. Resident #29 was admitted on [DATE] with a diagnosis of Multiple Sclerosis. Review of the significant change Minimum Data Set (MDS) dated [DATE] indicated Resident #29 had severe cognitive impairment was coded for no transfers out of bed during the 7 day look back period. She was coded as having no falls since prior MDS assessment. Review of Resident #29's care plan for falls initiated 9/20/21 read she had an assisted fall on 7/7/22. The intervention read to remind staff to take extra time to ensure equipment was ready for a transfer. Review of an incident report dated 7/7/22 at 8:45 PM read the aide was using the total body lift to transfer Resident #29 from her chair to the bed. When the aide attempted to put the lift sling under Resident #29 and secure the lift sling loops on the lift hooks, Resident #29 started to slide to the floor and was lowered to the floor. She did not sustain any injuries. A telephone interview was completed on 8/10/22 12:10 PM with Nursing Assistant (NA) #2. She stated she was assigned Resident #29 on 7/7/22 at the time of her fall at 8:45 PM. NA #2 stated the evening of 7/7/22, there was only herself and one other aide working. NA #2 stated she was aware that when transferring a total body lift resident, two staff had to be present but because the facility was short staffed, she tried to transfer Resident #29 using the lift alone without any assistance. She stated when only two aides were working, it was impossible to have two staff present for every total body lift. NA #2 stated that since she began working at the facility in June 2022, Resident #29 was transferred using the total body lift. NA #2 stated there was a document posted at Nurses Station (NS) #2 listing all the total body lift residents along with the correct sling size for each resident and Resident #29 was on that list. She stated the lift sling had been removed from underneath Resident #29 and she was attempting to get it under her and hook the sling to the lift but Resident #29 started to slide to so she eased her to the floor. She stated she was in-serviced at the time of the fall to have two staff present for a lift transfer. A telephone interview was completed on 8/10/22 at 3:30 with Nurse #4. She stated she was working the evening of 7/7/22 when there was one aide for each end of the hall and she was busy in another resident's room. The call light was going off in Resident #29's room and when she entered, she saw Resident #29 on the floor. NA #2 stated she tried to transfer Resident #29 using the total body lift by herself. NA #2 reported Resident #29 slid from her chair while she was attempting to put the sling underneath her and she could not reach the hooks on the lift to fasten the sling loops and eased Resident #29 to the floor. Nurse #4 stated Resident #29 did not sustain any injuries and she had been a total body lift transfer since admission per her family request and due to her stiffness. An interview was completed on 8/9/22 at 4:03 PM with NA #3. She stated due to Resident #29's muscle stiffness, she was difficult to transfer and required the use of a total body lift. NA #3 stated she thought Resident #29 had been a total body lift transfer since her admission. She further stated that there had to be two staff present when completing a total body lift transfer. An interview was completed on 8/10/22 at 8:20 AM with the Administrator. He stated the managers discussed any falls from the day/night before every Monday through Friday and discussed weekend falls on Mondays. He stated at that time, the Director of Nursing (DON) put interventions in place and the MDS Nurse revised the care plan. He stated the facility also reviewed resident falls during the Resident at Risk (RAR) monthly meeting and included the Director of Nursing, Nurse Managers, the MDS Nurse and himself. He stated the RAR meetings were weekly up until recently but offered no explanation as to why the weekly meetings were discontinued. The Administrator stated they were resuming the weekly RAR meetings weekly on 9/5/22. A telephone interview was completed on 8/10/22 at 9:30 AM with the previous DON. She stated her last day at the facility was 7/28/22. She stated all managers met Monday through Friday and discussed resident falls. She stated the facility could not provide 24 hour/7 days a week supervision but they did the best they could. She stated staffing was a challenge but it was a challenge everywhere in healthcare. An interview was completed on 8/10/22 at 12:16 PM with the PA. He stated it seemed that the staff were in the resident's rooms too long and if there was only two aides on the floor and the nurse was passing medications, there was a lack of enough staff to oversee residents' safety. An observation was completed on 8/10/22 at 1:30 PM with the interim Director of Nursing (DON). Located on the employee bulletin board in the breakroom at NS #2 was an undated document indicating Resident #29 used a total body lift for transfers. The DON stated the document had been posted on the bulletin board for a least 6 months when the new slings came in so staff would know the