**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (CR #1) of 5 residents reviewed for quality of care. -The facility failed to ensure treatment and care was provided to CR #1 consistent with professional standards of practice. CR #1, who was prescribed an anticoagulant, had a fall hitting her head on [DATE] at approximately 9:00 p.m. NP A recommended CR #1 be sent to the hospital immediately. Transport was not dispatched until 11:27 p.m. and CR #1 was not transported to the hospital until 12:48 a.m. on [DATE] where she later passed away. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 10:27 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). This failure could place residents at risk for a delay in medical treatment, of not receiving necessary medical care, hospitalization, and death. The findings included: Record review of CR #1's admission Record, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (brain dysfunction caused by underlying condition that affects metabolism), cerebral infarction (stroke) due to unspecified occlusion or stenosis of left middle cerebral artery (blockage in the brain caused by atherosclerosis, leading to disruption of blood flow to brain cells), and hypertensive heart (heart problems that occur due to long-term high blood pressure) and chronic kidney disease (gradual loss of kidney function) with heart failure and with stage 5 chronic kidney disease, or end stage renal disease. Record review of CR #1's MDS Assessment, dated [DATE], revealed a BIMS score of 5, indicating severe cognitive impairment. Further review revealed resident required a helper to complete toileting, shower/bathe, and lower body dressing. Record review of CR #1's care plan report, undated, revealed the resident was on anticoagulant therapy r/t atrial fibrillation (irregular and often very rapid heart rhythm) and CHF (chronic condition that affects the heart's ability to pump blood efficiently). Record review of CR #1's physician orders, undated, revealed an order for warfarin sodium oral tablet 2 MG, 1 tablet by mouth at bedtime to prevent blood clot, start date: [DATE]. Record review of CR #1's progress notes, dated [DATE] at 22:16 p.m. [10:16 p.m.], Author: Nurse A, read in part .around 9pm patient on the floor with unwitness fall, she stated she don't remember what happen, initiate neuro and skin assessment patient complains no pain, with obvious bruising/swelling on her left eye, informed RP who is the [family member], DON, and NP [name], ordered to transfer patient to ER for further evaluation. Record review of CR #1's Neuro Assessment Flow Sheet, dated 03/16 and 03/17, revealed neuro checks were completed at 10:00 [p.m.], 10:15 [p.m.], 10:30 [p.m.], 10:45 [p.m.], 11:00 [p.m.], 11:30 [p.m.], 12:00 [a.m.], 00:30 [12:30 p.m.], and 01:00 [a.m.] and vital signs were normal. Record review of CR #1's eInteract Change in Condition Evaluation, dated [DATE], read in part .B6. Skin Status Evaluation .6a. Describe skin changes .Discoloration .6b. Site other, Description left eye bruising .B. Provider Notification and Feedback .2. Date and time of clinician notification: [DATE] 21:30 [9:30 p.m.] .4a. Specify other: transfer to ER . Record review of CR #1's medical transport report, dated [DATE], revealed transport was dispatched at 23:27 (11:27 p.m.) and left facility at 00:48 (12:48 a.m.). Record review of CR #1's CT Brain WO IV Contrast, dated [DATE], read in part .Exam: CT Head without contrast [DATE] 1:20 AM .Impression: 1. No acute intracranial hemorrhage, midline shift, or mass effect. 2. Left frontal scalp soft tissue swelling. 3. Subacute left parieto-occipital infarct . Record review of CR#1's death certificate, issued date [DATE], read in part .immediate cause (final condition or disease resulting in death) ----> a. Intracranial Hemorrhage [bleeding inside the skull] .sequentially list conditions, if any leading to the cause listed on line a. Enter the underlying cause (disease or injury that initiated, the events resulting in death) last .b. Atrial Fibrillation . During a telephone interview on [DATE] at 10:57 a.m., Nurse A said he remembered he was passing out medications during the night shift on [DATE] when he found CR #1 on her bedroom floor. He said CR #1 kept telling him she was okay. He said he did not note any injuries, but resident was on a blood thinner. He said he called NP A and resident was sent out to the hospital immediately. He said CR #1 did not return back to the facility. He said he did not know how many days it was after she was sent out, but she passed away at the hospital. During an interview on [DATE] at 11:15 a.m., the DON said he got a telephone call from the nurse on duty (did not recall name) letting him know CR #1 fell and was found on the floor in her room. He said fall protocols were initiated. He said if he was not mistaken, the resident hit her left eye and had bruising. He said all parties were notified and the resident was sent out to the hospital. He said the resident did not return back to the facility and expired at the hospital. He said to his understanding the resident was alert upon transfer to the hospital. In a follow-up telephone interview on [DATE] at 11:28 a.m., Nurse A said CR #1 did not remember and could not tell them how she fell. He said she was awake and alert when transport arrived and transferred her to the ER. He said the resident had no bleeding but had some puffiness to her left or right eye. During a follow-up interview on [DATE] at 12:41 p.m., the DON said when CR #1 fell, they sent her out to the hospital right away. He said he was not certain if the resident was sent out via 911 or non-emergent transport. During a follow-up telephone interview on [DATE] at 12:56 p.m., Nurse A said a man who he believed was the resident's family member came up to the facility after CR #1 fell, and waited for transport to arrive and rode with the resident to the hospital. He said he thought the family member came to the facility around 11:00 p.m. or 12:00 a.m. He said NP A said to have the resident transported to the hospital but did not remember if NP A said to use regular or 911 transport. He said he called regular transport. He said he used regular transport because the resident and her vitals were stable. During an interview on [DATE] at 1:13 p.m., the Administrator said CR #1 did not remember what happened. She said the family member went to the facility 2 to 3 days after CR #1 passed away to pick up her belongings and he told her that the resident was okay on the day of the incident, that he did not even want her to be sent out to the hospital, and that it had something to do with her heart that the doctors found. She said they did not obtain any hospital records but there were no notifications about any fractures/injuries. She said based on what the NP told them, if the patient's vitals were within normal range, and if the resident was okay, then they would send out regular transport. During a follow-up interview on [DATE] at 2:00 p.m., Nurse A said he did not remember what time he called transport, but it was as soon as he received the order from NP A. He said he spoke to NP A around 9:00 p.m., and she told him to assess the resident for bleeding, check to see if the resident was on an anticoagulant, and to send her to hospital for further evaluation. He said he did not know what time transport arrived, but that they arrived kind of late, about 1 to 2 hours or something like that, after he called. During an interview on [DATE] at 3:08 p.m., NP A said she recalled receiving a telephone call about CR #1's fall on [DATE] but did not recall what time. She said when she spoke to the nurse, she gave the order to send out the resident immediately. She said she spoke to the resident's family member who was reluctant to send her out to the hospital. She said the