Vernon Green Nursing Home

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that nurses and LNAs possessed and demonstrated appropriate competencies for resident care, including medication-related tasks. State statutes require that nursing assistants be licensed and, to administer medications in a nursing home, complete a Board‑approved medication administration program, pass an examination, and be endorsed by the Board as medication nursing assistants. For one resident with an order for 4% lidocaine patches to be applied to both hips at bedtime for 12 hours on and 12 hours off, the assigned nurse stated that LNAs remove the lidocaine patches, but no LNA had reported patch removal to the nurse. During observation, the nurse entered the resident’s room to administer oral medications and did not check for or remove the lidocaine patches before or after medication administration. Review of the facility’s LNA job description showed no mention of assisting with medication administration, and review of training and competency records for five sampled LNAs revealed no training regarding medication administration or assisting with medication administration. The Administrator confirmed that no LNAs in the facility were certified or trained to assist with medication administration, including removal of lidocaine patches. The deficiency also includes a lack of documented competency assessments for nursing staff. Review of employee training and competency files showed that an RN hired in mid‑December had no proof that the facility had assessed her skills competency, even though she was already working shifts. Additionally, one of five LNA files reviewed contained no proof of completed competency assessments for two consecutive years and no evidence of related training. The DON reported that new staff are given a packet of competencies to complete with a preceptor and then return, but confirmed that the RN had not yet submitted her competencies and that the LNA had no competency documentation for the specified years.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency in the facility’s failure to maintain cleanliness of the kitchen, food preparation area, and dish storage area in accordance with professional standards. During an initial kitchen tour, a large metal box-style vent located above and to the right of a rack of clean plate covers was observed with vent grates covered in dust and several pieces of a white flaky substance. A kitchen staff member confirmed that dust and flaky material from this vent could fall onto the clean dishes and cause contamination. On a follow-up tour, surveyors observed ductwork with three vents running across the width of the kitchen over food preparation areas and dishwashing stations, with all three vent registers covered in dark substances and dust. The kitchen manager acknowledged that the dark substance and dust on these vents had the potential to contaminate food preparation and dishwashing areas and was unable to state when the vents were last cleaned. The maintenance supervisor also confirmed that the kitchen vents needed to be cleaned.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to timely develop, review, and revise comprehensive care plans based on residents’ changing conditions, despite an existing policy requiring an interdisciplinary team to do so. For one resident with anemia, GERD, a chronic left foot ulcer, and other malaise, a significant weight loss occurred between two recorded weights, dropping from 123.6 pounds to 114.4 pounds in 15 days, which meets CMS criteria for significant weight loss. Although this resident already had a care plan problem identifying risk for weight changes and an approach to monitor for sudden weight loss, the dietitian’s progress note later documented the weight loss and acknowledged awareness of it, yet the care plan was not updated with any new interventions. The DON stated there should have been a dietitian progress note in December addressing the significant weight loss, and the dietitian admitted awareness of the weight loss and that a note should have been written. Another resident with unspecified dementia, repeated falls, history of falling, weakness, and unsteadiness on feet had a care plan problem identifying fall risk related to decreased safety awareness. This resident sustained eight documented falls over a three‑month period, including unwitnessed falls in a bathroom and next to the bed, a fall with a “goose egg” or presumed hematoma to the head, a fall forward out of a wheelchair, and multiple other falls in the hallway, outside the room, and while attempting to get out of bed. Despite the repeated falls and detailed nursing progress notes describing each event and associated injuries or lack thereof, there were no new interventions documented in the resident’s care plan after any of these falls. In an interview, the DON confirmed that the care plan should have been updated after each fall but was not. A third resident identified as at risk for falls due to decreased cognition, poor safety awareness, and needing encouragement to sit or rest had four fall‑prevention interventions in the care plan, all dated the same day. Progress notes later documented that this resident fell while sleeping in a chair, leaning forward and hitting the right frontal head on the floor, resulting in a quarter‑sized bump, and then fell again two days later after a bed alarm sounded, with staff finding the resident on the floor next to the bed and noting a quarter‑sized abrasion to the forehead. Review of the care plan showed no updates or additional interventions added after either fall, and the DON confirmed the care plan was not updated following these events. A fourth resident with severe cognitive impairment (BIMS score of 99), dependent for ADLs and hygiene, and diagnoses including