correct sling size to use when transferring any total body lift resident. Resident #29's name appeared on the list as requiring a medium size sling. The interim DON also stated the electronic care guide was also utilized by the aides identifying the resident's lift status. Review of Resident #29's electronic care guide utilized by the aides read that Resident #29 was a Sit-to Stand lift ((lift designed to assist a resident who lacked the strength or muscle control to rise to the standing position) for all transfers on 11/19/21. The electronic care guide also read for the staff were to take extra time to ensure equipment was ready for a transfer as of 7/7/22. An interview was completed on 8/10/22 at 5:04 PM with the interim Director of Nursing (DON). She stated it was her expectation that two staff assist with transferring any total body lift resident. 3. Resident #18 was originally admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease and fracture of the left wrist. The admission Minimum data Set (MDS) assessment dated [DATE] indicated that Resident #18 had severe cognitive impairment, was occasionally incontinent of bladder, and was always continent of bowel. The assessment also indicated that the resident was able to walk in the room with supervision/set up help only, she needed limited assistance with 1-person physical assist with transfers and she was using a wheelchair for mobility. The assessment further indicated that the resident had history of falls and had a fracture related to a fall in the last 6 months prior to admission. A fall risk assessment dated [DATE] was completed for Resident #18, and she scored 12. The assessment indicated that if the score was 10 or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Resident #18's incident reports and nurse's notes from 3/15/22 through 8/9/22 were reviewed. The reports/notes revealed that the resident had 5 falls at the facility. The report/note dated 4/9/22 at 12:00 PM revealed that Resident #18 was observed sitting on the floor in front of a raised recliner with no injury noted. A family member stated that she slid out of the chair. The intervention to prevent further fall was to remind the resident to call for staff assistance for safety. The report did not include the root cause of the fall. The report/note dated 4/23/22 at 4:45 AM revealed that Resident #18 was observed sitting on her buttocks on the floor near the bathroom with her left leg turned outwards. The resident stated that she needed to go to the bathroom. She was placed in wheelchair and was assisted to the bathroom and back to bed. The physician was notified, and x-ray of the left tibia and fibula was ordered, and the report was negative for fracture. The intervention was to educate the resident on proper footwear when ambulating. The report did not include the root cause of the fall. The report/note dated 4/30/22 at 6:40 AM revealed that Resident #18 was noted on the floor between the foot of the bed and the dresser. Her walker was tipped over on the right side of the bed. The resident stated, I went to the bathroom and was getting back into bed. There was no injury noted from the fall. The intervention to prevent further falls was to provide frequent check for safety. The report did not include the root cause of the fall. The report/note dated 6/4/22 at 7:15 AM revealed that Resident #18 was noted on the floor. A few drops of blood were noted on her nose. The intervention to prevent further fall was to continue to provide frequent reminders to use her call bell for staff assistance. The report did not include the root cause of the fall. Nurse #1 was interviewed on 8/9/22 at 9:37 AM. She stated that she was assigned to Resident #18 when the resident had a fall on 6/4/22. The Nurse reported that when a resident had a fall an incident report was completed, the description of the fall, date, time, the location of the incident and type of injury, if any. On 6/27/22, Resident #18 was discharged to an assisted living facility and on 7/26/22, she was readmitted to the facility with a diagnosis of intertrochanteric fracture of the right femur. A fall risk assessment dated [DATE] was completed for Resident #18, and she scored 13. The assessment indicated that if the score was 10 or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. The incident report dated 7/29/22 at 8:20 PM revealed that Resident #18 was observed in the room next door. She was on the floor in front of the bathroom. The resident stated that she was trying to go to the bathroom. The resident stated that her right hip was sore and that she had a bad hip and was patting on her right hip. The intervention to prevent further fall was toileting schedule in place. The report did not include the root cause of the fall. The admission MDS assessment dated [DATE] indicated that Resident #18 had severe cognitive impairment, was occasionally incontinent of bladder and was frequently incontinent of bowel. She needed extensive assist with transfers, ambulation in room occurred only once or twice with 1-person physical assist and she was using a walker and a wheelchair