**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide foot care and make necessary podiatry appointments for two of sixteen sampled residents (Resident 109 and Resident 117) diagnosed with Type 2 Diabetes Mellitus (disease with impaired response to insulin, elevated blood sugar, decreased blood circulation in the feet), who had ingrown toenails (condition in which the side of the toenail grows into the flesh), and infected (disease caused by bacteria with swelling, redness and pus) toenails, and twenty-two unsampled residents that required podiatry assessments and treatments. This failure resulted in the incision, drainage of pus, and removal of the left great toenail, pain, and infection for Resident 117, and pain, and ingrown right great toenail for Resident 109 and placed the other twenty-two (22) residents at risk for pain, ingrown nails, and infections which had the potential to affect the mobility of all residents. Findings: During a concurrent observation and interview, on 10/5/21 at 9:00 a.m., with Resident 109, Resident 109 was lying in his bed, on top of the blankets, with no shoes or socks on. Resident 109's toenails were long, sharp, with brownish yellow discoloration on both feet. Resident 109's right great toenail was grown around the end of the toe in a circle and was pressing on his skin under the toe. Resident 109's skin on his feet was dry with a large amount white peeling flakes. The Licensed Vocational Nurse (LVN) 2 was present at the door of the room and stated Resident 109 can be quiet and likes to be left alone. Resident 109 was alert, pleasant, articulate, and spoke Spanish. Resident 109 stated he had not seen a podiatrist and he trimmed his own nails. Resident 109 stated, He had lived on the streets before coming to the facility and took care of himself. During a review of Resident 109's Face Sheet dated 3/1/21, the Face Sheet indicated Resident 109 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 109 had diagnosis of Type 2 Diabetes Mellitus, Hemiparesis Following Intracerebral Hemorrhage Left Side (weakness following a stroke [bleeding in the brain]), Congestive Heart Failure (weakness in the heart where fluid accumulates in the lungs), Hepatitis C (infection caused by virus that affects the liver), Chronic Kidney Disease (impaired kidney function that worsens over time), and Difficulty Walking. During an interview on 10/5/21 at 9:11 a.m., with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was familiar with Resident 109 and was aware his toenails were very long. LVN 1 stated nurses were responsible for cutting the nails for residents with diabetes. LVN 1 stated she had told the Social Services Director Resident 109 needed to see a Podiatrist. LVN 1 stated the SSD was responsible for getting appointments for podiatry but had not made Resident 109 an appointment for podiatrist. LVN 1 stated the long toenails could cause skin breakdown (Sores from pressure) or problems with infection if they were not taken care of. During an interview, on 10/5/21 at 9:38 a.m., with Certified Nursing Assistant 1 (CNA), CNA 1 stated Resident 109 had told her his toenails were too long. CNA 1 stated Resident 109's shoes probably rubbed the long toenails and hurt. CNA 1stated the LVN's were responsible for cutting the toenails of residents diagnosed with diabetes. CNA 1 stated the CNA's were allowed to file the residents toenails but she had not filed Resident 109's toenails because they were too long. CNA 1 stated Resident 109's long toenails could cause pain, infection, and that would be very bad for a diabetic resident. During an interview, on 10/5/21 at 9:47 a.m., with the Social Services Director (SSD), the SSD stated LVN 1 had told her about Resident 109's toenails and the need for a podiatry appointment. The SSD stated she had not made Resident 109 an appointment but should have. The SSD stated the Regional Director of Operations (RDO) was working on getting a podiatry contract for the facility but had not done it. The SSD stated she did not know when the facility would get a podiatrist. The SSD stated they would have to get an appointment for podiatry in another town. The SSD stated she could have made an appointment for Resident 109 but had not. The SSD stated she was aware Resident 109 was diabetic. The SSD stated Resident 109's toenails were long and looked like talons. The SSD stated when the toenails were that thick and tough only a podiatrist could cut them. The SSD stated Resident 109 could experience pressure sores from the nails pressing on his skin. During an interview, on 10/5/21 at 11:05 a.m. with the RDO, the RDO viewed a photograph of Resident 109's toenails. The RDO stated the facility should have made Resident 109 a podiatry appointment and not waited for the facility to get a contract. During a concurrent observation and interview, on 10/6/21 at 9:03 a.m., with Resident 117, Resident 117 was lying in his bed without socks or shoes. Resident 117's toenails were long, jagged, thick, and brownish yellow colored. Resident 117's fingernails were long and had yellow substance under the nails. Resident 117's skin on his feet had patches of thick, yellow colored, peeling skin. The tissue around the nails was dry and had peeling skin. Resident 117 pointed to his left great toenail and stated he was worried about, The bad one. The left great toenail had dark blackish coloration and was jagged and overgrown. Resident 117 stated he had not seen a podiatrist. During a review of Resident 117's Face Sheet dated 4/30/21, the Face Sheet indicated Resident 117 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 117 had diagnosis of Idiopathic peripheral Autonomic Neuropathy (decreased feeling in the arms and legs), Osteomyelitis Multiple sites (infection in the bones), Type 2 Diabetes Mellitus, Ingrown Nail, Fracture of the Cervical, Thoracic and Lumbar Region (broken bones of the back), Chronic Obstructive Pulmonary Disease (constriction of the airway with difficult breathing), and Difficulty Walking. During an interview, on 10/6/21 at 9:15 a.m., with the SSD, the SSD stated the facility had contracted a podiatrist to come to the facility on [DATE]. The SSD stated the podiatrist had been at the facility since 6:00 a.m. The SSD stated the podiatrist planned to see about 24 residents. When asked why the facility had not gotten a podiatrist before, the SSD stated, We couldn't find one to come out here. During a concurrent observation and interview, on 10/6/21 at 12:45 p.m., with the Podiatrist (DPM), the DPM stated she was informed 10/5/21 the facility needed her services. The DPM viewed a photograph of Resident 109's toenails and stated the toenails appeared not to have been trimmed in about six (6) months. The DPM stated she had treated Resident 109, and he had an active toenail fungus that caused the toenails to thicken and become discolored. The DPM stated she was very careful to not injure Resident 109 because he was diabetic. The DPM stated Resident 109 was high risk if the overgrown toenails grew into his skin and caused pressure sores. The DPM stated due to the condition of his toenails, Resident 109 should have seen a podiatrist and had his nails trimmed every two months by a podiatrist. The DPM stated she ordered A&D ointment (petroleum-based skin moisturizer) every other day to relieve the dry skin on his feet. The DPM stated she had assessed and treated 22 other residents at the facility, but Residents 109 and 117 toenails were in the worst condition. During a concurrent interview and record review, on 10/6/21 at 2:38 p.m., with the DPM, the DPM stated she had seen Resident 117. The DPM's notes for Resident 117 indicated she had removed the left great toenail. The DPM stated she had to remove Resident 117's left great toenail due to infection. The DPM stated the toenail had purulent (yellow fluid from a wound-which indicated a sign of infection) drainage under the toenail which caused redness and pain. The DPM stated the blackish color on the left great toenail was due to a previous injury where the nailbed bled and became blackened. The DPM stated she ordered antibiotics for Resident 117. The DPM stated she ordered a betadine (disinfectant for skin) treatment daily to the left great toe. The DPM stated she did not know how long Resident 117's toe was infected. The DPM stated Resident 117 should have been treated by a podiatrist every two months but was not. During a review of the DPM notes, dated 10/6/21, the notes indicated .Skin .Dry .Nails .Hypertrophic (overgrown) .Yellow .Thick .Subungual Debris (thickened discolored nails) .L [Left] Hallux (big toe) Paronychia (infection of tissue under nail) TNA (total nail avulsion (removal) Mod [moderate] Drainage & Pain .Absent right third toe nail .Comp History +Physical Exam High Complexity .Nail Debridement (removal of diseased nail bed tissue .Trimming of dystrophic (misshaped, thickened) nails .Rx (prescription) (L) Hallux Beta (betadine (antiseptic solution for injuries) x 21 days, Paronychia [with] infection ingrown .Rx Keflex (antibiotic used to treat infection) 500 mg 1 [by mouth] [twice a day] x7 days . During a concurrent interview and record review, on 10/12/21 at 4:01 p.m., with the Director of Nursing (DON), the DON was not able to find any documentation of nail care provided for Residents 109 or 117. The DON stated the LVN's were responsible for diabetic residents' foot care. The DON stated she did not monitor the nail care documentation of the LVN's. The DON stated she was responsible for supervision of the LVN's. The DON stated medical records monitored and told her when there were omissions. The DON stated she had not assessed Resident 109 or 117's feet because the LVN's had not told her there was a problem. The DON stated the LVN's had not told her about these two resident's nail care needs and they should have. During