dementia, history of TIA and cerebral infarction, and major depressive disorder experienced an acute change with facial droop and nonresponsiveness. Nursing progress notes described right‑sided facial droop, nonverbal status, and suspicion of a stroke, with documentation that the POA did not want hospital transfer and requested comfort measures. A physician late entry progress note further documented that staff suspected a cerebrovascular infarction, that the DPOA declined hospital transfer, and that comfort measures were to be initiated and the resident remain at the facility due to advanced dementia and declining quality of life. Despite this clear shift to comfort care, review of the resident’s care plan revealed no information indicating the resident had been placed on comfort care, and the DON confirmed that the care plan was not updated to reflect this change. The facility’s own care planning policy, which requires the interdisciplinary team to develop individualized comprehensive care plans based on the comprehensive assessment, was not followed in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of a shared electric shaver for multiple residents. During observation in the B-Wing shared shower room, an unlabeled electric razor was seen on a shelf by the bathtub, and a Registered Nurse confirmed that this shaver was used on multiple residents when they needed a shave. Two LNAs further stated that the shaver was used for residents who needed a quick shave after their bath and that they cleaned it between residents using only an alcohol pad. Review of the facility’s Infection Control Policy, issued 3/16/2020, showed that equipment likely to be contaminated with infectious body fluids must be handled to prevent transmission of infectious agents, including proper sterilization before use on another patient. In an interview, the DON reported she was not aware that staff were using this specific shaver or that it was being shared among residents, and she confirmed that cleaning the shaver with an alcohol pad between uses was not an appropriate or effective method, demonstrating a failure to ensure appropriate disinfection of shared resident care equipment. No specific resident medical histories or conditions at the time of the deficiency were described in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency related to inadequate mechanical ventilation on the licensed memory care unit (B‑Wing), where a strong odor of mildew was noted upon entering the unit and a combined mildew and urine odor was present down the entire hall near a specific resident room. The damp, musty, and urine smells persisted throughout the survey period. During an interview and walkthrough with the Director of Maintenance, he explained that some incontinent residents urinate on the carpet in various locations, and staff use carpet extractors to clean the rugs, attempting to do so immediately and more extensively in the evening. He reported difficulty getting the carpets to dry in the winter because windows cannot be opened and the HVAC system cannot be run as frequently without making the environment too cold for residents, and he confirmed that the dampness and odors have been an ongoing issue. He also stated that he does not keep a log of how often the ventilation system is run. These observations and statements show that the facility did not ensure adequate mechanical ventilation or effective odor control on the memory care unit, resulting in persistent dampness and strong mildew and urine odors in resident care areas.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a cognitively impaired resident from abuse during personal care. The resident had a BIMS score of 1 and diagnoses including dementia, Alzheimer's disease, and depression, and was dependent on staff for ADLs and hygiene. According to the facility’s internal investigation and witness statements, during an evening shift the resident required two showers due to bowel incontinence. During the second shower, the resident became agitated and attempted to pull on the shower hose and pipes. In response, one LNA, who reported feeling frustrated, sprayed the resident in the face with freezing cold water while another LNA assisted as the resident tried to rip the hose from the first LNA’s hands and continued pulling on the pipes. Per the witness statement, both LNAs involved in the shower incident later laughed about what had occurred while giving report to another staff member, and the resident expressed a desire to apologize to someone without knowing to whom. A subsequent addendum to the investigation documented that the resident was later noted to have five bruises on the left forearm in healing stages, which were assessed as likely related to staff holding the resident’s arm to prevent them from grabbing the water hose during the same shower incident. The resident was reported as having no recollection of the incident and no pain at the time of assessment. The DON confirmed during interview that the abuse occurred and stated that the allegation was substantiated.