family member told her that the resident fell a lot at home, and he would not take her to the hospital. She said she told the family member the resident needed to be sent out for safety and because she was on an anticoagulant. She said she could not say who ultimately decides if a resident was sent out 911 or regular transport [facility or physician/NP]. NP A said she could not say if the resident should have been sent out 911 or regular transport due to it being a hypothetical question. She said she could not say what the risk was to the resident who was on anticoagulant, fell and hit her head, and was not sent out 911 due to it being a hypothetical question and a case-by-case basis. During a telephone interview on [DATE] at 9:19 a.m., the DON said according to neuro checks, CR #1's vitals were stable. He said pupils and eye checks were meant to determine if there was any type of abnormalities. He said her eyes were not constricted or dilated and were brisk. He said they could not determine if there was internal bleeding through neuro checks but could determine if there were any abnormalities but not exactly what was wrong. He said a resident on an anticoagulant that sustained a head injury could be at risk for bleeding. During an interview on [DATE] at 10:42 a.m., CR #1's family member said the facility called him on the night of [DATE] around 9:00 p.m. to let him know CR #1 fell. He said he did not tell them not to send her to the hospital. He said he got up right away, went to the facility, and arrived between 10:00 p.m. and 10:30 p.m. He said when he arrived at the facility, the resident could not tell him what happened and told him she did not want to go to the hospital. He said he told CR #1 she had to go to the hospital because it was part of the facility's protocol. He said he did not recall if he spoke to NP A, but the facility told him about their protocol for sending CR #1 to the hospital. He said CR #1 had a little discoloration to her left eye, but that she was fine and talking to him. He said when transport arrived, she walked to the stretcher, and he followed behind transport. He said all test results completed at the hospital came back negative. He said he had a copy of the resident's death certificate and the cause of death listed was intracranial hemorrhage and atrial fibrillation. Record review of the facility's Provision of Quality Care policy, date implemented [DATE], read in part .1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being . Record review of the facility's Fall Prevention Program policy, date implemented: [DATE], read in part .each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . The Administrator was notified on [DATE] at 10:27 a.m. that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on [DATE] at 6:06 p.m.: Texas Health and Human Services Commission Regulatory Services Division [address] Re: Removal of Immediate Jeopardy/Letter of Removal [Facility Name] Facility ID/# [] [DATE]th, 2025 Dear Program Manager, Allegation of Immediate Jeopardy: -The facility failed to ensure treatment and care was provided to CR #1 consistent with professional standards of practice. CR #1, who is prescribed anticoagulants, had a fall hitting her head on [DATE] at approximately 9:00 p.m. NP recommended CR #1 be sent to hospital. Transport was not dispatched until 23:27 (11:27 p.m.) and CR #1 was not transported to the hospital until 00:48 (12:48 a.m.) on [DATE] where she later passed away. Resident #1 who is on anticoagulant (CR #1), a [AGE] year-old female admitted to the facility on [DATE] diagnosis of metabolic encephalopathy, cerebral infarction, chronic kidney disease with heart The following measures represent the immediate action [facility name] has taken to address the alleged-deficient practice and to prevent serious harm from occurring or recurring. Immediate Actions to Address Immediate Jeopardy On [DATE] at 11:00 am, the Director of Nursing (DON) completed head to toe assessments on all residents currently prescribed anticoagulant medications to ensure no signs of injury or delayed response to change in condition. Beginning [DATE] at 12:00 pm the administrator and DON initiated a 72 hour look back review of all falls and incidents from [DATE]-[DATE] involving head injuries to ensure appropriate emergency response and physician notification were documented. With no negative findings. At 1:00 pm during QAPI Administrator/Director of Nursing/Medical Director reviewed Fall policy with no revisions to the policy. Date of Action: [DATE] Objective: Ensure that resident receiving anticoagulant with head injury must be transported to hospital via 911 for further evaluation. Ensure that all nurse must assess, notify and document notification to Responsible Party, Physician/Nurse Practitioner, Director of Nursing and Administrator residents. 1. Review Resident Records o Action: Audit all records of residents on coumadin and head injuries. Audit revealed No residents on anticoagulants at this time. o Completion Date: [DATE] o Responsible Party: DON/Designee 2. Immediate Staff Training o Action: On [DATE] at pm an emergency inservice- training was held with all licensed nurses and CNAs on appropriate response protocols for head injuries, especially in resident on anticoagulants. o Topics covered: immediate assessment, neuro checks, when to call 911, and importance of timely physician notification. o Action: Provide training to 1all nursing staff on the importance of transferring residents to hospital via 911 for residents with head injuries and are receiving anticoagulants. Training to include post test. Provide training to all nursing staff to ensure nursing assessment is completed when there is a resident incident accident. Nurse must notify the Responsible party, Physician, Nurse Practitioner, Director of Nursing and Administrator. Any communication must also be documented in the medical records. o Action: DON/Admin in-serviced by corporate on response protocols for head injuries, falls and residents on anticoagulants. o Completion Date: [DATE] o Trainer: DON attendance documented. Staff not trained are removed from floor assignments until completed. 3. Documentation of Immediate Training and Competency Checks o Action: Head injury/anticoagulant transfer test will be completed by nursing staff currently on duty and for all active employed nurses prior to the start of the next scheduled shift. o Completion Date: [DATE] o Responsible Party: DON/Designee, documentation of completion on file. Goal: To Ensure nurses receive training on transferring resident to hospital via 911 for further evaluation and treatment on residents who are receiving anticoagulant with head injury 1. Training Sessions on Incident accident accident injury with anticoagulants and transfer to hospital o Action: Schedule inservice session on nursing staff to ensure Ensure that resident receiving anticoagulants with head injury must be transported to hospital via 911 for further evaluation and treatment o Completion Dates: Initial training and post test to be completed on 5 /24/25 or prior to next scheduled shift. o Trainer: DON/Designee o Competency Verification: All staff will be required to pass a posttest 2. Resident Monitoring Logs Implementation o Action: Audit to be completed daily on all resident receiving anticoagulant with head injury to ensure proper transfer to hospital is completed o Completion Date: [DATE] o Responsible Party: ED to develop log. DON/designee to complete and monitor 3. Quality Assurance and Performance Improvement (QAPI) Meeting o Action: Conduct a QAPI meeting to review the incident, corrective actions, and policy updates. Create a recurring agenda item for monitoring compliance with the new protocols. o Date of Meeting: [DATE] o Responsible Party: Administrator and QAPI Committee 4. Ongoing