a concurrent interview and record review, on 10/12/21 at 4:10 p.m., with the Director of Staff Development (DSD), the nail care records for Residents' 109 and 117 were reviewed. The DSD stated she was not sure how to run a report for nail care documentation. The DSD stated she did not monitor when the LVN's performed nail care for diabetic residents. The DSD stated the LVN's did weekly assessment and when they had concerns, they should report it to the DON. The DSD stated the condition of Residents' 109 and 117's toenails were concerning and should have been reported. The DSD stated she had not been informed of the condition of the residents' toenails. The DSD stated she expected the LVN's would have informed the doctor so he could have looked at it. The DSD stated Residents 109 and 117 could have experienced pain, infection, loss of the nail, inflammation and drainage. The DSD stated the DON was responsible for the nursing department. The DSD stated the last documentation for nail care for Residents 109 and 117 was 5/21. The DSD stated there was no nail care documentation by the LVN's for 6/21, 7/21, 8/21, 9/21, or 10/21. During a concurrent interview and record review, on 10/13/21, at 8:11 a.m., the Interim Medical Records (IMR) reviewed the Activities of Daily Living (ADL) and the weekly nursing assessments done by the LVN's for Residents 109 and 117. The IMR stated the last nail care documented on the ADL's for Resident 109 was 5/1/21 and for Resident 117 was 5/1/21. The LVN documentation for diabetic nail care dated 6/21, 7/21, 8/21, 9/21 and 10/21 for Residents 109 and 117 indicated there was no nail care. The IMR stated LVN's should have done more frequent nail care and referred them to a podiatrist. The IMR stated the DON was responsible for monitoring the LVN's work. The IMR stated the LVN's should have told the DON about the residents' nail care and incorporated her help. During a concurrent interview and record review, on 10/13/21, at 8:37 a.m., with LVN 2, the nursing assessments 5/21-10/21 were reviewed. LVN 2 stated she had assessed Residents 109 and 117 about a month ago. LVN 2 stated she told SSD Residents 109 and 117 needed a podiatrist because she was unable to trim their toenails. LVN 2 stated the SSD told her she would follow up with a podiatrist but had not. LVN 2 stated she did not know if the facility had gotten podiatrist. LVN 2 stated long toenail could cause cuts, get caught on something or cause an infection. LVN 2 stated the long toenails would most likely have been painful. LVN 2 stated she believed the DON did assessments on the residents but didn't know how often. LVN 2 stated the condition of Resident 109 and 117's toenails should not have gotten that bad. During an interview on 10/13/21, at 11:00 a.m., with the RDO, the RDO stated the facility had opened 12/3/21. The RDO stated it was difficult to get physician contracted services due to the distance. The RDO stated the facility had contracts when they opened but the podiatrist had not come to the facility since opening. The RDO stated it was his job to get physician contracted services for the facility. The RDO stated it was his expectation the facility would have sent Residents 109 and 117 to the podiatrist for treatment. The RDO stated the residents could have been harmed in many ways, especially since they were both diabetic. The RDO stated if he had been informed of the situation with Residents' 109 and 117's toenails, he would have acted but he was blindsided. During a review of the facility's undated document titled, Licensed Practical/Vocational Nurse-SNF Job Description, the document indicated, .This job description is a record of the essential functions of the listed job .This position involves direct patient care .The Licensed Vocational Nurse provides .Medical treatment and personal care services to .Persons in a skilled nursing facility setting by performing the following duties .Be dedicated to the provision of quality care, and use sound judgement in decision making .Responsibilities to the Patient .Observes patients and reports .To medical personnel in charge .Communicates the plan of nursing care for each patient through reports .Provides a level of competency to treat patients .Involves them with care planning by meeting any needs identified during assessment .Communication .Timely follow up . During a review of the facility's policy and procedure titled, Care Area Assessments dated 5/2011, the policy indicated, .Care Area Assessments (CAAs) will be used to .Develop individualized care plans .CAAs are the link between assessment and care planning .Identify areas of concern .Review by .doing an in-depth, resident specific assessment of the triggered condition .History .Physical assessment .The IDT will employ tools and resources .Factors that should be considered in developing the care plan .Any need for further evaluation by the physician or other healthcare provider . During a review of the facility's policy and procedure titled, Care of Fingernails/Toenails dated 2010, indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .Trimmed and smooth nails prevent the residents from accidentally scratching and injuring his or her skin .Watch for and report changes .Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if the nails are too hard or too thick to cut .DOCUMENTATION .The following information should be recorded in the resident's medical record .The condition of the resident's nails .Bluish or dark color of nail beds .ingrown nails .Pain .Any difficulties in cutting the resident's nails .Interventions taken . During a review of the Nursing Times article titled, Foot Assessment and Care for Older People dated 12/9/14, the article indicated, .Foot care can prevent mobility problems and social isolation; it is a crucial part of nursing care, particularly for older patients, who may be unable to care for their own feet .While foot problems can occur in all age groups, their prevalence increases with age. It is estimated that 80% of older people have foot problems . The prevalence of serious foot problems, such as peripheral arterial disease, does increase with age .Common foot problems in older people .Toenail disorders including hardened or ingrown nails .Toe deformities such as overlapping toes .Corns and calluses .Bunions .Fungal infections .If unattended such problems can lead to more serious issues .Those who are unable to perform this essential task for themselves need regular assessment and care to help prevent adverse effects from occurring .Dryness that is associated with reduced blood flow may cause the skin to split, resulting in painful fissures, while poor circulation may lead to a higher risk of infection .Toenails can thicken and become hard and brittle with age, which makes it difficult to cut them. Continuous pressure from inappropriate footwear can also cause more extreme nail deformity. Nails that become too long or thickened can damage the skin on adjacent toes .Ingrown toenails occur when a nail grows into the skin, and can cause pain, swelling, redness and infection .Fungal infection of skin, such as athlete's foot - which causes peeling, redness, itching, burning .Fungal nail infections occur when microscopic fungi enter the nail through a break; they result in thick, discolored and brittle nails .Foot assessment .When older people can no longer manage their own foot care, an initial assessment is required to identify what help they need .Podiatrists assess all new nursing home residents . After an individual has been assessed, care may be provided by Podiatrists . Referrals should be made to podiatrists, GPs, or pharmacists (for medication review) if patients have .Medical complications that put feet at risk, such as diabetes with peripheral vascular disease, significant peripheral arterial disease .Painful foot lesions, including severe deformities and toenails that are excessively thickened and cause pain, prevent mobility or are a risk to surrounding skin .Loss of sensation .Patients with diabetes who have an increased risk must have an expert assessment carried out by health professionals with specialist experience in the management of the foot in diabetes. Registered nurses should know who to refer and should ensure a timely referral is made and response given .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three (Residents 114, 112, 108) of 16 sampled residents when: 1. Resident 114 experienced an 8.7% weight loss within the three-month period and a 12.2% weight loss within the five-month period and the care plan did not address this situation. This failure resulted in Resident 114 to have an on-going severe significant unplanned weight loss for five months since admission to the facility. 2. Resident 112 did not have a care plan to address the 15.6% weight loss within the three-month period and the 13.2% weight loss within the four-month period. This failure resulted in Resident 112 to have an on-going severe significant unplanned weight loss for four months since admission to the facility. 