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to send a required discharge notice to the Long-Term Care Ombudsman for a resident who was discharged home. The resident had a BIMS score of 15, indicating no cognitive impairment, and medical diagnoses including non-ST elevated myocardial infarction and unspecified dementia, and was independent with ADLs and hygiene. Social services documented that the resident would be returning home with services, assistance from a friend, and transportation support, and that the resident and family representative were aware of the need to schedule a follow-up PCP appointment. An administrative note later documented that the resident was discharged. Review of the facility’s Documentation of Transfers and Discharges policy showed no requirement to send transfer or discharge notices to the Ombudsman, and in an interview, social services confirmed that the Ombudsman was not informed of the discharge and stated she did not know this was required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure required Preadmission Screening and Resident Review (PASARR) documentation was completed and present in the medical records for two of five sampled residents, identified as Residents #5 and #48. Record review showed that neither resident’s chart contained a PASARR, which is a federal requirement used to ensure that individuals with serious mental illness or intellectual/developmental disabilities are appropriately screened and directed to the most suitable setting with needed specialized services. A Level 1 PASARR screening is intended to identify conditions that require specialized services. During an interview, the Director of Social Services confirmed that all residents are required to have a Level 1 PASARR screening completed before admission. She explained that for new admissions from the community, she conducts the PASARR interview starting with the Level 1 screening. She further confirmed that PASARR documents were not present in the charts of Resident #5 and another resident (also referenced as Resident #109), verifying that the required screenings and documentation had not been completed or maintained for these residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves failure to ensure professional standards were maintained in the delegation and documentation of nursing duties related to medication administration for one sampled resident. The resident had a physician’s order for Lidocaine 4% external patches to be applied to the left and right hips at bedtime, to remain on for 12 hours and then be removed for 12 hours. Review of the Medication Administration Record (MAR) showed that licensed nursing staff documented application of the Lidocaine patches at 8:00 PM on January 12, 2026. On the morning of January 13, the staff nurse responsible for the resident stated that Licensed Nursing Assistants (LNAs) remove the Lidocaine patches and acknowledged having no concern about signing off on the MAR for patch removal before verifying that LNAs had actually removed them. The staff nurse also stated that no LNA had reported removing the patches, yet the nurse marked the electronic MAR order for removal of the two Lidocaine patches as completed at 7:59 AM on January 13, 2026. Observation at 9:14 AM on January 13 showed the staff nurse entering the resident’s room to administer oral medications and leaving the room without checking for or removing the Lidocaine patches. Review of the facility’s LNA job description revealed no mention of assisting with medication administration, and review of training and competencies for five sampled LNAs showed no training on medication administration or assisting with medication administration. The administrator and DON both confirmed that no LNAs in the facility were certified or trained to assist with medication administration, including removal of Lidocaine patches, and that delegating this task to LNAs was outside their scope of practice and job description. The DON further confirmed that facility policy requires medications to be administered only by persons legally authorized to do so, and that the staff nurse’s delegation of patch removal to an unqualified LNA and subsequent documentation of completion without verification violated facility policy and accepted professional standards.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to keep residents free from accident hazards and to provide adequate supervision and interventions to prevent accidents, particularly falls, for two residents. One resident had a care plan identifying fall risk related to decreased cognition, poor safety awareness, and a need for encouragement to sit or rest, with four fall-prevention interventions dated 12/5/2025. On 1/4/26, progress notes documented that this resident was sleeping in a chair, leaning forward, and fell to the floor, striking the right frontal head and developing a quarter-sized bump on the right lateral forehead. Despite this fall, no new interventions were added to the care plan. Two days later, at 4:30 a.m. on 1/6/26, the bed alarm sounded and staff found the same resident sitting on the floor next to the bed with a quarter-sized abrasion on the left forehead, and again, the care plan showed no new interventions to prevent future falls. Another resident with diagnoses including unspecified dementia with behavioral disturbance, repeated falls, history of falling, weakness, and unsteadiness on feet had a care plan problem stating the resident was at risk for falling due to decreased safety awareness. Between 9/29/25 and 12/27/25, this resident sustained eight documented falls, including being found sitting on the floor next to a wheelchair in a former room, on the bathroom floor of a former room, on the floor next to the bed with a head injury and headache after attempting to get into bed, on the floor on knees and forehead in front of the wheelchair, falling forward out of the wheelchair, sitting naked on the floor outside the room after incontinence, losing balance and falling while walking out of another patient’s room, and rolling out of bed while attempting to get out of bed. Record review showed no documented new interventions added to the resident’s care plan after any of these falls. In an interview, the DON confirmed that there were no new interventions implemented after the falls for either resident and acknowledged that new interventions should have been attempted after each fall.