Audits and Compliance Checks o Action: Schedule daily audits x30 days then weekly for 30 days to ensure compliance with proper transfer of patient on anticoagulants with head injury to hospital . Document findings and review corrective actions in monthly QAPI meetings. o Start Date:[DATE], continuing weekly until confirmed compliance o Responsible Party: Administrator 5. Progressive Action/Counseling o Nurse A, will receive 1:1 in servicing prior to next scheduled shift . They will also complete post test. o [Medical Director Name], Medical Director, was notified via telephone in regard to the IJ involving resident [initials] and attended ad-hoc QAPI via telephone. Documentation and Follow-Up -Documentation of Training and Competency Checks: All staff training records, test conducted will be filed in each employee's personnel record by [DATE] -Audit Logs and Monitoring Forms: Logs for audit on falls, head injury and anticoagulants will be maintained and reviewed weekly. Compliance will be tracked, and corrective actions will be implemented as necessary. Outcome: Through these corrective actions, the facility aims to protect resident safety, enhance monitoring and responsiveness, and achieve sustained compliance with respiratory care standards. Warm Regards, [Administrator Name] [Address] Email: [] Phone: [] Fax: []. On [DATE]-[DATE], surveyor confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by: Record review of head to toe assessments dated [DATE] reflected the DON assessed all residents currently prescribed anticoagulant medications. The assessments revealed 25 residents had an order(s) for anticoagulants. No negative findings were identified Record review of in-service trainings dated [DATE] reflected the Administrator and DON received training from the facility's Regional [NAME] President of Operation on emergency response to falls in residents on anticoagulants. Record review revealed on [DATE], Nurse A received 1:1 verbal warning/counseling and in-service training. Nurse A demonstrated an understanding of the information and passed the competency quiz. Record review revealed on [DATE], in-service training was initiated with licensed nurses and MAs on Falls/Injury on Residents on Anticoagulants must be Transported to ER via 911; 22 staff were in-serviced. Record review revealed on [DATE], in-service training was initiated with licensed nurses, CNAs, and MAs on All Incidents/Accidents Must be Assessed Immediately with Neuro Checks Initiated and Reported Immediately to MD, DON, RP, and ED; 50 staff were in-serviced. Record review revealed on [DATE], competency quiz was initiated with nursing staff. Nursing Staff demonstrated an understanding of responding to falls in residents on anticoagulants; 31 staff were quizzed and passed. Record review revealed on [DATE], a daily audit log was initiated to ensure compliance with proper transfer of patient on anticoagulants with head injury to hospital was initiated on all residents receiving anticoagulant with head injury. Record review revealed on [DATE] the facility conducted a 72-hour look back of all fall incidents from [DATE]-[DATE] involving head injuries to ensure appropriate emergency response and physician notification were documented. Record review revealed on [DATE] a daily audit log was initiated to ensure compliance with proper transfer of patient on anticoagulants with head injury to hospital was initiated on all residents receiving anticoagulant with head injury. Record review revealed on [DATE] a QAPI telephone conference was held, and staff members present were the Administrator, DON, and Medical Director. Interviews were conducted from [DATE] to [DATE] with staff from all shifts (6:00 a.m.to 6:00 p.m., 6:00 p.m. to 6:00 a.m., 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m.). Staff interviewed included the following: Administrator, DON, Nurse A, RNs C and D, LVNs B, C, E, and F, CNAs B, C, D, E, F, G, H, I and J, and MA B. All staff interviewed verbalized an understanding of the in-service training(s) they received. They understood to notify nurses when a resident has a fall, required nurse assessment, documentation, and notifications of residents who fall that are on anticoagulants, and calling 911 for transport. During an interview on [DATE] at 10:01 a.m., the DON said he completed the head-to-toe assessments on residents who were on anticoagulants and there were no negative findings. He said he and the Administrator completed the 72-hour look back and there were no negative findings. He said they conducted an audit and found there were no residents on coumadin. He said he received in-service training from Regional [NAME] President of Operation on [DATE] on response protocols for head injuries, falls, and residents on anticoagulants and verbalized an understanding. He said daily audits are being completed for the next 30 days then weekly for 30 days to ensure compliance with proper transfer of patient on anticoagulants with head injury to hospital. During an interview on [DATE] at 4:12 p.m., the Administrator said he and the DON completed the 72-hour look back on [DATE] and no negative findings were found. She said she received in-service training from Regional [NAME] President of Operations on response protocols for head injuries, falls, and residents on anticoagulants. She said he covered the assessments of residents with head injuries that are on an anticoagulant. She said nurses complete the assessment, and notification to physician and family is completed and documented. She said a QAPI meeting was held on [DATE] via telephone and she, DON, and Medical Director were in attendance. She said daily audits were being completed for 30 days and then weekly for 30 days to ensure compliance with proper transfer of patient on anticoagulants with head injury to hospital. She said findings were going to be documented. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 5:16 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #2) of 4 residents reviewed for accidents in that: -Physical Therapy Assistant performed a two person transfer alone on 08/18/23. Resident #2 suffered right femur fracture that was identified via X-ray on 08/19/23. The noncompliance was identified as PNC. The IJ began on 8/18/23 and ended on 8/21/23.The facility had corrected the noncompliance before the survey began. This failure can place residents at risk of injury, pain, hospitalization and a diminished quality of life. Findings include: Record review of Resident #2's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and was re-admitted on [DATE]. Her diagnoses included Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), type 2 diabetes mellitus without complications (A chronic condition that affects the way the body processes blood sugar (glucose) and pressure ulcer of sacral region, stage 4 (skin injuries that occur in the sacral region of the body, near the lower back and spine). Record review of Resident #2's Comprehensive MDS assessment, dated 5/23/23, revealed Resident #2 had a BIMS score of 7 out of 15 which indicated severely impaired cognition. She required extensive assistance from two person physical assist for transfers. Record review of Resident #2's Care Plan dated 5/17/2022 and revised on 6/3/22 revealed the following: Focus: Resident #2 has an ADL self-care performance deficit r/t Disease Process Goal: The resident will have increased function and endurance with ADL tasks Interventions: TRANSFER: The resident requires (EXTENSIVE assistance) by (1-2) staff to move between surfaces. Record review of Resident #2's Progress notes dated 8/18/2023 at 11:52 pm revealed read in part: .Health Status Note: Xray of right leg done for c/o of pain, resident stated it happen during therapy family aware .RP request xrays be done.MD notified and xrays ordered and were