Findings: Multiple observations, interviews and record reviews (Reference Federal Tags F550, F674, F584, F641, F656, F657, F658, F677, F687, F695, F710, F725, F761, F791, F800, F801, F804, F812, F835, F842, F865, F867, F868, F880 and Substandard Quality of Care Federal Tags F689 & F692) during the recertification survey conducted from 6/10/24 at 8:45 a.m. to 6/24/24 at 4:48 p.m., demonstrated the facility's actions, inactions and decisions, contributed to a facility in which residents were seriously harmed (F689 & F692), residents were not treated with dignity and respect (F550 and F584), residents did not receive the care and services they needed (F677, F687, F791 & F725), meals were not palatable, stored or prepared in a sanitary manner (F800, F804 & F812), medications were not stored properly (F761) and resident care plans were not created or revised (F657 & F658). In addition, despite inadequate staffing levels, they continued to accept new residents (F725 & F550). During an interview with the Director of Nursing (DON) on 06/21/24 at 5:01 p.m., the QAPI (Quality Assurance and Performance Improvement) program was presented and discussed. The DON stated there had been 28 resident falls in January 2024, 34 falls in February 2024, 35 falls in March 2024, 12 falls in April 2024 and 25 falls in May 2024 for a total of 134 falls for the first five months of the year. Three of these falls had resulted in major injuries. The DON stated that although the number of falls were being tracked, interventions for fall prevention measures were not being tracked. The DON stated Department Heads had not had a meeting to discuss falls specifically and decide what they were going to do to reduce the incidences of falls. The fall QAPI project presented to the Surveyors through the DON's computer had several areas that were blank or empty. The DON stated that although she was the person coordinating the QAPI plan, the Administrator was present during the meetings, therefore, she was aware of the recurrent falls. During this interview with the DON on 6/21/24 at 5:01 p.m., she was asked if they had a QAPI project regarding weight loss issues for the residents. The DON stated the Assistant Director of Nursing was responsible for tracking information regarding this issue but had not provided her with any information to enter into the QAPI plan. The DON presented the plan on her computer which was blank, as no data had been entered. The DON stated the Administrator was aware of the weight loss issues among the resident population of the facility. The DON stated no decisions had been made as to what they were going to measure regarding weight loss issues, in the QAPI plan. The DON was also asked if they were tracking staffing issues in the QAPI plan. The DON stated staffing was not being tracked. The DON stated that although she was the person coordinating the QAPI program, she was not being assisted by the Department Heads who were supposed to provide her with their reports. During a phone interview with Anonymous Witness O on 6/13/21 at 4:15 p.m., she stated staff at the facility were constantly being threatened by the Administration to not provide any information to family members or staff from the Department of Public Health about the care or lack of care the residents were provided, and in fact, staff had been terminated from the facility for speaking up about the unfair treatment residents were receiving. Anonymous Witness O stated incidents of abuse involving residents were not being reported to the required authorities, and staffing was so bad there were times when Certified Nursing Assistants were assigned up to 20 residents per shift. Anonymous Witness O also stated staff would get in trouble for entering the Administrator's office if not called by her, and if they discussed resident care concerns with the Administrator, she would look at them, deflect the situation, and made the staff member bringing up the concern, responsible for the issue being brought up. During an interview with Anonymous Witness J on 6/14/24 at 4:15 p.m., he/she stated certified nursing assistants were assigned 16 to 20 residents per shift, which did not provide them enough time to provide all needed services and supervise residents at risk for falls. Anonymous Witness J also stated that even if the facility had enough certified nursing assistants to work as a one to one (One staff working with only one resident) with a resident at risk for falls, the Administrator would send them home, and only once, in his/her employment at the facility, had he/she observed a one to one, and it was because the resident was extremely aggressive. Anonymous Witness J also stated staff were threatened by Administration against speaking to the Surveyors during this survey, and were told the Surveyors would, twist their words and take their CNA certificates away. They were also forbidden from entering the conference room where Surveyors were working without an Administrator present. The facility job description titled, Administrator, undated, indicated: Principal Responsibilities: . *Ensures Center compliance with all Federal, State and company regulations and policies. * Ensures that all practices and policies are carried out in the highest ethical manner. *Ensures that all Standard of Care and service provided is of the highest quality . Qualifications: .