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement interventions and update the care plan after a resident experienced a significant weight loss. The resident had diagnoses including anemia, GERD, a non-pressure chronic ulcer of the left foot, and other malaise, all of which present a risk for weight loss. The resident’s weight decreased from 123.6 pounds on 12/7/25 to 114.4 pounds on 12/22/25, a loss of 9.2 pounds or 7.4% in 15 days, which meets the MDS definition of significant weight loss. The resident’s care plan, dated 10/30/24, already identified risk for weight changes and altered fluid status due to variable meal intake related to physical limitations and cognitive/mood state, and included approaches to monitor for sudden weight loss, weigh per physician orders, and report significant weight changes to the physician and family. Record review showed that the dietician documented a weight warning on 12/29/25 noting the 12/22/25 weight of 114.4 pounds and the percentage changes from prior weights. However, the resident’s care plan was not updated to include any new interventions in response to the significant weight loss, and the record did not show that the physician or family were notified of the weight change as required by the care plan. During interview, the DON stated there should have been a dietitian progress note in December addressing the significant weight loss. In a separate interview, the dietician reported being aware of the weight loss and stated that, after discussing it with the resident who did not want additional interventions and preferred to wait and see if weight increased, no note was written documenting this discussion or decision.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure medication error rates remained below 5%, with surveyors identifying 2 errors in 32 opportunities (6.25%). Facility policy required medications to be administered safely, timely, and as prescribed, in accordance with good nursing principles and practices. For one resident, physician orders directed application of 4% lidocaine patches to the left and right hip at bedtime, to be on for 12 hours and off for 12 hours, with removal per schedule. The MAR showed that nursing staff documented application of the patches at 8:00 PM on January 12, 2026. The following morning, the staff nurse stated she had no concern signing off on removal of the lidocaine patches before checking whether the two patches were present and reported that no LNA had told her they removed the patches. She then documented completion of the removal order on the electronic MAR at 7:59 AM on January 13, 2026. Observation at 9:14 AM showed the same nurse entered the resident’s room to administer oral medications and did not check for or remove the lidocaine patches before or after the medication pass. For another resident, physician orders directed application of a 4% lidocaine patch to the mid-back at bedtime for pain, with removal every morning. The MAR showed that nursing staff documented application of the lidocaine patch at 8:00 PM on January 12, 2026. During observation the next morning at 9:24 AM, the staff nurse entered the resident’s room to administer oral medications and attempted to remove the lidocaine patch but was unable to locate it. Despite not confirming that the patch was present or removed, the nurse documented on the MAR that the removal order had been completed. In an interview, the DON confirmed that the lidocaine patch orders for both residents were not completed as ordered and that the RN erred in documenting removal of the patches on the MAR.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement 14-day stop dates on prescribed as-needed (PRN) psychotropic medications for three residents. Resident #24, diagnosed with Alzheimer dementia, was prescribed Quetiapine without a documented stop date or rationale for extending the medication. Similarly, Resident #205, with a diagnosis of Lewy body dementia, had PRN orders for Trazodone and Risperidone without stop dates. The Director of Nursing confirmed the absence of stop dates for these residents' medications, which is against the facility's policy requiring PRN psychotropic drugs to be limited to 14 days unless properly evaluated and documented by the attending physician. Resident #45, diagnosed with bipolar disorder and vascular dementia, had a PRN order for Lorazepam that extended beyond the 14-day limit without physician documentation to support the extension. A Registered Nurse confirmed the lack of physician rationale for the extended order. The facility's policy mandates that PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed without a physician's evaluation and documentation, which was not adhered to in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from physical abuse by another resident. The incident occurred when the resident attempted to enter their own room, which was occupied by another resident who became agitated. The agitated resident removed the victim's glasses, threw them across the room, poured soda on the victim's head, and moved the victim's wheelchair from side to side until the victim fell out of the wheelchair. The victim called for help, and staff responded promptly. The incident was witnessed by staff and verified through the facility's investigation. The facility's records indicate that the perpetrator had a history of behaviors such as grabbing, hitting, pushing, cursing, screaming, threatening, and rejecting care. These behaviors were monitored, and interventions were documented. However, the incident still occurred, indicating a failure to prevent the abuse. The facility's investigation confirmed the occurrence of the incident, and it was reported to the appropriate authorities.

Removal Plan

• The residents were separated and assessed for injuries.
• Close supervision was provided.
• Care plans for both residents were updated.
• Family, physician, and authorities were notified.
• The incident was reported to the State Agency and investigated.