done, results pending . Record review of Resident #2's facility's X-ray results dated 8/19/23 at 9:52 am revealed read in part: .Radiology Interpretation: Acute appearing fracture of the distal femoral metaphysis . Record review of Resident #2's Hospital Records dated 8/19/23 read in part: XXX[AGE] year-old woman with history of vascular dementia, hypertension, CKD, OSA, stage IV decubitus ulcer presented here with right leg pain. Patient resides in a nursing facility and was evaluated by physical therapy and transferred from wheelchair back to bed. While pivoting to her right leg Twisted and reports severe pain after was brought into the ER was noted to have x-rays done which show a minimally displaced predominantly transverse supracondylar fracture in the distal metaphysis. Orthopedic surgery has been consulted by the ER and now awaiting for further evaluation. Given fractures likely patient will be placed in a splint will defer that to orthopedic surgeon for further recommendations. Impression and Plan Diagnosis Femur fracture, right . Record review of Resident#2's PT Evaluation & Plan of Treatment dated 8/15/23 revealed read in part: .Functional Mobility Assessment: Transfers=Did Not Test (Patient at baseline of dependence for OOB with hoyer lift . In an interview on 8/22/23 at 8:14 a.m., with the Administrator, she said Resident #2 was due for quarterly MDS Part B for therapy. She said the Therapy department did an evaluation and the Patient agreed. She said the RP was not notified by the therapy department that the Pt was placed under their services. The Rehab Manager was out, and it was an oversight on their part. She said she called the hospital to confirm if the fracture was on the same knee that happened prior within this year. Hospital said it was new fracture. She said Pt was 2 person transfer but the PTA did one person transfer and had been suspended pending investigation. PTA's last working day was 8/18/23. In a telephone interview on 8/22/23 at 9:01 a.m., with Resident #2's Responsible party, she said last week, the facility started doing physical therapy with the resident. She said the family did not request therapy; the facility initiated it themselves. On Friday evening, 08/18/23, the resident reported her right leg was hurting. She said she removed the covers and noted that her right knee was swollen to the size of small basketball. The leg was also hot to the touch. The resident reported that physical therapy took her to down to therapy. Once back in her room, the therapy staff member got the resident's leg caught under the wheelchair during transfer. The physical therapy staff was transferring the resident to the bed by herself. She said the resident required two people transfer via hoyer lift. The resident's right leg did not move during the transfer and the resident felt her right leg twist around. The resident yelled out in pain. The therapy staff got some bio freeze and put it on her leg. she said she asked a nurse for a stat x-ray. she said she was notified of the x-ray results on 8/19/23. The facility reported a fracture to her right distal femur. Observation and interview on 8/22/23 at 9:21 a.m., with Resident #2 revealed she was resting in bed. She said she had returned from the hospital last night (8/21/23). She said her right leg got caught under the wheelchair while physical therapist was transferring her from wheelchair back to bed. She said she was in pain and the nurse had given her pain medication this morning. In an interview on 8/22/23 at 9:33 a.m., with LVN A, she said Resident #2 required 2 people assist with transfers from shower chair to bed using a hoyer lift. She said resident returned last night (8/21/23) from the hospital. In an interview on 8/22/23 at 9:39 a.m., with CNA CC, she said Resident #2 required 2 people transfer with a hoyer lift and sling. She said resident refused to get out of bed. Resident only got out of bed on her shower days. In an interview on 8/22/23 at 9:43 a.m., with the Rehab Director, she said Resident #2 was receiving services in the past and had gotten a custom wheelchair. She said Resident had wound and the resident laid in bed all the time that put her at risk. She said the Physical Therapist did an evaluation on Resident #2 and added her to the services sometime last week. Record review and interview on 8/22/23 at 9:45 a.m., with the Physical Therapist, she said Resident #2 was due for MDS quarterly screen. She said she found from the nursing staff that resident had not gotten out of bed. Resident only got up for showers. She said in the past resident had received physical therapy and part of the plan was for her to use the custom wheelchair so she could get out of bed. She said resident had wound which the resident laid on all day. She said she felt that resident would benefit from the therapy. She said the protocol was that the Physical Therapist completed the evaluation and created a plan of treatment and the treating Physical Therapy Assistant was to follow that plan of treatment. Physical Therapist reviewed the PT Evaluation & Plan of Treatment dated 8/15/23 with the Surveyor. Physical Therapist said under section Functional Mobility Assessment for Transfers patient was at baseline of dependence for OOB with hoyer lift. Physical Therapist said that meant the Resident was not treated for transfer because there were no goals for transfer. If Resident needed to get out of bed, then the hoyer lift was a safer way. When asked how the Physical Therapist checked to see if Physical Therapist Assistant was following the plan of treatment. Physical Therapist said she read the weekly progress notes to see what PTA had been treating. She said she looked to see if goals have been met or needed to be upgraded which required discussion with Physical Therapist. Physical Therapist said Physical Therapist Assistant was a licensed therapist, she did not need to be followed/spot checked during therapy sessions with Residents. Physical Therapist said she had her own case load and to work efficiently, the treating therapist was assigned one patient at a time and PTA were to follow the Physical Therapist's plan of treatment. She said, it was important to follow the plan of treatment, so PT and PTA were working toward the same goals. It puts them on the same page. She said PTA could have grabbed an aide to assist her with Hoyer transfer. In an interview on 8/22/23 at 10:07 a.m., with CNA DD, she said Resident #2 required a Hoyer lift to move between surfaces. She said Resident#2 always needed 2 persons to assist. She said Resident#2 did not like getting out of bed. She said Resident only got out of bed on her shower days which were Tuesday, Thursday and Saturdays. She said two staff transferred resident from bed to shower chair via hoyer lift on her shower days. In a telephone interview on 8/22/23 at 10:21 a.m., with Physical Therapist Assistant, she said Resident #2 was placed under therapy services sometime last week. She said she asked Resident#2 if she was ready to get up. Resident agreed. She said she moved her blankets, helped her sit on the edge of the bed. She said she performed lateral scoot partial stand pivot transfer with gait belt and draw sheet from edge of bed to wheelchair. When asked if she reviewed the Physical Therapist's plan of treatment dated 8/15/23 under transfer it mentioned the use of hoyer lift when out of bed. PTA said, I did look over it briefly. I scanned PT's evaluation she had sitting balance goal and wheelchair mobility goal. PTA said, I use gait belt on everyone. To increase trunk control and functional independence. PTA said hoyer lift was used when the Patient could not sit up, assist with transfer or can not hold their balance. she said she had worked with Resident#2 in the past and Resident was able to sit up. She said when