for mobility. She had a fall with no injury since admission, entry, reentry or prior assessment and had a fracture related to a fall in the last 6 months prior to admission. Resident #18's care plan dated 8/1/22 for falls was reviewed. The care plan problem was I am at risk for injury related to weakness, balance issues, needs for assistance with mobility and self-care and episodes of incontinence. I have very poor insights and judgment into my own deficits, and I receive medications that can make me dizzy. The goal was my staff will attempt to reduce risk of falls related injury. The approaches included staff will complete a fall risk assessment per facility protocol, staff will assist me during transfers from surface to surface as needed, staff will provide physical therapy and occupational therapy as ordered and to be offered toileting during rounds and as needed. Resident #18 was observed on 8/9/22 at 9:10 AM in bed with the door closed and on 8/10/22 at 10:01 AM up in a reclined chair in her room with the door closed. An interview was completed on 8/10/22 at 5:04 PM with the acting DON. She stated the facility should resume the weekly Resident At Risk (RAR) meetings to better identify the root cause of a fall and to help identify trends or patterns timely. She also stated it was her expectation that the facility identifies the root cause for each fall and implement effective interventions to lessen the number of falls. An interview was completed on 8/10/22 at 8:20 AM with the Administrator. He stated the managers discussed any falls from the day/night before every Monday through Friday and discussed weekend falls on Mondays. He stated at that time, the Director of Nursing (DON) put interventions in place and the MDS Nurse revised the care plan. He stated the facility also reviewed resident falls during the Resident at Risk (RAR) monthly meeting and included the Director of Nursing, Nurse Managers, the MDS Nurse and himself. He stated the RAR meetings were weekly up until recently but offered no explanation as to why the weekly meetings were discontinued. The Administrator stated they were resuming the weekly RAR meetings weekly on 9/5/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #14 was admitted with palliative care on 5/24/22 with cumulative diagnosis of a pressure ulcer to her left heel and protein malnutrition. Her admission Minimum Data Set (MDS) dated [DATE] indicated Resident #14 had severe cognitive impairment, required extensive assistance with eating, a pressure ulcer and her height of 63 inches with her weight recorded as 120 pounds (lbs.). The MDS was coded as unknown for any weight loss or weight gain. Resident #14 was care planned on 5/31/22 for a risk of a nutritional decline due to her poor appetite. Interventions included discussing her likes and dislikes, monitoring her weight and to notifying the Physician for any concerns. Interventions also included the Registered Dietitian (RD) would assess her weight and nutritional status as needed. Review of Resident #14's August 2022 Physician orders included an order dated 5/24/22 for a nutritional drink three times daily due to weight loss but the order read it was not started until 6/29/22. Another order dated 7/20/22 was for a frozen nutritional supplement twice daily due to poor nutrition and the ordered read it was started on 7/20/22. She was also ordered a regular diet and not prescribed a diuretic. Review of Resident #14's oral intake from 5/25/22 to 8/9/22 ranged from 0 to 100%. There was not any documented evidence of patterns for her meal refusals or zero consumption. Review of Resident #14's most recent lab work dated 5/27/22 indicated her Albumin was low at 3.1. Review of Resident #14's electronic medical record read her admission weight on 5/25/22 was 116.4 lbs. Her following weights were as follows: * 5/31/22 weight recorded at 109.8 lbs. * 6/5/22 and 6/7/22 weight recorded at 110 lbs. *7/5/22 weight recorded at 106.5 lbs. * 8/5/22 weight recorded at 103.6 lbs. This data revealed an 11% weight loss in the past 74 days (5/24/22 to 8/5/22). Review of Resident #14's Physician/Physician Assistant (PA) notes revealed the following: *6/21/22 Initial encounter-noted was a pressure ulcer to her left heel with no mention of her appetite or weight loss *6/28/22 routine encounter-eating well *7/5/22 routine encounter-eating well *7/12/22 routine follow up encounter-resident was in the dining room eating well and feeding herself Cheerios *7/18/22 routine follow up encounter-eating well and noted weight loss *7/25/22 routine follow up encounter-eating well *8/1/22 routine follow up encounter-eating well and noted weight loss. *8/8/22 routine follow up encounter-in room drinking a protein drink. Eating well Review of the comprehensive nutrition assessment completed by the RD and dated 5/31/22 read as follows: *Resident #14 receives a consistent carbohydrate diet with regular textures and thin liquids. Poor appetite reported, noted intakes of 0-50% for all meals per her seven day look back. Resident #14 received a nutritional drink three times daily to aid in meeting nutritional