*Possess effective communication skills to maintain positive relationship with residents, families, staff, physicians, consultants, providers, and governmental agencies, their representatives, and the community at large. *Ability to implement facility and company philosophy of care. *Current knowledge of local, state and federal guidelines and regulations . Based on observation, interview, and record review, the facility's Administrator failed to ensure effective oversight and necessary resources to ensure the residents' quality of care, safety, dignity, and dietary services, which include maintenance of the resident's nutrition and hydration were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all 81 residents when: 1. The Quality Assurance and Performance Improvement Committee, whose members included the Administrator did not make sure an action plan was implemented to reduce the number of falls in the facility and promote a resident safety plan by monitoring trends and implementing changes through careful analysis of the falls, which led to 134 falls from January 2024 through May 2024. Three of these falls had resulted in major injuries, Resident 15, Resident 28, and Resident 233 (Cross-Reference to F689 - Substandard Care). 2. The Administrator did not ensure the RD (Registered Dietician) was making frequent scheduled visits to oversee the day-to-day operations of the kitchen, which led to multiple issues in the kitchen including errors in plating prescribed diets and lack of dietary staff competencies in the cool down process, thawing process and three sink washing process. Failure to ensure adequate oversight may result in compromising the nutritional status of all residents and cross contamination of resident food and foodborne illness (Cross-Reference F800, F801, F804, & F812). 3. The Administrator did not ensure the RD made routine visits to residents with significant weight loss or gain in order to observe/interview residents to find out why they were having severe nutritional changes, and make sure new admission's nutritional assessments were done in person to minimize nutritional complications. This resulted in multiple residents, including Resident 12, Resident 20. Resident 25, Resident 29, and Resident 227, having various nutritional complications leading to further compromising the resident's medical state (Cross-Reference 692 - Substandard Care). 4. The Administrator did not ensure there were staff in sufficient numbers to meet the individual care needs of residents resulting in residents having to wait long periods for call lights to be answered and lack of ADLs (Activities of Daily Living: are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and assisted with eating or needing to be fed), which led to a resident being left in a soiled brief for a long period causing breakdown in the resident's skin, lack of dignity for multiple residents, and had the potential for residents to become dehydrated and weight loss to occur because of not being offered water and assistance during meals or with snacks, feeling unkept and unclean, loss of self-worth and feeling of low self-esteem, which could further impacting residents' physical and psychosocial wellbeing. Residents impacted included Resident 2, Resident 3, Resident 4, Resident 6, Resident 12, Resident 14, Resident 20, Resident 21, Resident 25, Resident 29, Resident 35, Resident 40, Resident 46, Resident 50, Resident 55, Resident 58, Resident 65, Resident 67, Resident 68, and Resident 232, but not limited to (Cross-Reference F550, F677, and F725). 5. The Administrator did not ensure charting for fluid and meal intake was being documented consistently, which had the potential for residents to become dehydrated and nutritional concerns causing one's health to be compromised, which could lead to residents being hospitalized and even death, which included Resident 25, Resident 29, and Resident 227 (Cross Reference F692 and F842).