resident was done eating her lunch. She asked Resident#2 if she was ready to get back in bed. Resident agreed. PTA said she did partial stand pivot with lateral scoot from wheelchair to edge of bed. Once in standing, Resident#2 reported increased pain in her right leg. She said she took her foot and slid her right foot forward to take pressure of resident's leg and assisted with positioning resident onto the edge of bed. Resident reported that right knee was still hurting. She said she tried to reposition for comfort. Placed pillows under knees. She said she asked nurse on duty, if resident could get pain medication as resident was reporting increased pain in the right side following treatment and transfer back to bed. The nurse explained that resident had pain medications prior to treatment and could not get them at that time. She said she asked resident if she would like her to get bio freeze and the resident agreed. She said she applied bio freeze to bilateral knees per request. She said she asked resident again if her pain was better or worse the resident reported that it was a little better but still hurting. In an interview on 8/22/23 at 12:08 p.m., with the DON, she said she found out on Saturday (8/19/23) from the Unit Manager that relied to her that x-ray results showed fracture. She said she was not aware of x-rays order and there was no incident report. She said she was then told about the rehab session on Friday (8/18/23). She said per the resident her legs got caught in wheelchair during transfer. she said after the incident was reported to HHSC on 8/19/23 and the facility began the investigation. She said she interviewed staff to determine the transfer status of Resident #2. She said the facility identified Resident #2 was a 2-person transfer. She said PTA should have asked for help with transfer. Record review of facility's In-service Education Program record dated 8/21/23 conducted by the Administrator on 8/21/23 to staff on Abuse Neglect protocal, Reporting/types of abuse. Record review of facility's In-service Education Program record dated 8/21/23 conducted by the DON on 8/21/23 to staff on Abuse & Neglect/ Transfer/Admssion/ POC documentation. Record review of facility's In-service Education Program record dated 8/21/23 conducted by the Administrator on 8/21/23 to Rehab department revealed read in part: .Therapist/PTA must follow the plan of care for treatment any concern regarding the plan of care must be communicated to DON/ED & MD . Record review of the facility's Safe Lifting and Movement of Residents policy (revised July 2017) read in part: .Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 2. Manual lifting of residents shall be eliminated when feasible.3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan such assessment shall include the following: b. Resident's mobility (degree of dependency): d. Weight-bearing ability: g. The resident's goals for rehabilitation, including restoring or maintain functional abilities. 8. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being charged .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or resident preferences indicated otherwise for 10 of 86 residents (Resident #56, #7, #44, #59, #18, #23, #72, #5, #14, and #45) reviewed for weight loss. 1. The facility failed to obtain accurate monthly weights for Resident #56. 2. The facility failed to ensure Resident #56 had appropriate interventions in place to prevent a severe weight loss of 39.3 % from 10/10/22 to 1/17/23. 3. The facility failed to obtain accurate monthly weights for residents from October 2022 to January 2023. The facility identified 10 (Residents #56, #7, #44, #59, #18, #23, #72, #5, #14, and #45) of 86 residents sustained significant and/or severe weight loss when an accurate weight was obtained by facility staff in January 2023. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 1/18/23 to 1/20/23. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of severe weight loss, delayed interventions, hospitalization, worsening health condition, and death. Findings include: Record review of Resident #56's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #56 had diagnoses which included Alzheimer's disease, unspecified severe protein-calorie malnutrition (1/21/21), vitamin B-12 deficiency anemia (11/16/21), anorexia (an eating disorder characterized by relentless drive for thinness with a fear of gaining body weight associated with self-induced behaviors towards thinness), weakness (12/2/20), vascular Parkinsonism (a disorder that affects muscle movement), and hospice care. Record review of Resident #56's quarterly MDS assessment, dated 12/8/22, revealed a BIMS score of 0 out of 15, which indicated severe cognitive impairment. She required extensive assistance of one person for eating. The assessment indicated no symptoms of poor appetite and no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Record review of Resident #56's care plan, revised on 1/22/23, revealed she had a potential for nutritional problem related to inadequate meal intake. Interventions were to have the RD (registered dietitian) evaluate and make diet change recommendations PRN and weigh and record: monthly and PRN. Record review of Resident #56's weight summary revealed the following: 10/10/22: 107.5 pounds 11/2022: no weight recorded 12/2022: no weight recorded 1/17/23: 65.2 pounds There was a calculated weight loss of 39.3% over 3 months. Record review of Resident #56's nutritional assessment, dated 2/28/22, written by the RD revealed a weight of 115.7 pounds and a BMI of 29 (normal BMI range was 23 - 30). Resident #56 was reviewed for her annual assessment. The RD documented the resident was readmitted to hospice. There was no significant weight loss but some weight loss with overall decline was expected with hospice and diagnosis. Record review of Resident #56's hospital record, dated 9/2/22, revealed a weight of 85 pounds. Record review of Resident #56's multidisciplinary care conference, dated 12/12/22, revealed the resident's appetite was fair. Her oral intake was 25-50%. Her weight was recorded at 107.5 pounds (from October 2022). There were no issues at the time. Patient was on hospice services. Record review of the facility's nutrition recommendations from August 2022 - January 10, 2023, revealed no dietary recommendations were made for Resident #56. Record Review of Resident #56 Hospice Records dated 1/2/23 revealed Resident gargling when she drinks water and unable to tolerate but able to eat regular food. HN recommended to change thin liquid to thickened liquid and was approved. Resident appears to be weak and frail and sleeps +12 hours a day. Record review of Resident #56's nutrition/dietary note, dated 1/18/23, written by the RD read in part, .CBW (current body weight) is at 65.2 pounds, -39.3% in 90 days, -40.8% in 180 days. BMI is below favorable for age at 16.3. Noted facility recently had scale recalibrations. Resident also on hospice care at this time . weekly weights ordered to monitor and re-establish baseline. Resident is on a regular, mildly thick liquid diet and has PO intake average at less than 50% but varies with sometimes increased intake. No recent labs, noted hospice. Resident with sacral and hip wounds being followed by wound care. Weight loss with overall decline is expected with hospice. Recommend magic cup TID with meals. Recommend increase 2.0 supplement to 60 cc TID related to weight loss. Recommend snacks of preference as desired. Goal is for resident to enjoy meals and supplements for comfort care. RD will continue following this resident Record Review of Resident #56 laboratory results dated [DATE] revealed resident's pre-albumin level was 7.2 mg/dL (normal range 17.0 - 34.0) and her albumin level was 2.5 mg/dL (normal range: 3.5-5.7). (The prealbumin blood test