3. Resident 108's care plan for oral/dental health problems contained interventions that were not followed. This failure resulted in Resident 108's oral/dental health not being followed and had the potential for Resident 108 to have oral/dental infections. These findings placed Residents 114, 112 and 108 at risk for a decline in their health and safety and unable to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Findings: 1. During a review of Resident 114's Medical Record (MR), dated 10/8/21, the medical record indicated, Resident 114 was admitted on [DATE], with diagnoses that included Unspecified Dementia with Behavioral Disturbance (diminished memory with episodes of agitation or restlessness), Bipolar Disorder (feeling very sad or very excited), Circadian Rhythm Sleep Disorder (unable to sleep), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Hyperlipidemia (elevated fat levels in the body), Muscle Weakness, Muscle Wasting and Atrophy (decreased muscle tissues), Psychotic Disorder with Delusions (a disorder characterized by a disconnection from reality) , and Essential Hypertension (abnormally high blood pressure). The most recent Minimum Data Set (MDS, a resident assessment tool used to identify resident care needs) dated 8/18/21, indicated a BIMS (brief interview for mental status) score of 99 out of a possible 15, indicating Resident 114 was unable to complete the interview. Section C1000 of the MDS indicated, Resident 114's Cognitive (ability to think and reason) Skills for Daily Decision Making was severely impaired. Section K of the MDS indicated, Resident 114 had a weigh loss of 5% or more in the last month and not on physician-prescribed weight-loss regimen. During a review of the facility's document titled, Weights and Vitals Summary (WVS), dated 10/8/21, the form indicated the following weights and comparisons for Resident 114: 5/7/21 121.2 lbs. (pounds., unit of measurement) 5/9/21 120 lbs. 5/15/21 122.1 lbs. 5/23/21 118.8 lbs. [-3.3. lbs. in one week] 5/29/21 117.8 lbs. 6/2/21 116 lbs. 6/6/21 117 lbs. 7/1/21 116.4 lbs. 8/6/21 111.6 lbs. (-7.5% change [comparison weight 5/15/21, 122.1 lbs., -8.6%, -10.5 lbs.]) 9/3/21 111.6 lbs. 10/1/21 109.6 lbs. (-10% change [comparison weight 5/15/21, 122.1 lbs., -10.2%, -12.5 lbs.]) During a review of Resident 114's Order Summary Report (OSR), dated 10/8/21, indicated, Resident 114 diet was ordered on 5/07/21 by the physician, indicating Regular diet, Regular texture, and Regular Liquids Consistency. During a concurrent interview and record review, on 10/07/21, at 12:55 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Focus Section of the CP indicated, the RD (Registered Dietician) admission Assessment was completed on 5/13/21. The interventions/tasks section of the CP indicated, monitor/record/report to MD PRN signs and symptoms (s/s) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. Provide, serve diet as ordered. Monitor intake and record every meal. During a concurrent interview and record review, on 10/07/21, at 12:55 p.m., with LVN 1, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Interventions/Tasks of the CP indicated, RD to evaluate and make diet change recommendations PRN. LVN 1 was unable to confirm documentation the RD evaluated or make a diet change recommendation for Resident 114 after establishing the initial care plan on 5/11/21. LVN 1 stated Resident 114's care plan for RD to evaluate and make diet change recommendations was not followed. During a concurrent interview and record review, on 10/07/21, at 3:07 p.m., with the DON, Resident 114's Progress Notes (PN), were reviewed. The DON was unable to confirm documentation the physician was notified for s/s of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. The DON stated Resident 114's care plan to notify the physician for significant weight loss was not followed. The DON stated Resident 114's significant severe unplanned weight loss could result in anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss. During a concurrent interview and record review, on 10/07/21, at 12:55 p.m., with the DON, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Interventions/Tasks of the CP indicated, RD to evaluate and make diet change recommendations PRN. The DON was unable to confirm documentation the RD evaluated or make a diet change recommendation for Resident 114 after establishing the initial care plan on 5/11/21. The DON stated Resident 114's care plan for RD to evaluate and make diet change recommendations was not followed. During an interview on 10/8/21, at 3:48 p.m., with RD 1, RD 1 confirmed the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 and the significant severe unplanned weight loss of 10.2 % within a five-month timeframe from 5/7/21 to 10/1/21 for Resident 114 were not addressed by the RD. RD 1 further stated the weight loss for Resident 114 was not acceptable. During a review of the facility's policy and procedure, titled, Care Plans - Comprehensive dated 9/2010, indicated, An individualized comprehensive care plan that is measurable objective and timetables to meet resident's medical, nursing, mental and psychological needs is developed for each resident .1. Our facility's Care Planning .care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that is not limited to the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .f. Identify professional services that are responsible for each element of care .9. The Care Planning/Interdisciplinary Team (IDT) is responsible for the review and updating of the care plans: a. When there has been a significant change in resident's condition .d. At least quarterly. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, .Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, indicated, .Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . 2. During a review of Resident 112's Medical Record (MR), dated 10/5/21, indicated, Resident 112 was admitted on [DATE], with diagnoses that included Unspecified Dementia with Behavioral Disturbance (diminished memory with episodes of agitation or restlessness), Anxiety Disorder, unspecified Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), Unspecified Urinary Incontinence, Wedge Compression Fracture of First Lumbar Vertebra (a fracture often caused by trauma such as sustaining a fall, occurs in front of the vertebra and resulting on a wedge shape), Vitamin D deficiency (lack of) and Muscle Wasting and Atrophy (decreased muscle tissues). The most recent Minimum Data Set (MDS) dated [DATE], Section C1000 indicated, Resident 112's Cognitive Skills for Daily Decision Making was severely impaired. Section K of the MDS indicated, Resident 112 has a swallowing disorder and complaints of difficulty or pain with swallowing. During a review of the facility's document titled, Weights and Vitals Summary (WVS), dated 10/8/21, the form indicated the following weights and comparisons for Resident 112: 5/25/21 107.4 lbs. (pounds., unit of measurement) 6/3/21 92.5 lbs. 6/20/21 92.0 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -14.3%, -10.6lbs.]) 7/1/21 95.3 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -11.3%, -12.1lbs.]) 8/1/21 96.4 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -10.2%, -11 lbs.]) 8/29/21 90.9 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -15.6%, -16.8 lbs.]) 9/3/21 90.6 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -15.6%, -16.8 lbs.]) 10/1/21 93.2 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -13.2%, -14.2 lbs.]) During a concurrent interview and record review, on 10/08/21 at 12:44 p.m., with the Director of Staff Development (DSD), Resident 112's WVS and Care Plan (CP), dated 10/8/2021 were reviewed. DSD stated, all newly admitted residents were weighed every week for four weeks and if stable, then weights were done monthly. The WVS indicated, on 7/1/21, Resident 112's weight was 95.3 lbs., a 12.1 lbs., 11.3% weight loss in one month since admission to the facility. On 8/29/21, Resident 112's weight was 90.9 lbs., a 16.8 lbs., 15.6% weight loss in three months. Resident 112's admission weight on 5/25/21 was 107.4 lbs. The DSD reviewed resident 112's care plans and stated there was no care plan developed to address the weight loss on 6/20/21, 7/21/21, 8/1/21, 8/29/21, 9/3/21, and 10/1/21. The DSD stated, Resident 112 should have a weight loss care plan and nutrition care plan as soon as the weight loss was identified. The DSD stated it was the responsibility of the licensed nurse or DON to initiate the care plan. During a review of the facility's policy and procedure, titled, Care Plans - Comprehensive dated September 2010, indicated, .An individualized comprehensive care plan that is measurable objective and timetables to meet resident's medical, nursing, mental and psychological needs is developed for each resident .1. Our facility's Care Planning .care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that is not limited to the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .f. Identify professional services that are responsible for each element of care .9. The Care Planning/Interdisciplinary Team (IDT) is responsible for the review and updating of the care plans: a. When there has been a significant change in resident's condition .d. At least quarterly . During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, the journal indicated, .Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . 3. During a review of Resident 108's Face Sheet (document that contains residents name, date of birth , room number, resident representative, diagnoses, insurance information and more) titled, admission and Records, dated 10/5/21 at 3:44 p.m., indicated, .Resident 108 was admitted on [DATE] for Apraxia (Difficulty with skilled movements even when a person has the ability and desire to do them) following unspecified Cerebrovascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain) . Acute Kidney Failure (A condition in which the kidneys suddenly can't filter waste from the blood.) . Type 2 Diabetes (A chronic condition that affects the way the body processes blood sugar.) with Diabetic Nephropathy (deterioration of kidney function) . Conversion disorder (a medical condition in which the brain and body's nerves are unable to send and receive signals properly) with seizures (a sudden, uncontrolled electrical disturbance in the brain) . Essential hypertension (high blood pressure that has no clearly identifiable cause) . Vitamin B 12 Deficiency Anemia (a condition in which your body does not have enough healthy red blood cells, due to a lack (deficiency) of vitamin B12) . Muscle weakness (generalized) . Benign Prostatic Hyperplasia ( condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine) with lower urinary tract symptoms (hesitancy, poor and/or intermittent stream, straining, feeling of incomplete bladder emptying, dribbling, etc.) . The admission record did not indicate Resident 108 had no teeth and had lost his dentures. During a review of Resident 108's Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) - Version 3.0 Resident Assessment and Care Screening, dated 9/22/21, indicated, Resident 108 has the ability to express ideas and wants and had a Brief Interview of Mental Status (BIMS- The total possible BIMS score ranges from 00. to 15. 