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 2 of 24 sampled residents (Resident 28 and Resident 15) and one discharged resident (Resident 233) who were at risk for falls and had a history of falls, were provided with supervision by direct care staff, and had effective revisions and implementation of their nursing care plans to prevent further falls to keep them safe. Facility policies on safety and management of falls were not followed. As a result, Resident 28, Resident 15 & Resident 233 suffered falls with major injuries at the facility. This may have contributed to Resident 233's death, and Resident 28's dramatic decline, as she is now expected to pass away within 6 months. In addition, 2 of 24 sampled residents suffered falls without major injuries (Resident 227 and Resident 51), due to lack of supervision, creation, revision, and implementation care plans to prevent falls. This had the potential to result in injuries with major injuries, including death to the residents involved. Findings: Record review indicated Resident 28 was admitted to the facility on [DATE] with medical diagnoses including History of Falling (History of having suffered falls, which may indicate increased risk for future falls), Difficulty in Walking, and Muscle Weakness, according to the facility Face Sheet (Facility Demographic). Record review of Resident 28's MDS (Minimum Data Set-An assessment tool) area GG (Section of the MDS that evaluates the amount of assistance a patient needs) dated 4/29/24 indicated she required supervision or touching assistance from staff to transfer to the toilet, transfer to the chair from bed, and walking 10 feet. Record review of a General Acute Care Hospital (GACH) physician progress notes dated 7/08/22 at 5:05 p.m. indicated Resident 28 underwent surgery to repair a left femoral (thigh bone) neck (Upper section of the bone below the head) fracture, which occurred as a result of a fall at the facility. This note indicated, [Resident 28] is a [AGE] year old female . who resides at [Name of Facility], who usually ambulates (Ability to walk) with a walker complaining of left hip pain after ground level fall yesterday. She presented to the ER (Emergency room) today where x-rays demonstrated a impacted left femoral neck fracture. Orthopedics was consulted and she was admitted to the hospitalist service in anticipation of surgical treatment. During an interview with the Medical Records Director on 6/18/24 at 1:40 p.m., she was asked to provide the following documents for every fall Resident 28 has sustained at the facility after January 1st, 2024 (Resident 28 had a long history of falls, therefore, a decision was made to concentrate on the falls suffered this year for the succinctness of this investigation): Fall Risk Evaluation Post-Fall Assessment Neurological assessments (A healthcare provider's evaluation of a person's nervous system after a fall to help determine the extent of damage from head trauma and understand its effects) if applicable During an interview with the Director of Nursing (DON) on 6/18/24 at 4:46 p.m., she provided some of the documents requested above for every fall for Resident 28, but not all the documents. The DON stated the ones not provided were not found. 1st Fall: Record review of Resident 28's progress note dated 1/18/24 at 12:45 a.m., indicated, Responded to resident's room after a CNA (Certified Nursing Assistant) stated that the resident was observed on the floor. Resident was sitting on her bottom on the floor at the foot of her bed. Record review of the Fall Risk Evaluation dated 1/18/24 at 2:31 p.m., indicated Resident 28's fall risk score after the fall on 1/18/24 was 21, which indicated she was at high risk for falls. Record review of a Post-Fall assessment dated [DATE] (No time documented) indicated that as a result of this fall, Resident 28 suffered a laceration to the back of the head and the right elbow, with bleeding. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among these documents was the neurological assessment documentation after this fall on 1/18/24. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 1/18/24 with the Director of Staff Development (DSD) on 6/20/24 at 5:10 p.m., she stated that after the fall on 1/18/24, a care plan for falls had been developed with the following interventions, 72 hour Neuro (Neurological assessments) started (The DON could not find neurological checks for this fall, above) .[GACH] evaluation offered and refused .Wound care provided. The DSD confirmed there were no interventions were present in the care plan for increased supervision of Resident 28 to prevent further falls. 2nd Fall Record review of a nursing progress note dated 2/12/24 at 12:44 p.m., indicated, Resident was observed, sitting on the ground with her arm and elbow stuck in the bed rail of the bed. The resident stated she just slipped trying to get up causing her arm to get stuck in the bed rail. An abrasion is present on her right elbow. Record review of the Fall Risk Evaluation dated 2/12/24 at 1:22 p.m., indicated Resident 28's fall risk score after the fall on 2/12/24 was 29, which indicated she was at high risk for falls. Record review indicated a Post-Fall Assessment was completed after the fall on 2/12/24. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among these documents was the neurological assessment documentation after this fall on 2/12/24. During a concurrent interview and record review of Resident 28's care plans for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 2/12/24. The DSD confirmed there were no new interventions were added, included increased supervision. 3rd Fall Record review of a nursing progress note dated 2/16/24 at 3:05 p.m., stated, resident was observed on the floor in her bathroom, when asked what happened the resident stated that she slipped in water or something and landed on her knee. Record review of a Fall Risk Evaluation dated 2/16/24 at 3:08 p.m., indicated Resident 28's score was 13, which indicated her she was at moderate risk for falling, although she had just fallen twice for the month of February 2024. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the Post-Fall Assessment or neurological assessment documentation after this fall on 2/16/24. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 2/16/24. The DSD confirmed there were no new interventions were added, included increased supervision. 4th Fall Record review of a facility report titled, #2214 Fall, dated 2/24/24 (No time documented) indicated, Resident was observed sitting on her bottom at bed side. Her bed was in the lowest position and she appeared to slid off the bed onto the floor when trying to get up. Record review of a Fall Risk Evaluation dated 2/24/24 at 7:45 a.m., indicated Resident 28's score was 20, which indicated she was at high risk for falls. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 2/16/24. The DSD confirmed there were no new interventions added, including increased supervision. 5th Fall Record review of a progress note dated 3/17/24 at 3:15 a.m., stated, Resident [Resident 28] was observed sitting on her bottom on the floor by the side of the bed. Resident stated that she slid right of the bed. Record review of a Fall Risk Evaluation dated 3/17/24 at 7:06 a.m., indicated Resident 28 received a score of 20, which indicated she was at high risk for falls. Record review of a Post-Fall assessment dated [DATE] indicated the resident sustained a 2 cm (Centimeter) right elbow laceration as a result of this fall. Record review of a neurological flowsheet dated 3/17/24 indicated neurological checks were initiated for this fall on 3/17/24 and completed on 3/20/24. During a concurrent interview and record review of Resident 28's care plans with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 3/17/24. The DSD stated the care plan for falls did get revised on 4/02/24 (16 days after the fall on 3/17/24) with the following intervention, Hourly Rounding. 6th Fall Record review of a progress note dated 4/04/24 at 3:39 p.m., indicated, called to resident room STAT (Immediately), upon getting to room resident noted on the floor in the sitting position .resident stated she was standing eating her Peanut Butter and jelly sandwich, then fell to the ground hitting her Right elbow. Record review of a Fall Risk Evaluation dated 4/15/24 at 2:33 p.m. (More than 10 days after the fall on 4/04/24) indicated Resident 28's fall risk score was 14, which indicated she was at moderate risk for falls, despite having just fallen on 4/04/24 according to the progress note dated 4/04/24 at 3:39 p.m. (above) During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the Post-Fall Assessment or neurological assessment documentation after this fall on 4/04/24. During a concurrent interview and record review with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 4/04/24. The DSD confirmed no new interventions were added, including increased supervision. 7th Fall Record review of a progress note dated 5/10/24 at 9:39 p.m., indicated, Resident had a fall this shift around 9pm. Observed on her R (Right) side on the [NAME] hallway with only one shoe on. Voiced that she lost her balance. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the Fall Risk Evaluation or neurological assessment documentation after this fall on 5/10/24. A Post-Fall assessment was completed on 5/10/24 and indicated there were no obvious signs of injury. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 4/04/24. The DSD confirmed there were no new interventions added, including increased supervision. 8th Fall Record review of Resident 28's progress note dated 5/13/24 at 9:53 p.m., indicated, resident had an unwitnessed fall in her room. Resident was observed on the ground outside her bathroom. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the Fall Risk Evaluation or neurological assessment documentation after this fall on 5/13/24. Record review of a Post-Fall Assessment completed on 5/13/24 indicated there were no obvious signs of injury. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 5/13/24. The DSD confirmed there were no new interventions added, including increased supervision. 9th Fall Record review of a progress note dated 5/19/24 at 5:48 p.m., indicated, This writer went in to check on resident and observed the resident with her RT (Right) knee on the ground holding on to her wheeled walker trying to come to a standing position. When resident was asked what happened she stated that she had fallen like that multiple time (The documentation did not indicate what time this occurred) today. Record review of a Fall Risk Evaluation dated 5/19/24 at 7:13 p.m., indicated Resident 28's score was 25, which indicated she was at high risk for falls. Record review of a Post-Fall assessment dated [DATE] indicated the resident had pain of 8/10, All over, although no obvious signs of injury were present. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the neurological assessment documentation after this fall on 5/19/24. During a concurrent interview and record review of Resident 28's care plans for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 5/19/24. The DSD confirmed there were no new interventions added, including increased supervision. 10th Fall Record review of a progress note dated 5/26/24 at 1:25 p.m., indicated, Resident [Resident 28] had a fall this afternoon. Found on the floor lying in front of her bathroom. Stated that she lost her balance. Record review of a Fall Risk Evaluation dated 5/26/24 at 1:29 p.m. indicated her score was 12, which indicated she was at moderate risk for falls, although she had fallen 10 times in five months. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the Post-Fall Assessment after the fall on 5/26/24. Record review of neurological assessments initiated on 5/26/24 after the fall, indicated several boxes were not documented on and left blank; therefore, the neurological assessment was incomplete. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 5/26/24. The DSD confirmed there were no new interventions added, including increased supervision. 11th Fall Record review of a progress note dated 5/31/24 at 8:07 a.m. indicated, Responded to a nurse stat. Resident was laying on her stomach on the floor with her arms out in front of her and her wheeled walker out in front of her. Resident stated that she fell to her knees and then the walker kept going without her. Record review of the Fall Risk Evaluation dated 5/30/24 at 4:25 p.m., indicated Resident 28's score was 27, which indicated she was at high risk for falls. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the Post-Fall Assessment after the fall on 5/31/24. Record review of a progress note dated 5/31/24 at 4:35 a.m. indicated Resident 28 refused neurological assessments after the fall on 5/31/24. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 5/26/24. The DSD confirmed there were no new interventions added, including increased supervision. 12th Fall, with Major Injury Record review of a progress note dated 6/12/24 at 4:25 a.m., indicated, 0320 (3:20 a.m.) CNA found resident sitting on floor, stat called resident stated she slipped out her wheelchair onto the floor .resident c/o (Complained of) right hip pain 8/10 (Pain level of 8 out of 10, where 0 signifies no pain, and 10 is the worst pain experienced in a person's lifetime. A level of 8 out of 10 indicates severe pain) has history of right hip FX (Fracture), sent resident out to [GACH] for assessment. Record review of a Fall Risk Evaluation dated 6/12/24 at 8:35 a.m., indicated Resident 28 score was 22, which indicated she was at high risk for falls. Record review of neurological flow sheets indicated no neurological assessments were documented, probably because Resident 28 was transferred to a GACH right away. Record review of a GACH after visit summary dated 6/17/24 (No time documented) indicated Resident 28 was diagnosed with a fracture of the right femoral neck on 6/12/24 (After the fall on 6/12/24 at 3:20 a.m.) This GACH after visit summary indicated Resident 28 underwent surgery to repair the fracture to the right hip. Record review of a Post-Fall assessment dated [DATE] indicated resident 28 developed pain on her right hip as a result of the fall. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated the care plan for falls was updated on 6/16/24 with the following interventions, continue to offer safety equipment and devices in the event resident changes her preferences .encourage resident to make safe choices to minimize risk for injury .patient education. The DSD confirmed there was no mention of increased supervision. The DSD reviewed all of Resident 28's active care plans and could not find a care plan for care of the right hip fracture. Record review of all care conferences conducted for Resident 28 since January 1st to the present (6/21/24) indicated only one care conference was conducted for Resident 28 in 2024, and this was on 1/15/24, despite all her falls. This care conference did not include any documentation on falls. During an interview with Unlicensed Staff H (Resident 28's assigned nursing assistant) on 6/19/24 at 5:35 p.m., she stated she checked on Resident 28 every hour. Unlicensed Staff H stated Resident 28 thought she could do more than she was capable of doing, and sometimes she would forget things. Unlicensed Staff H also stated Resident 28 needed supervision for toileting. During an interview on 6/19/24 at 5:45 p.m., Licensed Staff I, (Resident 28's assigned nurse) stated that prior to Resident 28's last fall with fracture (Which occurred on 6/12/24) Resident 28 was very wobbly because she was recovering from a urinary tract infection. Licensed Staff I stated she did not check on the resident at regular time intervals. During a concurrent observation and interview with Resident 28 on 6/20/24 at 10:05 a.m., she stated she could not remember any falls and did not know anything about fractures. Resident 28 did state she felt very uncomfortable, and her pain level was a 10/10. Resident 28 stated the pain came from her pelvic area. Resident 28 was observed with fresh sutures from the hip surgery on the right hip. Resident 28 was observed in bed at the time of the interview. During an interview with Anonymous Witness J on 6/14/24 at 4:15 p.m., he/she stated Resident 28 had fallen frequently because administration would not institute a one to one (One staff assigned to only one resident for increased care or supervision) to work with her, and in addition, Resident 28 did not have tab alarms (Alarms that detect motion and notify staff that a resident is on the move). Anonymous Witness YY stated certified nursing assistants were assigned 16 to 20 residents per shift, which did not provide them enough time to perform all activities of daily living (Activities for personal care, such as showering, toileting, etc.) and supervise residents at risk for falls. Anonymous Witness J also stated that even if the facility had enough certified nursing assistants to work as a one to one with a resident at risk for falls, the Administrator would send them home, and only once, in his/her employment at the facility, had he/she observed a one to one, and it was because the resident was extremely aggressive. Record review of a progress note dated 6/13/24 at 11:16 a.m., indicated, Resident RP (Patient representative) mailed a letter for IDT (Interdisciplinary team) conference to discuss falls and 6 month or less to live prognosis. Record review of a progress note dated 6/19/24 at 1:01 p.m., indicated, resident [Resident 28] appears to be declining. The resident needed her medication put in applesauce and she never has before. The residents teeth kept shaking uncontrollably. The resident has been resting for most of the shift. Resident 15 Record review indicated Resident 15 was admitted to the facility on [DATE] with medical diagnoses including Muscle Weakness, and Difficulty in Walking, according to the facility Face Sheet. Record review of an untitled and undated facility report for falls, indicated Resident 15 had suffered 18 falls at the facility since her admission, with the first one occurring on 10/11/20 at 1:30 p.m., (6 days after her admission), and the last one on 4/08/24 at 7:45 p.m. The investigation below focuses on the last three falls suffered at the facility. Record review of a care plan for falls initiated on 7/02/22 indicated, Anticipate my needs Assist with transfers as needed .Hourly Rounding checks for safety. First Fall: Record review of a progress note dated 8/24/23 at 1:51 p.m., indicated, Patients roommate came out of the bathroom and observed her roommate lying on the floor and came and got a nurse. Observed resident sitting on floor next to bed. No visible injuries noted. Record review of a Fall Risk Evaluation dated 8/24/23 at 2:56 p.m., indicated Resident 15 was at low risk for falls (although she had just fallen) because no questions in this form were answered, in fact, nothing was filled out. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. Record review of the care plan for falls for Resident 15 indicated it was not revised or updated after the fall on 8/24/23, and no new interventions were added, including increased supervision. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. 