Based on record review, staff interview, and policy review, the facility failed to notify the responsible party when a resident experienced a significant weight loss. This affected one (#32) of two residents reviewed for notification of change. The facility census was 38. Findings include: Review of the medical record of Resident #32 revealed an admission date of 02/19/21. Diagnoses included essential hypertension, muscle weakness, and cognitive communication deficit. Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 06/17/21, revealed the resident had impaired cognition. Review of Resident #32's weights revealed: on 02/21/21, she weighed 144 pounds; on 03/01/21 at 140 pounds; on 04/06/21 at 127 pounds; on 04/19/21 at 125 pounds; and on 05/01/21 at 127 pounds. This revealed a 17 pound weight loss and a 11.8 percent significant weight loss in less than three months. Review of the progress notes dated 04/2020 through 06/01/2020 revealed no indication of family notification of weight loss. Interview on 07/08/21 at 9:54 A.M. with Registered Dietitian (RD) #350 stated she does not personally notify the responsible party of a resident's weight loss and the nurse does the notification when they call to notify of the new orders associated with the weight loss. RD #350 further verified the medical record of Resident #32 lacked evidence of notification of responsible party of weight loss. Interview on 07/08/21 at 11:48 A.M. with Licensed Practical Nurse (LPN) #287 stated the nurses notify the responsible party of weight loss when they call to notify of the new orders associated with the weight loss. LPN #287 further stated the notification was documented in the progress notes when the notification was completed. Review of the facility's undated policy titled, Notification and Reporting of Changes in Health Status, Illness, Injury, and Death of a Resident, revealed the appropriate associates will promptly inform the resident representative of a significant change in the resident's status, such as a deterioration in health and document the notification in the medical record.

Based on medical record review, family interview, staff interview, and policy review, the facility failed to include residents and resident representatives to participate in care planning. This affected one (#12) of 16 residents reviewed during the annual survey. The facility census was 38. Findings include: Review of the medical record for Resident #12 revealed an admission date of 11/03/18. Diagnoses included weakness, essential tremor, squamous cell carcinoma, Alzheimer's disease with late onset, unspecified macular degeneration, essential hypertension, chronic obstructive pulmonary disease, spinal stenosis, and primary generalized osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/21/21, revealed the resident had severely impaired cognition. Review of the medical record revealed documentation of care conferences held on 04/21/20 and 12/16/19. There were no other documented care conferences held from 05/01/20 to 07/05/21. Interview on 07/06/21 at 1:45 P.M. with the daughter of Resident #12 stated the facility had not invited her to any care conferences since prior to the COVID-19 pandemic. Interview on 07/07/21 at 1:45 P.M. with the Director of Nursing (DON) verified the last care conference held for Resident #12 was 04/21/20. The DON stated she was unsure why additional care conferences were completed. Subsequent interview on 07/08/21 at 11:39 A.M. with the DON stated the expectation of a care conference was to be offered at least quarterly. Review of the facility's undated policy titled, Care Conference, revealed every resident and responsible party will be invited to a quarterly meeting that is held for the dual purpose of educating the resident about new issues that might impact his/her care and discussing his/her current physical, mental, and emotional status.

Based on medical record review, staff interview, and policy review, the facility failed to ensure resident's code status was accurate in the medical record. This affected three (#12, #22, and #32) of four residents reviewed for advanced directives. The facility census was 38. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 11/03/18. Diagnoses included weakness, essential tremor, squamous cell carcinoma, Alzheimer's disease with late onset, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/21/21, revealed the resident had severely impaired cognition. Review of the physician orders revealed an active order dated 03/09/19 for Do Not Resuscitate-Comfort Care-Arrest (DNR-CCA). Review of the DNR Order Form revealed Resident #12 was a Do Not Resuscitate-Comfort Care (DNR-CC), signed by the physician on 11/08/18. 2. Review of the medical record for Resident #32 revealed an admission date of 02/19/21. Diagnoses included peripheral vascular disease, muscle weakness, cognitive communication deficit, and repeated falls. Review of the Medicare five-day MDS assessment, dated 06/17/21, revealed the resident had impaired cognition. Review of the physician orders revealed an active order dated 06/09/21 for DNR-CC. Review of the DNR Order Form revealed Resident #32 was a DNR-CCA, signed by the physician on 05/25/21. 3. Review of the medical record for Resident #22 revealed an admission date of 07/07/20. Diagnoses included other fracture of right pubis, dementia without behavioral disturbance, anxiety, asthma, muscle weakness, mood disorder, gastro esophageal reflux disease, venous insufficiency, and unspecified psychosis. Review of the quarterly MDS assessment, dated 04/28/21, revealed the resident had severely impaired cognition. Review of the physician orders revealed an active order dated 04/23/21 for DNR-CC. Review of the DNR Order Form revealed Resident #22 was a DNR-CCA, signed by the physician on 01/23/20. Interview on 07/06/21 at 3:30 P.M. with Registered Nurse (RN) #294 verified the code status orders did not match the signed DNR forms for Residents #12, #22, and #32. Review of the facility's undated policy titled Advance Directives, revealed all advance directive document copies will be obtained, filed in medical record and readily retrievable by associates.