helps determine if you ' re getting enough nutrients -- namely, protein -- in your diet. Albumin is a protein in the blood plasma.) Record review of Resident #56's arm body mass measurements summary measured by hospice revealed (upper-arm circumference roughly correlates with BMI in the average person. A measure below 23.5 centimeters indicates that the person may be underweight or borderline underweight with a BMI of 20 or lower): 01-03-23 13.5 cm 01-02-23 13.5 cm 12-27-22 13.5 cm 12-07-22 14 cm 12-05-22 14 cm 11-21-22 14 cm 11-14-22 14 cm 11-28-22 14 cm 10-24-22 14 cm 09-29-22 14.5 cm 08-29-22 15 cm In an interview on 1/22/23 at 3:21 p.m., the Administrator said the previous ADON oversaw a lot of the facility's systems and was recently let go. He said the facility noticed significant discrepancies in the weight logs and submitted a self-report to the state survey agency. He said the weight logs reflected some residents were repetitively documented as weighing the same every month. He said approximately 34 residents were identified with weight changes in January, all were reweighed, and would be weighed every Thursday for the next 4 weeks. He said the identified concern was taken to quality assurance, in-services were done, and the RD was consulted. In an interview on 1/22/23 at 3:22 p.m., the Corporate Nurse said it appeared the previous staff responsible for weights were making up weights. He said a QAPI was done, and the facility was aggressively working to turn it around. He said both persons involved were terminated. In an interview on 1/23/23 at 1:18 p.m., the RD said the DON and Administrator notified her of a weight discrepancy this month when they had someone else weigh the residents. She said she did an intervention for approximately 35 residents who had significant weight loss and said some residents needed more supplements than others. She said Resident #56's weight loss was not seen or documented (prior to the discovery). She said the resident was on hospice services but made recommendations for hospice residents the same way as non-hospice residents. She said she did not want the resident to starve to death and her meal intake flexed up and down. She said, prior to the facility becoming aware of the weight discrepancy in January 2023, she did not assess Resident #56 and said there were no dietary recommendations for the resident between August 2022 and January 2023 because the resident did not flag for weight loss. The last Nutrition assessment was completed on 2/28/22. The RD said she only assessed residents for weight or nutritional needs if there was a referral from the facility based off a trigger of significant weight gain or loss. She said skin issues and abnormal laboratory values could be a negative outcome of the untreated weight loss. She said the dietitians came to the facility three times a month and reviewed admissions, readmissions, annuals, weight loss, dialysis, pressure wounds, tube feedings, and any consults. She said residents were reviewed annually if there was no weight loss identified. She said the review consisted of interpreting the BMI, identifying weight goals, diet order, preferences, reviewing supplements, laboratory values, skin for pressure wounds, and nutritional needs. In an interview on 1/24/23 at 11:30 a.m., the Administrator said he terminated the previous ADON on 1/3/23 due to integrity issues. He said they noticed a big discrepancy with actual weights and recorded weights. He said as they reviewed the weight logs, they noticed the previous RA was the one consistently entering the weights. He said the previous staffing coordinator weighed most of the residents and asked other CNAs to give her weights. He said during their QAPI meetings prior to the discovery, there were no alarms of weight loss. The previous ADON and previous RA were responsible for accuracy of weights. He said the previous ADON was the analyzer and should have been reviewing dietitian recommendations, physician notes, and overseeing the weight system. He said Resident #56 currently weighed 65 pounds. He said the wound care nurse conducted a head-to-toe assessment of the resident and said she did not have any new pressure ulcers but did have excoriation (damage or remove part of the surface of the skin). In an interview on 1/24/23 at 1:27 p.m., the RD said it was normal for hospice resident's dietary plans to be reviewed only annually. It would be reviewed more if there were concerns noted. She said, at the time, there were no concerns noted for Resident #56. In an interview on 1/24/23 at 3:07 p.m., the DON said she began employment with the facility in September 2022. She said the previous ADON was responsible for obtaining the weight data from the floors and ensuring the data was entered into PCC. She said she became suspicious of the weights in January 2023 because there was a delay in obtaining the weights of newly admitted residents, in addition to other concerns. She assigned a new team to obtain resident weights and noticed discrepancies in previously documented weights and current weights. She said upon review of previous weights they found several resident weights did not fluctuate more than 0.1 to 0.3 pounds in a 2-year period. She said in her professional opinion those were not realistic weight fluctuations. The DON said prior to December 2022, no one identified any weight changes, and no one reported changes in condition related to skin turgor, change in overall appearance, dehydration, lethargy, decrease activity, or skin impairment to her. During the QAPI meetings no issues were reported with the weights. She said she acknowledged there was a weight loss in some residents but questioned a lot of the weights. She said on 1/18/23 it was discovered Resident #56 had severe weight loss. She said Resident #56 was on hospice care and had a progressive decline in her ADLs and ability to mobilize. She said she had a history of not eating a lot and her family brought in food from home that she liked. She said she consulted with the MD and families and did not think any of the residents were harmed due to the unidentified weight loss. She said she would need to speak with Resident #56's MD about her decline to determine if it was a progression of her illness. In an interview on 1/24/23 at 3:15 p.m., the Corporate Nurse said the MDs and families did not report any concerns regarding weight loss. He said he spoke with the previous Staffing Coordinator and was informed she weighed over half of the residents. He said he could not confirm the integrity of the weights. In an interview on 1/24/23 at 3:17 p.m., the RD said the staff reported meal intake issues to her. She said Resident #56's dietary recommendations would depend on her nutritional needs. She would recommend fortified meals if the resident was still eating and then after that supplements, ice cream, and med pass 2.0. In an interview on 1/25/23 at 10:47 a.m., the NP said she recently started seeing Resident #56. She said the resident was on hospice care due to dementia and did not want to do aggressive measures such as inserting a PEG tube. She said she expected the resident to decline with normal process. She said she referenced the monthly weight to ensure the resident was not losing too much weight. She said a significant weight loss or a drop of 40 pounds in a month would raise red flags. She said she would do a dietary consultation and if the RD made recommendations, they would get approval from hospice. She said she would also try Remeron (an appetite stimulant) if hospice approved. She said she would recommend these interventions to prevent the resident from losing too much weight but if hospice did not think it was appropriate, they would not implement it. She said with residents on hospice you want to ensure the quality of life but not