13 - 15: cognitively intact. 08 - 12: moderately impaired. 00 - 07: severe impairment) score of 10, indicating moderately impaired. During a concurrent observation and interview on 10/7/21, at 11:50 a.m., with Resident 108, in his room, Resident 108 had no teeth and no dentures at bed side. Resident 108 stated he does not have any teeth and does not have his dentures here, they (the facility staff) do not offer oral care to me nor have they since I have been here. During a review of Resident 108's Care Plan (CP) titled, [name of resident] has oral/dental health problems (missing teeth r/t (related to) Poor dentition), date initiated 9/18/21, the CP indicated, Goal The resident will be free of infection, pain or bleeding in the oral cavity by review date . interventions/Tasks Coordinate arrangements for dental care, transportation as needed/as ordered . [resident's name] requires mouth inspections q shift [every shift] during oral cares. Report changes to the nurse . Monitor/document/report PRN [as needed] any s/sx [signs and symptoms] of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions . Provide mouth care as per ADL [activities of daily living] personal hygiene . During an interview on 10/11/21, at 9:26 a.m., with the Director of Staff Development/ Infection Preventionist (DSD/IP), the DSD/IP stated, We [the facility] offer oral care to residents . the DON [Director of Nursing] does the bulk of the care planning, the nurses do some once in a while and I help occasionally too. DSD/IP was observed checking her three education binders and stated she was unable to locate any education she had provided to staff on oral care. DSD/IP stated it is important for residents to have oral care to prevent decay, sores, and infection; all these issues can affect the resident's ability to eat. During a concurrent observation and interview on 10/13/21, at 12:29 p.m., with Certified Nursing Assistant/Sitter (CNA/S) in Resident 108's room, CNA/S was seen helping Resident 108 with his lunch. Resident 108 was sitting up in bed and his hands were shaking. CNA/S stated she has been a sitter for Resident 108 on four different days, I assist him with eating and drinking, help him to the bathroom, get dressed and help keep him safe. CNA/S stated she does not look at the residents care plan and she has not looked in Resident 108's mouth, I was not aware that I should inspect the residents (Resident 108's) mouth at least once a shift and let the nurse know if there are any issues. CNA/S pulled out Resident 108's mouth wash from her pocket and stated, I have offered it to him and will offer it again. During a concurrent interview and record review on 10/13/21, at 1 p.m., with Licensed Vocational Nurse (LVN) 6, Resident 108's care plans were reviewed. LVN 6 stated she was not aware that Resident 108 had a care plan for his mouth. LVN 6 stated, I look at the care plans for residents at least once daily . I was not aware that we should be checking his (Resident 108's) mouth every shift. LVN 6 stated it is very important to monitor his mouth for signs and symptoms of infection. LVN 6 confirmed the care plan had not been followed. During a review of the facility's policy and procedure (P&P), titled, Mouth Care, dated 10/2010, the P&P indicated, .Purpose The purpose of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth. Preparation 1. Review the resident's care plan to assess for any special needs of the resident . During a professional reference review the Centers for Disease Control and Prevention, last updated 11/3/2020, article titled, Oral Health, was reviewed. The Oral Health article indicated, . Oral health is essential to general health and well-being. Oral disease can cause pain and infections that may lead to problems with eating, speaking, and learning. It can also affect social interaction . the three oral conditions that most affect overall health and quality of life are cavities, severe gum disease, and severe tooth loss . Tobacco use and diabetes are two risk factors for gum disease . During a review of the facility's P&P, titled, Care Plans - Comprehensive dated 9/2010, indicated, .An individualized comprehensive care plan that is measurable objective and timetables to meet resident's medical, nursing, mental and psychological needs is developed for each resident .1. Our facility's Care Planning .care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that is not limited to the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .f. Identify professional services that are responsible for each element of care .9. The Care Planning/Interdisciplinary Team (IDT) is responsible for the review and updating of the care plans: a. When there has been a significant change in resident's condition .d. At least quarterly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 114) maintained acceptable parameters of nutritional status when: 1. Licensed nurses did not communicate two episodes of significant severe unplanned weight loss to the interdisciplinary team (IDT - members of the care team that include nurses, social workers, doctors, therapists, dietician and others). Licensed nurses documented Resident 114's weight loss of 8.6% between 5/7/21 and 8/6/21 and a weight loss of 10.2% between 5/7/21 and 10/1/21 and did not report this to the IDT and appropriate assessments and effective interventions were not implemented. 2. The Registered Dietician (RD) did not conduct a nutritional assessment to address the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 and the significant severe unplanned weight loss of 10.2 % within a five-month timeframe from 5/7/21 to 10/1/21 for Resident 114 in accordance with the facility's policy and procedure. As a result of these failures, Resident 114's compromised nutritional status was not addressed which could lead to further medical complications. Findings: 1. A review of Resident 114's Medical Record (MR), dated 10/8/21, indicated, Resident 114 was admitted on [DATE], with diagnoses that included Unspecified Dementia with Behavioral Disturbance (diminished memory with episodes of agitation or restlessness), Bipolar Disorder (feeling very sad or very excited), Circadian Rhythm Sleep Disorder (unable to sleep), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Hyperlipidemia (elevated fat levels in the body), Muscle Weakness, Muscle Wasting and Atrophy (decreased muscle tissues), Psychotic Disorder with Delusions (a disorder characterized by a disconnection from reality) and Essential Hypertension (abnormally high blood pressure). The most recent Minimum Data Set (MDS, a resident assessment tool) dated 8/18/21, indicated a BIMS (brief interview for mental status) score of 9 out of a possible 15, indicating Resident 114 was unable to complete the interview. Section C1000 of the MDS indicated, Resident 114's Cognitive Skills for Daily Decision Making was severely impaired. Section K of the MDS indicated, Resident 114 had a weigh loss of 5% or more in the last month and was not on a physician- prescribed weight-loss regimen. A review of the facility document titled, Weights and Vitals Summary (WVS), dated 10/8/21, indicated the following weights and comparisons for Resident 114: 5/7/21 121.2 lbs (pounds., unit of measurement) 5/9/21 120 lbs 5/15/21 122.1 lbs 5/23/21 118.8 lbs [-3.3. lbs in one week] 5/29/21 117.8 lbs 6/2/21 116 lbs 6/6/21 117 lbs 7/1/21 116.4 lbs 8/6/21 111.6 lbs (-7.5% change [comparison weight 5/15/21, 122.1 lbs., -8.6%, -10.5 lbs.] 9/3/21 111.6 lbs 10/1/21 109.6 lbs (-10% change [comparison weight 5/15/21, 122.1 lbs., -10.2%, -12.5lbs.] A review of the facility document titled Order Summary Report (OSR), dated 10/8/21, indicated, on 5/07/21 a Regular diet, Regular texture, and Regular Liquids Consistency was ordered by the Physician for Resident 114. A review of the facility document titled, History and Physical (H&P), dated 5/9/21, 6/17/21, and 8/31/21 for Resident 114 completed by the Physician indicated the section titled, Physical Findings, WT [weight] was not documented. A review of the facility document titled, 30-day Evaluation - Monthly dated 7/13/21 and 9/1/21 for Resident 114 completed by the Physician indicated VS [Vital Signs] WNL [Within Normal Limits]. Exam unchanged. During a concurrent interview and record review, on 10/07/21 at 12:44 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 114's Weights and Vitals Summary (WVS), dated [DATE] was reviewed. The LVN 1 stated, all newly admitted residents were weighed every week for four weeks and if stable, then weighted monthly. The LVN 1 stated, she would ask the Certified Nurse Assistant (CNA) to reweigh the resident for any weight loss. The LVN 1 stated, she would notify the doctor, the RD, the dietary department, and the responsible party (RP) for any significant or severe weight loss. The WVS indicated, on 5/15/21, Resident 114's weight was 122.1 lbs. On 8/6/21, Resident 114 weight was 111.6 lbs., a 10.5 lb., 8.6% weight loss in three months. On 10/1/21, Resident 114's weight was 109.6 lbs., a 12.5 lb., 10.2% weight loss in five months. The LVN 1 was unable to confirm nursing documentation in Resident 114's medical record which indicated the Physician, the RD, the dietary department, and