• The perpetrator was psychologically evaluated and medications were adjusted.
• Res. #35 was moved off the perpetrator's unit.
• Social Services and Behavioral Health Services were involved in care and treatment for both residents.
• The facility conducted a Behavior Analysis Report regarding the perpetrator's behaviors.
• Interventions implemented to halt the behavior and new interventions implemented to prevent future incidents were documented and noted effective.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement care planned interventions for two residents, leading to deficiencies in their care. Resident #25, who has advanced dementia, developed a stage 2 pressure ulcer on the left heel and experienced significant weight loss. Despite a care plan that included the use of pressure relief boots and frequent repositioning, observations revealed that the resident was not wearing the boots and was not repositioned for extended periods. Additionally, dietary recommendations made by a dietician to support wound healing and prevent further weight loss were not implemented until over a month later. Resident #30, diagnosed with vascular dementia, dysphasia, and reflux disease, was observed sitting in a reclining chair at the dining table, leaning over to the left side. The care plan required the resident to be seated upright at 90 degrees during meals to reduce the risk of aspiration and reflux. However, the resident was not repositioned before receiving a meal, and the LNA confirmed that the resident should have been repositioned and required assistance during meals. These observations and interviews with staff confirmed that the facility did not adhere to the care plans for these residents, resulting in a failure to provide necessary interventions for pressure ulcer prevention, nutritional support, and safe positioning during meals. The deficiencies highlight lapses in the implementation of care plans and the monitoring of residents' needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise the comprehensive care plan for two residents as their conditions changed. For one resident, observations on two consecutive days showed that staff were assisting the resident with eating, indicating a need for total assistance. However, the resident's care plan contained contradictory information, with one approach suggesting the resident was dependent on staff for meal assistance, while another encouraged independent eating. Interviews with staff confirmed the resident was dependent on staff for all activities of daily living (ADLs), yet the care plan had not been updated to reflect this dependency. Another resident experienced an unwitnessed fall resulting in a major injury, specifically a left hip fracture with internal bleeding, requiring hospitalization and surgery. Despite the facility's policy to review and revise care plans after such incidents, the resident's care plan had not been updated following the fall. The Director of Nursing confirmed that the care plan remained unchanged after the incident, indicating a failure to address the resident's increased risk of falls and injury.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet professional standards of quality by allowing a Licensed Nursing Assistant (LNA) to act outside their scope of practice. At approximately 2:00 PM on 10/28/2024, an LNA was observed administering medications to Resident #205 at the nurse's station. A Licensed Nurse confirmed that the task was delegated to the LNA due to their good rapport with the resident, despite the LNA not being trained by the facility to administer medications. The LNA admitted to having administered medications to the resident, crushed in ice cream, and stated that this was not the first time they had been delegated such tasks by nurses. The Director of Nursing confirmed that administering medications is not within an LNA's scope of practice, as per the [NAME] State Board of Nursing guidelines, which prohibit LNAs from performing activities beyond their licensure level, including medication administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision and maintain a safe environment for Resident #15, who was at risk for falls due to decreased activity tolerance and safety awareness. The resident, admitted with conditions including atrial fibrillation, depression, hypertension, and dementia, had a care plan indicating a risk for falls. Despite this, the facility did not conduct a thorough evaluation of potential environmental hazards in the resident's room that could contribute to falls. On 9/28/24, Resident #15 experienced an unwitnessed fall in their room, resulting in a left hip fracture and a small extraperitoneal pelvic hemorrhage. The resident was subsequently transported to the hospital for surgery. The facility's internal report lacked documentation of an evaluation and analysis of hazards and risks in the resident's environment, and there were no individualized interventions implemented to mitigate these risks, as required by the facility's Falls Risk Assessment and Care Planning policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement the recommendations made by a Registered Dietician to support wound healing and prevent weight loss for a resident. The resident experienced a significant weight loss of 11.48% over three months and developed a stage 2 facility-acquired pressure ulcer. On 9/11/2024, the dietician recommended increasing the resident's dietary supplement to three times per day and administering Centrum Silver daily. However, a follow-up note on 10/28/2024 revealed that these recommendations had not been implemented. The resident's Medication Administration Record confirmed that the dietary changes were not initiated until 10/29/2024. The Director of Nursing acknowledged the delay in implementing the dietician's recommendations during an interview on 10/30/2024.