prolong life. In an interview on 1/25/23 at 11:33 a.m., Resident #56's RP said the family noticed the resident was losing weight but could not tell how much. He said the resident lost more weight than he expected and said he was shocked to learn how much. He said the resident's normal weight was 115 pounds, but the facility recently informed him she weighed 75 pounds. He said the resident was put on hospice care because he and his family member were unable to see the resident during COVID-19 and the facility nurse said if the resident was put on Hospice care another nurse would come in and make her comfortable. He said he and his family member made a plan to encourage the resident to eat more because she slept so much and would gradually eat less and less. He said around the start of COVID-19, she lost a lot of weight but was still responsive and could walk around. He said the facility did not say what they would do to help with her appetite. He said when he was at the facility, he tried to assist her with meals and notified the CNAs when she would not eat well. He said they informed him they would try to get her to eat later. He said the resident got weaker and every time she walked around, she would fall and go to the hospital. He said he wanted the resident on physical therapy to walk and move around again so he removed her from hospice, but when she plateaued in therapy the facility convinced him to place her back on hospice. He said she had not been able to get out of bed very often because of unsteadiness. He said he had a care plan meeting in the past to discuss her diet preferences, such as no bones in her chicken and no spicy foods, but they did not discuss her specific dietary requirements. He said last Wednesday, 1/18/23, the facility changed her diet to a higher calorie, soft food diet which the resident took to very readily. He said she took everything on her plate on Friday, 1/20/23 but was unable to wake her to eat on Monday 1/23/23. He said she used to be able to feed herself and would eat the regular diet. He said he expressed to the facility there must be a high calorie diet that would help her eat, because the amount she was eating was small. He said he informed the facility that whatever they could do to help with her nutrition would be great. He said the hospice agency did not specifically say the resident would progressively lose weight. In an interview on 1/25/23 at 12:06 p.m., CNA A said she noticed Resident #56 lost weight and reported it to LVN A. She said the resident did not eat too much. She said last month the resident ate approximately 75% of a meal she assisted her with. She said she noticed the resident did not eat by herself but previously did not like when people fed her. In an interview on 1/25/23 at 12:29 p.m., LVN A said she noticed a few residents lost weight on her hallway not too long ago, which included Resident #56. She said she normally reported weight loss concerns to the resident's hospice nurse. She said Resident #56 was always fatigued and would refuse everything with feeding. She said her meal intake was around 25% but she liked to drink. She said her weight loss was obvious when the staff got her up to weigh her last week. She said she did not know who weighed the residents prior to January 2023. She said the RP would come to ensure she got enough food. She said the resident was on med pass 2.0 and the hospice nurse started her on Sucralfate. She said she was supposed to report weight concerns to the facility doctor and the hospice nurse, and they would schedule blood work and send it to the doctor. She said she was not sure when to notify the RD. She said she reported Resident #56's weight concerns to the previous ADON and was informed to notify hospice and the resident's doctor. She said the previous ADON did not say anything about informing the RD. She said the RD monitored the food the residents ate and monitored the weight. Based on the weights they could tell if the patient was going up or down. She said the CNAs would report Resident #56's appetite changes to her. She said she reviewed Resident #56's weight and noticed the weight was previously around 100 and now it went down to 67. She said she knew the resident was losing weight based on her intake but never questioned the weights in the system because they looked right. She questioned the amount of weight she lost because it was a lot. She said she was recently in serviced on reporting weight concerns to the RD and conducting an assessment when there was a decline. In an interview on 1/25/23 at 2:00 p.m., Resident #56's Hospice Nurse said she assessed Resident #56 for the last 2 years. She said in the last 3-4 months Resident #56 had a decline in appetite and weight loss. The Hospice Nurse said the resident declined food and had low food intake. The Hospice Nurse determined the resident had a decline in body mass based off the mid-upper arm circumference body mass checked every 2 weeks during hospice visits. She said she received weight updates from various CNAs and nurses when she visited the resident. The last weight recording the Hospice Nurse recalled was approximately 97 pounds from the resident's recent hospital visit (exact date unknown). In an interview on 1/25/23 at 4:09 p.m., the DON said she was not previously aware of any weight changes for Resident #56. She said the Hospice Nurse, previous ADON, and charge nurses did not report any information about Resident #56's weight or appetite changes to her. She said if she was aware of the weight or intake changes, she would have notified the physician and obtained appropriate referrals such as for the RD. In an interview on 1/26/23 at 9:31 a.m., the previous ADON said she never weighed residents or documented weights. She said she only followed up on any recommendations from the RD if the RD saw weight loss or weight changes and if she wanted supplements or adjustments made. She said any CNA on the hall did the weights then gave those weights to the previous Staffing Coordinator. In an interview on 1/26/23 at 10:00 a.m., the previous Staffing Coordinator said the facility told her she falsified resident weights. She said she documented weights in the system when the CNAs gave them to her. She said she did weigh some residents and a lot of their weights changed. She said she recorded weekly weights in a binder but corporate was destroying papers in her old office when she was suspended. She said the scales were not calibrated and there was always an issue with the Hoyer lift scales jumping up and down. She said the last time she weighed Resident #56 was in November because the RD said she did not have to weight hospice residents. In an interview on 1/26/23 at 11:12 a.m., the DON said because of the internal audit, weights would be obtained on admission, the day after, and weekly for 4 weeks. She said she would review the weights and look at consistency in weighing procedures (i.e. hoyer lift, wheelchair scale, and same time of day). She said the DON, Administrator, or designee would be responsible for weekly spot checks of weights on each hall. She said they would select a resident and verify their weight with another person. In an interview on 1/26/23 at 11:24 a.m., the DON said the previous Staffing Coordinator was not the only person weighing residents but was the person who made sure the weights were done and entered in the system. She said the previous Staffing Coordinator worked with different CNAs to obtain weights. She said after the facility identified the weight discrepancies, she educated the lead nurses on how to identify weight loss and when to report. She said the scales were calibrated quarterly and no one ever reported any issues with the scale. Record review of the 10 residents identified with weight loss revealed new dietary physician orders