the RP were notified when Resident 114 experienced an 8.6% significant severe unplanned weight loss in three months and when Resident 114 experienced a 10.2% significant severe unplanned weight loss in five months. During a concurrent interview and record review, on 10/07/21 at 12:55 p.m., with LVN 1, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Focus Section of the CP indicated, the RD admission Assessment was completed on 5/13/21. The interventions/tasks section of the CP indicated, monitor/record/report to MD PRN signs and symptoms (s/s) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. Provide, serve diet as ordered. Monitor intake and record every meal. During a concurrent interview and record review, on 10/07/21 at 1:00 p.m., with the LVN 1, Resident 114's Progress Notes (PN), were reviewed. The LVN 1 was unable to confirm documentation the physician was notified for s/s of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. During a concurrent interview and record review, on 10/07/21 at 1:15 p.m., with the LVN 1, Resident 114's CP, initiated on 5/11/21, was reviewed. The CP indicated, Resident 114's has the potential nutritional problem related to Diet restrictions. The LVN 1 was unable to confirm Resident 114's care plan was updated to address the significant unplanned weight loss of 3.3 lbs. in a week on 5/23/21, 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21, and a significant unplanned weight loss of 12.5 lbs, 10.2% in five months, from 5/15/21 through 10/1/21. During a concurrent interview and record review on 10/7/21 at 3:07 p.m., with the Director of Nursing (DON), the WVS and the PN, dated 10/7/21 for Resident 114 were reviewed. The DON stated, all newly admitted residents were weighed every week for four weeks and if stable, were weighed monthly. The DON confirmed Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs, 8.6% in three months, from 5/15/21 through 8/16/21 and a significant severe unplanned weight loss of 12.5 lbs, 10.2% in five months, from 5/15/21 through 10/1/21. The DON stated, Resident 114's significant severe unplanned weight loss could result in further medical complications including anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss. The DON was unable to confirm nursing documentation in Resident 114's medical record which indicated the Physician, the RD, the dietary department, and the RP were notified when Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs, 8.6% in three months, from 5/15/21 through 8/16/21 and a significant severe unplanned weight loss of 12.5 lbs, 10.2% in five months, from 5/15/21 through 10/1/21. Resident 114's CP, initiated on 5/11/21 was reviewed with the DON. The CP indicated, Resident 114's has the potential nutritional problem related to Diet restrictions. The DON was unable to confirm Resident 114's care plan was updated to address the significant unplanned weight loss of 3.3 lbs. in a week on 5/23/21, 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 and a significant unplanned weight loss of 12.5 lbs, 10.2% in five months, from 5/15/21 through 10/1/21. The DON stated, licensed nurses should update the care plan to address the weight loss or create a new care plan for new problems. The DON stated, Resident 114's significant unplanned weight loss could result in further medical complications including anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss. During a concurrent interview and record review, on 10/7/21, at 3:07 p.m., with the DON, the facility documents titled IDT Weight Management Assessment (IDT-WMAU), dated 5/25/21, 6/4/21, 6/9/21, and 6/15/21 for Resident 114, were reviewed. Section A of the IDT-WMAU dated 5/25/21 indicated, Resident 114 was on a regular diet and tolerated well. Resident 114 lost 3.3# in a week. PO intake was 58%. She eats in her room and is able to feed herself. Continue to monitor weekly weights. Intake 25% to 75%. Section B of the IDT-WMAU indicated, Recommendations: Current Plan of Care remains appropriate, no changes needed at this time. The IDT-WMAU was completed by the the DM 1. The DM 1, SSD, AD, and DSD attended the IDT meeting. The DON confirmed the IDT-WMAU. The IDT Weight Management Assessment (IDT-WMAU), dated 6/4/21 for Resident 114, indicated for Section A, Resident 114 was on a regular diet and tolerated well. Resident 114 lost 3.3# in a week. PO intake was 58%. She eats in her room and is able to feed herself. Continue to monitor weekly weights. Intake 75% to 100%. Section B of the IDT-WMAU indicated, Recommendations: Current Plan of Care remains appropriate, no changes needed at this time. The IDT-WMAU was completed by the DM 1. The DM 1, SSD, AD, and DSD attended the IDT meeting. The DON confirmed the IDT-WMAU. The IDT Weight Management Assessment (IDT-WMAU), dated 6/9/21 for Resident 114, indicated for Section A, Resident 114 was on a regular diet and tolerated well. Resident 114 lost 0.8# in a week. PO intake was 79%. She eats in her room and is able to feed herself. Continue to monitor weekly weights. Intake 75% to 100%. Section B of the IDT-WMAU indicated no changes needed. The IDT-WMAU was completed by DM 1. The DM 1, SSD, AD, and DSD attended the IDT meeting. The DON confirmed the IDT-WMAU. The IDT Weight Management Assessment (IDT-WMAU), dated 6/15/21 for Resident 114, indicated for Section A. Resident 114 was on a regular diet and tolerated well. Resident 114 lost 0.4# in a week. PO intake was 72%. She eats in her room and is able to feed herself. Weight was stable, continue to monitor weights monthly. Intake 50% to 100%. Section B of the IDT-WMAU indicated, Recommendations: Current Plan of Care remains appropriate, no changes needed at this time. The IDT-WMAU was completed by DM 1. The DM 1, SSD, AD, and DSD attended the IDT meeting. The DON was unable to confirm further IDT-WMAU meetings were conducted after 6/15/21. During an interview on 10/7/21, at 5:24 p.m., with the LVN 3, the LVN 3 stated, Resident 114 fed herself, refused help, and frequently paced the hallway. During a concurrent observation and interview inside Resident 114's room, on 10/7/21, at 5:30 p.m., with the CNA 3, the CNA 3 stated, Resident 114 fed herself, had good and bad days. The CNA 3 stated, she would offer a sandwich or something else if Resident 114 consumed 25% or less of her meals. During an observation of the dinner meal service on 10/7/21, at 5:35 p.m., in Resident 114's room, Resident 114 was observed struggling to cut the chicken meat with a fork. Resident 114 used her hands to eat the chicken meat. Resident 114 consumed 90% of chicken, 75% of rice, 75% of vegetable and 100% of dessert. Resident 114 did not drink the milk. Resident 114 attempted to remove the water pitcher cover to drink water, however she was unable to remove the water pitcher cover. The CNA 3 assisted Resident 114 to remove the water pitcher cover and Resident 114 drank water directly from the pitcher. During an interview on 10/7/21, at 5:51 p.m., with the LVN 1, the LVN 1 stated, she was not notified or aware of any change in intake or weight loss for Resident 114. During an interview on 10/8/21 at 10:16 a.m., with the RD 1, the RD 1 stated, he started working at the facility two weeks ago. The RD 1 stated the facility had a loose system for monitoring weights. The RD 1 stated, there was not much communication between nursing and the RD or dietary department. The RD 1 stated, the CNAs were responsible for weighing residents weekly and monthly. The CNAs notified the licensed nurses of the weekly and monthly weights. The licensed nurses were responsible to enter the resident's weights in the electronic medical record. The RD 1 stated, the licensed nurses were responsible to notify the RD of any significant weight change. The RD 1 further stated the facility's goal was to manage resident's weight loss proactively. On 10/8/21, at 11:55 a.m., an observation of Resident 114 was conducted. Resident 114 was observed walking slowly with a steady gait, wearing a loose blue upper garment, loose pants, and a pair of slippers. When Resident 114 was asked in her native language how she was doing, Resident 114 stated she was hungry. During a concurrent observation and interview on 10/8/21, at 12:05 p.m., with the CNA 4 outside Resident 114's room, the CNA 4 stated, Resident 114's upper and lower garments were loose and looked too big for her. During a concurrent observation and interview on 10/8/21, at 12:33 p.m., with the CNA 5 inside Resident 114's room, the CNA 5 stated, Resident 114 was on a regular diet and needed assistance with tray set-up. The CNA 5 set-up Resident 114's meal tray and Resident 114 begin eating her meal vigorously. CNA 5 stated, Resident 114 liked to be left alone during mealtimes. Upon completion of Resident 114's lunch meal, on 10/8/21, at 12:51 p.m., Resident 114 consumed 100% of the fish, gelatin, and dinner roll. Resident 114 consumed 75% of the french fries and 25% of the cabbage salad. Resident 114 drank 100% (240 ml) of milk. During a concurrent observation and interview on 10/8/21, at 1:19 p.m., with the CNA 6, the CNA 6 stated, Resident 114 consumed 100% of her lunch meal and drank 100% of her milk. CNA 6 validated Resident 114 didn't eat 100% of her cabbage salad. During an interview on 10/8/21, at 3:48 p.m., with the RD 1, the RD 1 confirmed the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 and the significant severe unplanned weight loss of 10.2 % within a five-month timeframe from 5/7/21 to 10/1/21 for Resident 114 was not addressed by the RD. The RD 1 further stated the weight loss for Resident 114 was not acceptable. During an interview on 10/11/21 at 1:47 p.m., with the CNA 7, the CNA 7 stated, the diet ordered for Resident 114 had not changed since admission. The CNA 7 stated, Resident 114's weights were taken every month by the RNA (Restorative Nurse Assistant) or CNA and reported to the charge nurse. During a concurrent interview and record review on 10/12/21 at 1:25 p.m., with the DSD, Resident 114's Meal Percentage Report Documentation Survey Reports (MPR), dated 8/1/2021 through 10/7/21 were reviewed. The MPR indicated, of the 204 meals (breakfast, lunch, and dinner), served between 8/1/21 and 10/7/21, Resident 114 refused of her meals 9% of the time and consumed 50% or less 21% of the time. The DSD confirmed Residents 114's intake. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident on resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . Review of the facility's Policy and Procedure titled Care Planning- Interdisciplinary Team revised September 2010 showed, an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; f. Identify the professional services that are responsible for each element of care; .4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) .5.When possible, interventions address the underlying source(s) of the problem area (s) .9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition. During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, the Journal indicated, Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality.https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1 In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . 2. During a concurrent interview and record review, on 10/07/21 at 1:00 p.m., with LVN 1, Resident 114's PN was reviewed. The LVN 1 was unable to confirm documentation the RD was notified of the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 and the significant severe unplanned weight loss of 12.5 lbs., 10.2% in five months, from 5/15/21 through 10/1/21 for Resident 114. During a concurrent interview and record review on 10/7/21 at 3:07 p.m., with the Director of Nursing (DON), Resident 114's the WVS and the PN, dated 10/7/21 were reviewed. The DON stated, all newly admitted residents were weighed every week for four weeks and if stable, then weights were done monthly. The DON confirmed Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 and a significant unplanned weight loss of 12.5 lbs., 10.2% in five months, from 5/15/21 through 10/1/21. The DON stated, Resident 114's significant unplanned weight loss could result in anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss. During a concurrent interview and record review on 10/7/21 at 3:15 p.m., with the Director of Nursing (DON), Resident 114's Dietician Nutritional Assessment (DNA), dated 5/13/21 was reviewed. The DON stated, the DNA for Resident 114 was completed by the Registered Dietician (RD) 2. Section B of the DNA indicated, Resident 114's caloric needs were between 1,230 and 1,420 calories. Section D of the DNA indicated, Resident 114's fluid needs were between 1,230 and 1,420 ml (unit of measurement). Section F of the DNA indicated the goal for Resident 114 was Resident will not have a significant weight change. Section G of the DNA indicated interventions for Resident 114's was diet is liberalized. Continue POC (Plan of Care). RD to monitor weights and follow up as needed. The DON was unable to validate a DNA addressing the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21, and the significant severe unplanned weight loss of 12.5 lbs., 10.2% in five months, from 5/15/21 through 10/1/21 was completed by the RD. The DON confirmed Resident 114 did not receive the appropriate follow-up assessment required by the RD according to the facility's policy. During an interview on 10/8/21, at 3:48 p.m., with the RD 1, the RD 1 confirmed the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 and the significant severe unplanned weight loss of 10.2 % within a five-month timeframe from 5/7/21 to 10/1/21 for Resident 114 were not addressed by the RD. RD 1 further stated the weight loss for Resident 114 was not acceptable. A review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident on resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, the journal indicated, Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality.https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1 In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide outside services of Podiatry (DPM), Registered Dietician (RD), and Psychiatry for three (3) of sixteen (16) sampled residents and twenty-two (22) unsampled residents when: 1. A physician of podiatry was not contracted to provide services to the facility from 12/3/20 to 10/6/21. This failure resulted in podiatry services not being provided to Resident 117 and 109 as well as 22 other residents in need of podiatry physician evaluation. Resident 117 experienced pain, infection, and removal of the left great toenail and pain, and ingrown right great toenail for Resident 109 and placed the other twenty-two (22) residents at risk for pain, ingrown toenails, and infections. 2. A Registered Dietitian (RD) was not contracted to provide services to the facility from July 21, 2021 to August 19, 2021. This failure resulted in no RD assessments for Resident 114 and no effective interventions to address a significant severe weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 for Resident 114 to not be assessed or monitored by the RD. 3. A psychiatrist was not contracted to provide services to the facility from 12/3/20 to 10/14/21. This failure resulted in psychiatry services were not provided to Resident 114. This failure resulted in Resident 114 did not receive psychiatric assessments and placed Resident 114 at risk for decline in her mental health status. These failures place the residents at risk for a decline in their health and safety. Findings: 1. During a concurrent observation and interview, on 10/5/21 at 9:00 a.m., with Resident 109, Resident 109's toenails were extremely long, sharp, with brownish yellow discoloration on both feet. Resident 109's right great toenail was grown around the end of the toe in a circle and was pressing on his skin under the toe. Resident 109 stated he had not seen a podiatrist since admission to the facility 3/1/21. During an interview on 10/5/21 at 9:11 a.m., with the Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was familiar with Resident 109 and his toenails were long. LVN 2 stated she had told the Social Services Director Resident 109 needed to see a Podiatrist. LVN 2 stated the SSD was responsible for getting appointments for podiatry but had not made Resident 109 an appointment for podiatrist. LVN 2 stated the facility did not have a podiatrist. During an interview, on 10/5/21 at 9:47 a.m., with the Social Services Director (SSD), the SSD stated LVN 2 had told her Resident 109 needed a podiatrist. The SSD stated the Regional Director of Operations (RDO) was working on getting a podiatry contract for the facility but had not done it. The SSD stated she did not know when the facility would get a podiatrist. The SSD stated Resident 109's toenails looked like talons. The SSD stated when the toenails were that thick and tough only a podiatrist could cut them. The SSD stated Resident 109 could experience sores from the nails pressing on his skin. During a review of Resident 109's Face Sheet dated 3/1/21, the Face Sheet indicated Resident 109 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 109 had diagnosis of Type 2 Diabetes Mellitus, Hemiparesis Following Intracerebral Hemorrhage Left Side (weakness following a stroke (bleeding in the brain), Congestive Heart Failure (weakness in the heart where fluid accumulates in the lungs), Hepatitis C (infection caused by virus that attacks the liver), Chronic Kidney Disease (impaired kidney function that worsens over time), and Difficulty Walking. During a review of Resident 109's clinical records there was no documentation of assessment of his toenails in the nursing progress notes, physician's notes, or Activities of Daily Living (ADL) or any other records to indicate he was seen by a podiatrist. During an interview, on 10/5/21 at 11:05 a.m. with the RDO, the RDO viewed a photograph of Resident 109's toenails taken 10/5/21. The RDO stated the facility did not have a contracted podiatrist. The RDO stated should have not waited to get a podiatrist. During a concurrent observation and interview, on 10/6/21 at 9:03 a.m., with Resident 117, Resident 117's toenails were long, jagged, thick, and brownish yellow colored. Resident 117 pointed to his left great toenail and stated he was worried about, The bad one. The left great toenail had dark blackish coloration and looked infected and overgrown. Resident 117 stated he had not seen a podiatrist. During a review of Resident 117's clinical records there was no documentation of assessment of his toenails in the nursing progress notes, physician's notes, or Activities of Daily Living (ADL) or any other records to indicate he was seen by a podiatrist. During a review of Resident 117's Face Sheet dated 4/30/21, the Face Sheet indicated Resident 117 was admitted to the facility on [DATE]. The Face Sheet indicted Resident 117 had diagnosis of Idiopathic peripheral Autonomic Neuropathy (decreased feeling in the arms and legs), Osteomyelitis Multiple sites (infection in the bones), Type 2 Diabetes Mellitus, Ingrown Nail, Fracture of the Cervical, Thoracic and Lumbar Region (broken bones of the back), Chronic Obstructive Pulmonary Disease (constriction of the airway with difficult breathing), and Difficulty Walking. During an interview, on 10/6/21 at 9:15 a.m., with the SSD, the SSD stated she was aware the facility needed a podiatrist. The SSD stated the RDO had found a podiatrist 10/5/21 and the podiatrist came to the facility 10/6/21 to treat 24 residents. When asked why the facility had not gotten a podiatrist before, the SSD stated, We couldn't find one to come out here. During a concurrent observation and interview, on 10/6/21 at 12:45 p.m., with the Podiatrist (DPM), the DPM stated