needs. She required assistance with most meals. Recent weight loss reported. Current body weight 116.4 lbs., body mass index 20.6 is low for her age. Continues weekly weights. Unstageable pressure wound to her left heel. Will continue to monitor weights, labs, oral intake and nutritional status. The interventions goals read to maintain her current body weight +/- 5%, maintain oral intake of >50% at all meals and to continue to tolerate regular textures. Will continue to monitor weights, oral intakes, lab work, skin integrity through next review. Review of the only other documented RD note dated 7/18/22 read as follow: *RD visited Resident #14 due to weight loss. Current body weight was 106.5. Resident #14 on a consistent carbohydrate regular diet and a nutritional drink was ordered three times daily for weight loss. The Nurse in the room reported that Resident #14 did not eat well. Noted her oral intakes over 7 days varied from 0-100%. Recommend liberalizing diet to regular to provide more options and encourage oral intakes. Will continue to monitor oral intakes, weights and labs through the next review. There were no recommendations or evidence that the Physician or PA were notified of continued weight loss. An observation and interview was completed on 8/8/22 at 12:25 PM. Resident #14 was in the dining room with Nursing Assistant (NA) #3 prompting her with lunch. NA #3 stated her appetite was poor and she was losing weight. She stated the staff try to get her up for all meals. She stated Resident #14 needed more staff assistance if she was eating in bed. NA #3 stated she normally ate 0 to 50% of all her meals but drink her nutritional drink if it was chocolate. An observation and interview was completed on 8/10/22 at 8:00 AM. Nurse #2 stated Resident #14's appetite was poor and she had lost weight since her admission but she ate 100% of her breakfast. Nurse #4 stated ate better when up in the dining room but Resident #14 was still in bed to allow for the observation of her wound care. Nurse #4 stated Resident #14 liked the chocolate nutritional drink and she ate better when she was served items that she could pick up to eat rather than eating with a fork or spoon. She stated Resident #14 liked to snack on Cheerios. A review of Resident #14's electronic wound care provider notes also indicated healing to her left heel pressure ulcer. An interview was completed on 8/10/22 at 8:20 AM with the Administrator. He stated previously the facility employed a full-time RD but the current RD started in February 2022 and only worked part-time. He stated the facility reviewed resident's with weight loss during the monthly Resident at Risk (RAR) meeting and included the Director of Nursing, Nurse Managers, the MDS Nurse and himself. He stated the RAR meetings were weekly up until recently but offered no explanation as to why the weekly meetings were discontinued. An interview was completed on 8/10/22 at 12:16 PM with the PA. He stated any time a resident was admitted on palliative care, it was understood that the resident was expected to recover. He stated when a resident was admitted to hospice, the resident was not expected to recover. The PA stated since Resident #14 was on palliative care, it was expected that she would recover and return to her baseline. The PA stated the delay in implementing the nutritional drink may have impacted her weight loss. He stated he had not been notified on Resident #14's weight loss and he expected the RD to have identified her weight loss, notified him and implement interventions timely but apparently that did not happen. A telephone interview was completed on 8/10/22 at 3:45 PM with the RD. She stated she started working part-time at the facility 2/28/22 and she was at the facility 2-3 times weekly. The RD stated she was out for surgery 6/2/22 through 7/11/22 but she worked remotely during that time. She stated she last saw Resident #14 on 7/18/22 and she was aware of her weight loss. The RD stated she did not notify the Physician or the PA about Resident #14's weight loss. The RD stated Resident #14 was prescribed a nutritional drink on admission 5/24/22 but she was not aware that the order was not implemented until 6/29/22. The RD stated she received a list of residents with MDS assessment due so she could complete her quarterly nutritional assessments. She stated she also completed a nutritional assessment for all new admissions and she reviewed all the residents weights monthly to see which residents were having weight loss. An interview was completed on 8/10/22 at 5:04 PM with the interim Director of Nursing (DON). She stated apparently when Resident #14 was admitted on [DATE] with orders for a nutritional drink three times a day, the dietary department was not made aware or given a copy of the order. She stated it appeared as if someone realized this on 6/29/22 and notified the dietary department. The DON stated the RD was not able to write her own orders unless they were approved by the Physician or the PA. She stated the current RD was not involved in the IDT process and apparently did not communicate effectively