were obtained and entered and care plans updated. Record Review of Resident #7 revealed was a [AGE] year-old female admitted on [DATE] with diagnoses mobility (severe) obesity due to excess calories, moderate protein- calorie malfunction, gastrostomy status, chronic kidney disease stage 3 unspecified, and gastro-esophageal reflux disease without esophagitis. Record Review of Resident #7 weights revealed that resident had a weight loss of 37.2% weight loss from 12/05/22 to 01/18/23. Resident #7 weight 155.5 lbs. dated 01/18/23 and 247.7 lbs. dated 12/05/22. Record Review of Resident #44 revealed was a [AGE] year-old female initially admitted on [DATE] with diagnoses chronic diastolic (congestive) heart failure, morbid (severe) obesity due to excess calories, vitamin B12 deficiency anemia, unspecified, vitamin D deficiency, unspecified gastro-esophageal reflux disease without esophagitis, and muscle weakness (generalized). Record Review of Resident #44 weights revealed that resident had a weight loss of 36.9% weight loss from 10/10/22 to 01/18/23. Resident #7 weight 201 lbs. dated 01/19/23; 318.6 lbs. dated 12/12/22; 317.57 lbs. dated 11/07/22 and 318.8 lbs. dated 10/10/22. Record Review of Resident #59 revealed was a [AGE] year-old female initially admitted on [DATE] acquired absence of left leg below knee, acquired absence of right leg below knee, cerebral infarction, unspecified, essential primary hypertension, anemia in other chronic diseases classified elsewhere, slow transition constipation, pressure of artificial left leg (complete) (partial), encountered for surgical aftercare following surgery on the digestive system, iron deficiency, anemia, unspecified, abnormal posture, muscle weakness (generalized), bed confinement status, Record Review of Resident #59 weights revealed that resident had a weight loss of 17.8% weight loss from 09/08/22 to 01/17/23. Resident #59 weight 97.6 lbs. dated 01/17/23; 118.8 lbs. dated 12/12/22; 119 lbs. dated 11/09/22; and 119.8 lbs. dated 09/28/22. Record Review of Resident #18 revealed was a [AGE] year-old male initially admitted on [DATE] with diagnoses of unspecified severe protein-calorie malnutrition, chronic kidney disease, stage 3 unspecified, anemia in chronic kidney disease, and benign prostatic hyperplasia without lower urinary tract symptoms, Record Review of Resident #18 weights revealed that resident had a weight loss of 18.5% weight loss from 10/14/22 to 01/19/23. Resident #18 weight 149.4 lbs. dated 01/19/23; 183.3 lbs. dated 12/10/22; 184.0 lbs. dated 11/09/22; and 184.4 lbs. dated 10/14/22. Record Review of Resident #23 revealed was a [AGE] year-old female admitted on [DATE] with diagnoses of heart failure, single episode, unspecified, gastro-esophageal reflux disease without esophagitis. Record Review of Resident #23 weights revealed that resident had a weight loss of 10.1% weight loss from 10/10/22 to 01/17/23. Resident #23 weight 145.2 lbs. dated 01/17/23; 161.5 lbs. dated 12/10/22; 161.9 lbs. dated 11/07/22; and 161.6 lbs. dated 10/10/22. Record Review of Resident #72 revealed was a [AGE] year-old female admitted on [DATE] with diagnoses of deficiency of vitamin K, aphasia, muscle weakness generalized, cognitive communication deficit, and dysphonia, oropharyngeal phase. Record Review of Resident #72 weights revealed that resident had a weight loss of 22.1% weight loss from 10/10/22 to 01/17/23. Resident #72 weight 106.2 lbs. dated 01/17/23; 136.3 lbs. dated 12/09/22; 136.8 lbs. dated 11/09/22; and 136.3 lbs. dated 10/10/22. Record Review of Resident #5 revealed was a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes mellitus without complications, vitamin D deficiency, unspecified, and muscle weakness (generalized). Record Review of Resident #5 weights revealed that resident had a weight loss of 22.4% weight loss from 10/10/22 to 01/17/23. Resident #43 weight 143.4 lbs. dated 01/17/23; 176.8 lbs. dated 12/09/22; 176.2 lbs. dated 11/09/22; and 176.8 lbs. dated 10/10/22. Record Review of Resident #14 revealed was an [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes,unspecified severity protein calorie value function now nutrition mode morbid severity obesity due to excess calories, anemia and other chronic diseases classified elsewhere, vitamin D deficiency, other specified disorders of bone density and structure, unspecified site, other specified disorders of bone intensity and structure, unspecified site, bed confinement status, and muscle weakness (generalized). Record Review of Resident #14 weights revealed that resident had a weight loss of 27.5% weight loss from 9/9/22 to 01/19/23. Resident #43 weight 122 lbs. dated 01/19/23; 190 lbs. dated 11/09/22; 190.6 lbs. dated 10/10/22; and 191.8 lbs. dated 9/9/22. Record Review of Resident #45 revealed was an [AGE] year-old male admitted on [DATE] with diagnoses of heart failure, unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris, type 2 diabetes mellitus with diabetic neuropathy, unspecified, Record Review of Resident #45 weights revealed that resident had a weight loss of 27.5% weight loss from 11/7/22 to 01/19/23. Resident #45 weight 97 lbs. dated 01/19/23; 134.3 lbs. dated 12/10/22; 134.3 lbs., and 134.0 lbs. dated 11/7/22. Record Review of the facility's, undated, Weight Assessment and Intervention Policy Statement revealed: Weight Assessments 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 5. The dietitian will review the unit weights record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for 'significant' weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss =(usual wight - actual weight) / (usual weight) x 100]: a. 1 month - 5% weights loss is significant; greater than 5% is severe. b. 3 month - 7.5% weights loss is significant; greater than 7.5% is severe. c. 6 month - 10% weights loss is significant; greater than 10% is severe. Record Review of the facility's, undated, Weighing and Measuring the Resident Level II. revealed Preparation 4. Weight is usually measured upon admission and monthly during the resident's stay. Documentation: The following information should be recorded in the resident's medical record. 2. The name and title of the individual(s) who performed the procedure. Record Review of the facility's, undated, Nutritional Assessment Policy Statement revealed: As part of the comprehensive assessment and nutritional assessment including current nutritional status and risk factors for impaired nutrition shall be conducted for each resident A. Nursing: (1) usual body weight (2) current height and weight (3) a description of the resident's usual intake and appetite (4) a history of reduced appetite or progressive weight loss or gain prior to admission (5) current clinical conditions and recent events that may have affected the residents nutritional status and risk factor (7) general appearance under scription of the residence overall appearance (8) the residents usual routine(s) intake (e.g. , oral, enteral, parenteral). Record Review of In-Service Education Program Record dated 1/18/23 Instructed by DON on the subject of Weight Assessment and Interventions and Review of Facility Policy and Procedures for Obtaining Resident Weights, Signs and Symptoms of Weight Loss of Resident and reporting Suspected wight Loss . Record Review of Statement of Inservice Training for Employees dated 1/20/23 Instructed by DON on the subject of Weight Assessment and Interventions and Review of Facility Policy and Procedures for Obtaining Resident Weights, Signs and Symptoms of Weight Loss of Resident and reporting Suspected wight Loss . This was determined to be a Past Noncompliance IJ that began on 1/18/23 and ended on 1/20/23. The Administrator was notified on 1/26/23 at 5:37 p.m. The Administrator was provided with IJ template on 1/26/23 at 5:37 p.m. No plan of removal was required.