she was informed 10/5/21 the facility needed her services. The DPM viewed A photograph of Resident 109's toenails and stated the toenails appeared not to have been trimmed in about six (6) months. The DPM stated she had treated Resident 109 and he had an active toenail fungus that caused the toenails to thicken and become discolored and an ingrown right great toenail. The DPM stated she was very careful to not injure Resident 109 because he was diabetic. The DPM stated Resident 109 was high risk if the overgrown toenails grew into his skin and caused pressure sores. The DPM stated due to the condition of the toenails, Resident 109 should have seen a podiatrist and had his nails trimmed every two months. The DPM stated she had assessed and treated 22 other residents, but Residents 109 and 117 toenails were in the worst condition. During a concurrent interview and record review, on 10/6/21 at 2:38 p.m., with the Podiatrist (DPM), the DPM stated she was made aware 10/5/21 the facility needed podiatry services. The DPM stated she had been coming to the area but no one from the facility had contacted her until yesterday. The DPM stated she had seen Resident 117, had removed the left great toenail and treated him for infection. The DPM stated the toenail had purulent (Yellow fluid from a wound-sign of infection) drainage under the toenail which caused redness and pain. The DPM stated the blackish color on the left great toenail was due to a previous injury where the nailbed bled and became blackened. The DPM stated she had ordered a betadine (disinfectant for skin) treatment daily to treat the left great toe. The DPM stated she did not know how long Resident 117's toe was infected. The DPM stated Resident 117 should have been treated by a podiatrist but was not. During an interview, on 10/11/21 at 9:09 a.m., with the Administrator (ADM), the ADM stated the facility had been unable to get the Podiatrist to come to the facility. The ADM stated there was no Podiatry services at the facility from 12/2/20 to 10/6/21. During an interview, on 10/13/21 at 8:37 a.m., with LVN 1, LVN 1 stated she had assessed Residents 109 and 117 about a month ago. LVN 1 stated she told SSD Residents 109 and 117 needed a podiatrist because she was unable to trim their toenails. LVN 1 stated the SSD told her she would follow up with a podiatrist but had not. LVN 1 stated long toenail could cause cuts, get caught on something or cause an infection. LVN 1 stated the long toenails would most likely have been painful. LVN 1 stated the condition of Resident 109 and 117's toenails should not have gotten that bad. During a concurrent interview and record review, on 10/13/21 at 11:00 a.m., with the RDO, the contracts for outside services were reviewed. The RDO stated the facility had opened 12/3/20 and did not have a contracted podiatrist 12/3/20 to 10/6/21. The RDO stated it was his job to get physician contracted services for the facility. The RDO stated it was his expectation the facility would have podiatry care for the residents. The RDO stated the residents could have been harmed in many ways, especially since they were both diabetic. The RDO stated if he had been informed of the situation with Residents' 109 and 117's toenails, he would have acted but he was blindsided. During a professional reference review of the Nursing Times article titled, Foot Assessment and Care for Older People dated 12/9/14, the article indicated, .Foot care can prevent mobility problems and social isolation; it is a crucial part of nursing care, particularly for older patients, who may be unable to care for their own feet .While foot problems can occur in all age groups, their prevalence increases with age. It is estimated that 80% of older people have foot problems . The prevalence of serious foot problems, such as peripheral arterial disease, does increase with age .Common foot problems in older people .Toenail disorders including hardened or ingrown nails .Toe deformities such as overlapping toes .Corns and calluses .Bunions .Fungal infections .If unattended such problems can lead to more serious issues .Those who are unable to perform this essential task for themselves need regular assessment and care to help prevent adverse effects from occurring .Dryness that is associated with reduced blood flow may cause the skin to split, resulting in painful fissures, while poor circulation may lead to a higher risk of infection .Toenails can thicken and become hard and brittle with age, which makes it difficult to cut them. Continuous pressure from inappropriate footwear can also cause more extreme nail deformity. Nails that become too long or thickened can damage the skin on adjacent toes .Ingrown toenails occur when a nail grows into the skin, and can cause pain, swelling, redness and infection .Fungal infection of skin, such as athlete's foot - which causes peeling, redness, itching, burning .Fungal nail infections occur when microscopic fungi enter the nail through a break; they result in thick, discolored and brittle nails .Foot assessment .When older people can no longer manage their own foot care, an initial assessment is required to identify what help they need .Podiatrists assess all new nursing home residents . After an individual has been assessed, care may be provided by Podiatrists' . 2. A review of an email provided by the facility from the Nutrition Consulting Company A, dated 7/23/21, at 4:55 p.m., indicated the last day of service for the Nutrition Consulting Company A was July 21, 2021. A review of the contract with the Nutrition Consulting Company B indicated the contract began on August 19, 2021. On 10/5/21 at 3:23 p.m. an interview was conducted with the Administrator (ADM). The ADM stated the RD 1 started consulting for the facility last week. A review of Resident 114's Medical Record (MR), dated 10/8/21, indicated, Resident 114 was admitted on [DATE], with diagnoses that included Unspecified Dementia with Behavioral Disturbance (diminished memory with episodes of agitation or restlessness), Bipolar Disorder (feeling very sad or very excited), Circadian Rhythm Sleep Disorder (unable to sleep), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Hyperlipidemia (elevated fat levels in the body), Muscle Weakness, Muscle Wasting and Atrophy (decreased muscle tissues), Psychotic Disorder with Delusions (a disorder characterized by a disconnection from reality) and Essential Hypertension (abnormally high blood pressure). The most recent Minimum Data Set (MDS, a resident assessment tool) dated 8/18/21, indicated a BIMS (brief interview for mental status) score of 9 out of a possible 15, indicating Resident 114 was unable to complete the interview. Section C1000 of the MDS indicated, Resident 114's Cognitive Skills for Daily Decision Making was severely impaired. Section K of the MDS indicated, Resident 114 had a weigh loss of 5% or more in the last month and was not on a physician- prescribed weight-loss regimen. A review of the facility document titled, Weights and Vitals Summary (WVS), dated 10/8/21, indicated the following weights and comparisons for Resident 114: 5/7/21 121.2 lbs (pounds., unit of measurement) 5/9/21 120 lbs 5/15/21 122.1 lbs 5/23/21 118.8 lbs [-3.3. lbs in one week] 5/29/21 117.8 lbs 6/2/21 116 lbs 6/6/21 117 lbs 7/1/21 116.4 lbs 8/6/21 111.6 lbs (-7.5% change [comparison weight 5/15/21, 122.1 lbs., -8.6%, -10.5 lbs.] 9/3/21 111.6 lbs A review of the facility document titled Order Summary Report (OSR), dated 10/8/21, indicated, on 5/07/21 a Regular diet, Regular texture, and Regular Liquids Consistency was ordered by the Physician for Resident 114. During a concurrent interview and record review, on 10/07/21 at 12:44 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 114's Weights and Vitals Summary (WVS), dated [DATE] was reviewed. The LVN 1 stated, all newly admitted residents were weighed every week for four weeks and if stable, then weighted monthly. The LVN 1 stated, she would ask the Certified Nurse Assistant (CNA) to reweigh the resident for any weight loss. The LVN 1 stated, she would notify the doctor, the RD, the dietary department, and the responsible party (RP) for any significant or severe weight loss. The WVS indicated, on 5/15/21, Resident 114's weight was 122.1 lbs. On 8/6/21, Resident 114 weight was 111.6 lbs., a 10.5 lb., 8.6% weight loss in three months. The LVN 1 was unable to confirm nursing documentation in Resident 114's medical record which indicated the Physician, the RD, the dietary department, and the RP were notified when Resident 114 experienced an 8.6% significant severe unplanned weight loss in three months. During a concurrent interview and record review, on 10/07/21 at 12:55 p.m., with LVN 1, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Focus Section of the CP indicated, the RD admission Assessment was completed on 5/13/21. The interventions/tasks section of the CP indicated, monitor/record/report to MD PRN signs and symptoms (s/s) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. Provide, serve diet as ordered. Monitor intake and record every meal. During a concurrent interview and record review, on 10/07/21 at 1:00 p.m., with the LVN 1, Resident 114's Progress Notes (PN) were reviewed. The LVN 1 was unable to confirm documentation the RD was notified of the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21. During a concurrent interview and record review on 10/7/21 at 3:07 p.m., with the Director of Nursing (DON), the WVS and the PN for Resident 114 were reviewed. The DON stated, all newly admitted residents were weighed every week for four weeks and if stable, were weighed monthly. The DON confirmed Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs, 8.6% in three months, from 5/15/21 through 8/16/21. The DON stated, Resident 114's significant severe unplanned weight loss could result in anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss. The DON was unable to confirm nursing documentation in Resident 114's medical record which indicated the Physician, the RD, the dietary department, and the RP were notified when Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs, 8.6% in three months, from 5/15/21 through 8/16/21. During a concurrent interview and record review on 10/7/21 at 3:15 p.m., with the Director of Nursing (DON), Resident 114's Dietician Nutritional Assessment (DNA), dated 5/13/21 was reviewed. The DON stated, the DNA for Resident 114 was completed by the Registered Dietician (RD) 2. Section B of the DNA indicated, Resident 114's caloric needs were between 1,230 and 1,420 calories. Section D of the DNA indicated, Resident 114's fluid needs were between 1,230 and 1,420 ml (unit of measurement). Section F of the DNA indicated the goal for Resident 114 was Resident will not have a significant weight change. Section G of the DNA indicated interventions for Resident 114's was diet is liberalized. Continue POC (Plan of Care). RD to monitor weights and follow up as needed. The DON was unable to validate a DNA addressing the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 was completed by the RD. The DON confirmed Resident 114 did not receive the appropriate follow-up assessment required by the RD according to the facility's policy. During an interview on 10/7/21, at 5:24 p.m., with the LVN 3, the LVN 3 stated, Resident 114 fed herself, refused help, and frequently paced the hallway. During a concurrent observation and interview inside Resident 114's room, on 10/7/21, at 5:30 p.m., with the CNA 3, the CNA 3 stated, Resident 114 fed herself, had good and bad days. The CNA 3 stated, she would offer a sandwich or something else if Resident 114 consumed 25% or less of her meals. During an observation of the dinner meal service on 10/7/21, at 5:35 p.m., in Resident 114's room, Resident 114 was observed struggling to cut the chicken meat with a fork. Resident 114 used her hands to eat the chicken meat. Resident 114 consumed 90% of chicken, 75% of rice, 75% of vegetable and 100% of dessert. Resident 114 did not drink the milk. Resident 114 attempted to remove the water pitcher cover to drink water, however she was unable to remove the water pitcher cover. The CNA 3 assisted Resident 114 to remove the water pitcher cover and Resident 114 drank water directly from the pitcher. During an interview on 10/7/21, at 5:51 p.m., with the LVN 1, the LVN 1 stated, she was not notified or aware of any change in intake or weight loss for Resident 114. On 10/8/21 at 10:16 a.m., an interview was conducted with the RD 1. The RD 1 stated he started working at the facility two weeks ago. The RD 1 stated the facility had a loose system for monitoring weights. The RD 1 stated, there was not much communication between nursing and the RD or dietary department. The RD 1 stated, the CNAs were responsible for weighing residents weekly and monthly. The CNAs notified the licensed nurses of the weekly and monthly weights. The licensed nurses were responsible to enter the resident's weights in the electronic medical record. The RD 1 stated, the licensed nurses were responsible to notify the RD of any significant weight change. The RD 1 further stated the facility's goal was to manage resident's weight loss proactively. On 10/8/21, at 11:55 a.m., an observation of Resident 114 was conducted. Resident 114 was observed walking slowly with a steady gait, wearing a loose blue upper garment, loose pants, and a pair of slippers. When Resident 114 was asked in her native language how she was doing, Resident 114 stated she was hungry. During a concurrent observation and interview on 10/8/21, at 12:05 p.m., with the CNA 4 outside Resident 114's room, the CNA 4 stated, Resident 114's upper and lower garments were loose and looked too big for her. During a concurrent observation and interview on 10/8/21, at 12:33 p.m., with the CNA 5 inside Resident 114's room, the CNA 5 stated, Resident 114 was on a regular diet and needed assistance with tray set-up. The CNA 5 set-up Resident 114's meal tray and Resident 114 begin eating her meal vigorously. CNA 5 stated, Resident 114 liked to be left alone during mealtimes. Upon completion of Resident 114's lunch meal, on 10/8/21, at 12:51 p.m., Resident 114 consumed 100% of the fish, gelatin, and dinner roll. Resident 114 consumed 75% of the french fries and 25% of the cabbage salad. Resident 114 drank 100% (240 ml) of milk. During a concurrent observation and interview on 10/8/21, at 1:19 p.m., with the CNA 6, the CNA 6 stated, Resident 114 consumed 100% of her lunch meal and drank 100% of her milk. CNA 6 validated Resident 114 didn't eat 100% of her cabbage salad. During an interview on 10/8/21, at 3:48 p.m., with the RD 1, the RD 1 confirmed the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 for Resident 114 were not addressed by the RD. The RD 1 further stated the weight loss for Resident 114 was not acceptable. A review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident on resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, the journal indicated, .Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . During a review of the facility's policy and procedure titled, CONSULTANTS dated 12/2009, the policy indicated, .Our facility uses outside resources to furnish specific services provided by the facility .To furnish specific services .On a consultant basis .Consultant services may be uses in the following areas .Dietary Services .Written, signed, dated agreements are maintained for each consultant .Each agreement contains .The responsibility of the consultant .The responsibility of the facility .The minimum number of hours to be provided by the consultant .Consultants provide the Administrator with written, dated, signed reports .Recommendations .Plans for implementation .Findings .Plans for continued assessments . 3. During a concurrent interview and record review, on 10/11/21 at 8:51 a.m., with the Director of Nurses (DON), the Physician's Orders (PO) for Resident 114 was reviewed. The DON stated Resident 114 had diagnosis of Bipolar Disorder (mental condition marked by periods of elation and depression), Major Depressive Disorder (chronic loss of interest/sadness), Psychotic Disorder (chemical imbalance in the brain marked by seeing or hearing things that are not there). The DON stated Resident 114 received two medications for mental illness, Olanzapine (medication for psychosis (hallucinations) 10 milligrams (mg-weight measurement) daily and Valproic acid (mood stabilizer) 125 mg twice a day since admission 5/7/21. The DON stated Resident 114 had behaviors of screaming, hitting herself, hallucinations and elopement. The DON confirmed there was no psychological evaluation for Resident 114. The DON stated the facility did not have a Psychiatrist to evaluate residents with mental illness. The DON stated the facility should have had psychiatric consultation for Resident 114 but did not. During a concurrent interview and record review, on 10/11/21 at 11:32 a.m., with the Social Services Director (SSD), the SSD reviewed Resident 114's clinical records. The SSD confirmed Resident 114 was diagnosed with Psychosis and Bipolar Disorder and had not been evaluated by a psychiatrist. The SSD stated the facility did not have a psychiatrist since opening 12/3/20 to present. The SSD stated when she had asked corporate Regional Director of Operations (RDO) about psychiatric services, the RDO had told them the main hospital had taken too long to obtain the psychiatrist's credentials and psychiatric services were never started. The SSD stated corporate was responsible for contracting outside services for the facility but had not done it. During an interview on 10/11/21 at 9:09 a.m., with the Administrator (ADM), the ADM stated the facility originally had contracts but were unable to get the Psychiatrist to come to the facility. The ADM stated there was no psychiatric services at the facility since opening 12/3/20. The ADM stated the facility should have had Resident 114 evaluated by a psychiatrist but did not. During a review of Resident 114's Face Sheet dated 10/7/21, the Face Sheet indicated the admission date was 5/7/21. The Face Sheet indicated Resident 114 had diagnosis of Dementia (memory impairment), Bipolar Disorder (mental condition marked by periods of elation and depression), Major Depressive Disorder (chronic loss of interest/sadness), Psychotic Disorder (chemical imbalance in the brain marked by seeing or hearing things that are not there), Circadian Sleep Disorder (unable to sleep at regular times), Muscle Wasting (weakness and shrinking in the muscles), and Hypertension (higher than normal pressure in the blood vessels). During a review of the facility's policy and procedure titled, Antipsychotic Medication Use dated 3/15, the policy indicated, .Antipsychotic medication may be considered for residents .Only after .Psychological, emotional psychiatric evaluations . During a review of the facility's policy and procedure titled, CONSULTANTS dated 12/2009, the policy indicated, .Our facility uses outside resources to furnish specific services provided by the facility .To furnish specific services .On a consultant basis .Written, signed, dated agreements are maintained for each consultant .Each agreement contains .The responsibility of the consultant .The responsibility of the facility .The minimum number of hours to be provided by the consultant .Consultants provide the Administrator with written, dated, signed reports .Recommendations .Plans for implementation .Findings .Plans for continued assessments .The facility retains the professional and administrative responsibility for all services provided by consultants .Consultants serve on various committees of the facility .