with the facility regarding the residents with identified with undesired weight loss. Based on record review, observation and interview with the Registered Dietician (RD), Dietary Manager (DM), Physician Assistant (PA), resident and staff, the facility failed to address and to intervene when a resident was identified to have a weight loss (Residents #13,& #3) which resulted in continued weight loss and failed to provide a nutritional supplement on admission for a resident with history of weight loss and continued to lose weight (Resident #14). This was for 3 of 4 sampled residents reviewed for nutrition (Residents # 13, #3, #14). Findings included: 1. Resident # 13 was admitted to the facility on [DATE] with multiple diagnoses including dysphagia (difficulty swallowing food/liquids) and hemiplegia (partial paralysis on one side of the body) following cerebral infarction affecting the right dominant side. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #13 had severe cognitive impairment, was independent with eating and was on a mechanically altered diet. The assessment further indicated that the resident's weight was 189 pounds (lbs.). Resident #13's care plan for nutrition dated 5/29/22 was reviewed. The care plan problem was I am at risk for nutritional decline related to dysphagia from a stroke and on a dysphagia 1, puree consistency and nectar thick liquids. The goal was I will tolerate diet as ordered with no complications and will maintain my weight within 5% of 189 lbs. The approaches included staff to monitor my weight as ordered and notify the physician and my family of any concerns, Registered Dietician (RD) will assess my weight and nutritional status as needed throughout my stay at the facility. Resident #18's weights were recorded as follows: 5/13/22 - 189 lbs. 6/10/22 - 154 lbs. 7/5/22 - 168 lbs. - 21 lbs. weight loss in 2 months 8/5/22 - 147 lbs. - 42 lbs. weight loss in 3 months (since admission) and 21 lbs. weight loss in 1 month. Review of the RD documentation revealed that Resident #13 was last assessed by the RD on 5/20/22. The RD note indicated that the resident was on puree diet nectar thick liquids, and feeds self with set up help. His meal intakes were at 75% and has good appetite prior to admission. His current body weight was 188.9 lbs. Continue to monitor nutritional status, skin integrity, meal intakes and laboratory (labs) as available. Interventions/goals were for the resident to maintain current body weight +/- 5%, will maintain meal intake of more than 50% of all meals, will tolerate puree texture, nectar thick liquids, will monitor weights, intakes, labs and skin integrity. Review of the meal intake documentation for June, July and August 2022 revealed that some days there were no documentation of meal intake. There were no documentation for breakfast, lunch and dinner on 6/1/22, 6/3/22, 6/4/22, 6/5/22, 6/7/22, 6/8/22, 6/11/22, 6/12/22, 6/17/22, 6/18/22, 6/19/22, 6/24/22, 6/26/22, 6/28/22, 7/1/22, 7/2/22, 7/3/22, 7/9/22, 7/10/22, 7/12/22, 7/15/22, 7/16/22, 7/17/22, 7/22/22, 7/26/22, 7/28/22, 8/1/22 and 8/7/22. Resident #13 was observed on 8/8/22 at 12:40 PM with the Speech Therapist and on 8/10/22 at 12:30 PM. He was in his room eating lunch. He was served regular portion of puree diet with nectar thick liquids. He ate almost 100% of his food during each observation. The Dietary Manager was interviewed on 8/10/22 at 11:12AM. The DM stated that the RD has oversight of resident's weights and weight loss. The acting Director of Nursing (DON) was interviewed on 8/10/22 at 10:13 AM. The acting DON stated that residents were weighed monthly by nursing unless it was ordered differently. The weights were recorded electronically on the Medication Administration Records (MARs) and on the weight tracking form. She stated that nobody from nursing was responsible for monitoring/tracking weight loss/gain, however, the RD had access to the resident's weights recorded on the electronic records. The Physician Assistant (PA) was interviewed on 8/10/22 at 12:15 PM. The PA stated that he was never notified that Resident #13 had a significant weight loss. However, if nursing notified him of weight loss, he would normally refer the resident to the RD to assess and to intervene. The Nursing Aide (NA) #4, assigned to Resident #18 was interviewed on 8/10/22 at 3:25 PM. The NA stated that Resident #13 was confused and was able to feed himself. He has good appetite most of the time. She reported that the facility was short of staff, and she tried her best to provide the care and most of the time she did not have the time to document meal intakes. The RD was interviewed on 8/10/22 at 3:49 PM. The RD stated that she started working at the facility in February 2022. She came to the facility 2-3 times per week to see the residents and the rest of the week, she reviewed the residents remotely. She normally assessed residents with weight loss, new admission and quarterly. She reported that from 6/2/22 through 7/11/22, she had not been coming to the facility due to a medical reason, so she reviewed the residents remotely. She had access to the residents' weights electronically and was aware that Resident #13 had a significant weight loss from 189 lbs. in May 2022, 168 lbs. in July 2022 and 147 lbs. in August 2022. The RD reviewed her notes and stated that the last time she assessed Resident #13 was on 5/20/22. The RD did not have an explanation as to why she did not assess and intervene when she identified Resident #13 having a significant weight loss. 2. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including dysphagia (difficulty swallowing food/liquids) and hemiplegia (partial paralysis on one side of the body) following cerebral infarction. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #3's cognition was intact, was independent with eating and was on a mechanically altered diet. The assessment further indicated that the resident's weight was 169 pounds (lbs.). Resident #3's care plan for nutrition dated 5/30/22 was reviewed. The care plan problem was I am at risk for nutritional decline related to dysphagia diet and recent weight loss of 10 lbs. The goal was I will tolerate diet as ordered with no complications and will maintain my weight within 5% of my admission weight. The approaches included Registered Dietician (RD) will assess my weight and nutritional status as needed though out my stay at the facility. Resident #3's weights were recorded as follows: 4/29/22 - 169 lbs. 5/13/22 - 169 lbs. 6/5 - no recorded weigh 7/5/22 - 156 lbs. - 13 lbs. weight loss in 3 months (more than 7.5 % in 3 months) Review of the meal intake documentation for June, July and August 2022 revealed that some days there were no documentation of meal intake. There were no documentation for breakfast, lunch and dinner on 6/1/22, 6/2/22, 6/4/22, 6/5/22,6/6/22, 6/7/22, 6/8/22, 6/12/22, 6/17/22, 6/19/22, 6/24/22, 6/25/22, 6/26/22, 6/28/22, 7/1/22, 7/2/22, 7/9/22, 7/10/22, 7/15/22, 7/16/22, 7/17/22, 7/22/22, 7/23/22, 8/2/22, 8/5/22, 8/6/22, and 8/7/22. Review of the RD documentation revealed that Resident #3 was last assessed by the RD on 5/12/22. The note indicated that Resident #3 received mechanically altered diet with thin liquids, feeds self with set up help and his meal intakes were 25-100%. Prostat (a protein supplement) 30 milliliter was added to provide additional 100 kilo calories, 15 grams of protein for wound healing. His admission weight was 169 lbs. Interventions/goals were for the resident to maintain current body weight of +/- 5%, will maintain meal intake of more than 50% of all meals, will tolerate mechanically altered diet with thin liquids. Will monitor weights, meal intakes, laboratory and skin integrity. Resident #3 was observed on 8/8/22 at 12:37 PM and on 8/10/22 at 12:25 PM. He was in his room eating lunch. He was served regular portion of soft diet with thin liquids. He did not eat much of the food in his tray. When interviewed, he stated that he ate what he wants, and he had no appetite. The Dietary Manager was interviewed on 8/10/22 at 11:12AM. The DM stated that the RD has oversight of resident's weights and weight loss. The acting Director of Nursing (DON) was interviewed on 8/10/22 at 10:13 AM. The acting DON stated that residents were weighed monthly by nursing unless it was ordered differently. The weights were recorded electronically on the Medication Administration Records (MARs) and on the weight tracking form. She stated that nobody from nursing was responsible for monitoring/tracking weight loss/gain, however, the RD had access to the resident's weights recorded on the electronic records. The DON stated that she was aware that Resident #3 had a missing weight in June 2022. The Physician Assistant (PA) was interviewed on 8/10/22 at 12:15 PM. The PA stated that he was never notified that Resident #3 had a significant weight loss. However, if nursing notified him of weight loss, he would normally refer the resident to the RD to assess and to intervene. The Nursing Aide (NA) assigned to Resident #3 was interviewed on 8/10/22 at 3:25 PM. The NA stated that Resident #3 was able to feed himself. He had poor appetite most of the time. She reported that the facility was short of staff, and she tried her best to provide the care and most of the time she did not have the time to document meal intakes. The RD was interviewed on 8/10/22 at 3:49 PM. The RD stated that she started working at the facility in February 2022. She came to the facility 2-3 times per week to see the residents and the rest of the week, she reviewed the residents remotely. She normally assessed residents with weight loss, new admission and quarterly. She reported that from June 2 through July 11, 2022, she had not been coming to the facility due to a medical reason, so she reviewed the residents remotely. She had access to the residents' weights electronically and was aware that Resident #3 had a significant weight loss from 169 lbs. in April 2022 to 156 lbs. in July 2022. She reviewed her notes and stated that the last time she assessed Resident #3 was on 5/12/22. The RD did not have an explanation as to why she did not assess and intervene when she identified Resident #3 having a significant weight loss.