2nd Fall Record review of a progress note dated 9/13/23 at 7:46 a.m., indicated, S/P (Status post [After]) fall, day #1. There were no other progress notes or documentation indicating how the fall occurred, or the circumstances surrounding the fall. Record review of a Fall Risk Evaluation dated 9/12/23 at 1:38 p.m., indicated Resident 15 received a score of 16, which indicated she was at high risk for falls. Record review of the care plan for falls for Resident 15 indicated it was not revised or updated after the fall on 9/13/23, and no new interventions were added, including increased supervision. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. 3rd Fall Record review of a facility report titled, 2263 (Unknown what this number means) Fall, dated 4/08/24 at 7:45 p.m., indicated, [Resident 15] Observed on floor in resident's bathroom. Lying on left side, head up against the wall, feet at the toilet area. Floor was wet .Resident stated that her right ankle hurt. Record review of a progress note dated 4/09/24 at 1:26 a.m., indicated, Resident arrived back at the facility around 12:46 am from [GACH] via stretcher .Dx (Diagnosis) of closed ankle fracture (Broken bone that does not protrude through the skin at the level of the ankle) .Rt (Right) ankle with splint and compression bandage intact. Record review of a Fall Risk Evaluation dated 4/09/24 at 12:02 a.m., indicated Resident 15's score was 5, which indicated she was at low risk for falls (although she had just fallen and fractured her right ankle). During an interview with the DSD on 6/20/24 at 10:30 a.m., she confirmed this Fall Risk Evaluation had been answered inaccurately as it indicated Resident 15 had no history of falls. Record review of neurological assessments initiated for Resident 15 on 4/08/24 (after the fall) were initiated but not completed as several boxes were left without documentation and were blank. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. During a concurrent interview and record review or Resident 15's care plans for falls with the DSD on 6/20/24 at 10:30 a.m., the DSD confirmed no new interventions were added after the fall on 4/08/24 (including increased supervision). The DSD confirmed she could not find a care plan for care of the fracture. Resident 233 Record review indicated Resident 233 was admitted to the facility on [DATE] with medical diagnoses including Dementia (Memory loss), Difficulty in Walking, and Muscle Weakness, according to the facility Face Sheet. Record review of Resident 35's MDS dated [DATE] indicated her BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 5, which indicated her cognition was severely impaired (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). In this assessment, Resident 233 was asked to repeat the words, sock, blue and bed, after they were spoken by the MDS evaluator and Resident 233 was only able to repeat one word after the first attempt. Resident 233 was unable to remember the word, blue, according to this assessment. 1st Fall Record review of a progress note dated 3/27/24 at 11:45 p.m., indicated, Witnessed fall, by one of the aids. Slow decent to the floor after tripping over wheelchair when trying to pick up something up off the floor. Record review of a Fall Risk Evaluation dated 3/27/24 at 11:54 p.m., indicated Resident 233 received a score of 2, which indicated she was at low risk for falls, although she had just fallen hours earlier at the facility. A section of this Fall Risk Evaluation titled, Gait Analysis, was left blank by the person filling out the form, therefore, the fall risk score was inaccurate, according to the DSD during an interview on 6/20/24 at 10:30 a.m. Record review of a care plan initiated on 3/27/24 after the fall, had only one intervention. The intervention indicated, Staff will continue to educate resident about waiting for staff to help pick up items off of floor when they fall. Resident 233 had been unable to recall the word, blue, during the MDS assessment dated [DATE] (above) and her cognition was noted to be severely impaired. There were no interventions to increase Resident 233's supervision added to the care plan. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. 2nd Fall with Major Injury Record review of a facility report titled, #2254 (Unknown what this number indicates) Fall, dated 3/29/24 at 10:19 p.m., indicated, Resident was observed lying beside her bed on her bottom .Resident Unable to Give Description. Record review of a Fall Risk Evaluation dated 3/29/24 at 11:24 p.m., indicated Resident 233 received a score of 10, which indicated she was at moderate risk for falls, despite having just fallen twice in less than one week according to the facility report titled #2254 Fall, dated 3/29/24 at 10:19 p.m., and progress note dated 3/27/24 at 11:45 p.m. Record review indicated neurological assessments were initiated after the fall on 3/29/24 but portions of the form were not completed. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. Record review of a progress note dated 4/02/2024 at 11:41 a.m., indicated that as a result of the fall on 3/29/24, Resident suffered a left femur (Thigh bone) fracture. Record review of a progress note dated 4/14/22 at 8:13 a.m., indicated, Resident has passed away on 4/14/24. Her death occurred 16 days after the fall with fracture, suffered at the facility. Record review of a care plan initiated on 3/29/24 after the fall, had only one new intervention. The intervention indicated, Hourly Rounding. There were no care plans created to care for the fracture. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. Resident 227 A review of Resident 227's admission Record, indicated resident 227 was admitted on [DATE], with a diagnosis including cerebral infarction (stroke), difficult walking, dysphagia (difficulty in swallowing), age-related osteoporosis (causes bones to become weak and brittle), tremor (involuntary quivering movement), restless leg syndrome (an overwhelming urge to move your legs), high blood pressure, hemiplegia (paralysis), aphasia (trouble communicating or understanding), osteoarthritis (wear and tear disease on the joints in one's hands, legs, knees, hips, lower back and neck causing pain and stiffness), amongst others. A review of Resident 227's admission Fall Risk Evaluation, dated 5/10/24, indicated Resident 227 was at moderate risk for falls. Fall 1 A review of Resident 227's Change of Condition Summary, dated 5/11/24 at 1:30 a.m., indicated Resident 227 had an unwitnessed fall in the bathroom, which caused a skin tear to Resident 227's right arm below her elbow. A review of Resident 227's care plan indicated no Fall care plan was implemented after Resident 227's fall on 5/11/24. A review of Resident 227's admission MDS, dated 5/17/24, indicated Resident 227 had a BIM score of 3, which meant Resident 227's cognitive skills for decision making was severely impaired. Section J - Health Condition indicated Resident 227 had a fall in the last month prior to admission/entry or reentry into the facility and Resident 227 had a fall in the last two-six months prior to admission/entry or reentry into the facility. Section V- Care Area Assessment (CAA) Summary of Resident 227's MDS, indicated the Care Area for Falls triggered. Fall 2 A review of Resident 227's Change of Condition Summary dated 5/26/24, indicated Resident 227 had an unwitnessed fall at 6 a.m. A Certified Nursing Assistant (CNA) found Resident 227 on the floor in the bathroom and alerted Resident 227's nurse. An assessment was performed. Resident 227 was complaining of pain to her right arm and Resident 227 had a small bump assessed at the back of her head. Resident 227 did not want to go to hospital. A review of Resident 227's care plan indicated no Fall care plan was implemented after Resident 227's second fall. A review of Resident 227's Change of Condition Summary, dated 5/26/24 at 10:33 p.m., indicated Resident 227 went to the hospital to be assessed for further evaluation after falling that morning at 6 a.m. A review of Resident 227's Change of Condition Summary, dated 5/27/24 at 1:53 a.m., indicated Resident 227 had gone to the hospital to have her right shoulder checked. Resident 227 returned from the hospital via a non-emergency ambulance at 12:25 a.m. with a diagnosis Contusion of Right Shoulder. The Administrator, DON, and Resident 227's physician was notified about the diagnosis from the 5/26/24 post fall. Fall 3 A review of Resident 227's Change of Condition Summary, dated 5/28/24 at 6:39 a.m., indicated the nurse was notified by a staff employee Resident 227 was on the floor next to her bed. The nurse found Resident 227 in a semi sitting position, an assessment was performed, a minor skin tear noted at Resident 227's left forearm, and no other inj[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Record review indicated Resident 25 was admitted to the facility on [DATE] with medical diagnoses including Dementia (Memory loss) and Heart Failure (Inability for the heart to pump enough blood to meet the body's needs) according to the facility Face Sheet. During a dining observation on 6/10/24 at 1:03 p.m., Resident 25 had just finished eating, and was observed leaving the social dining room. Resident 25 had consumed approximately 10% of her lunch meal. Resident 25 appeared extremely thin and frail, with merely skin covering her bones. Record review of a facility document titled, Weights and Vitals Summary, indicated Resident 25's weights were the following: 12/05/23: 110.1 lbs. 1/04/24: 100.6 lbs. (Weight loss of 8.6%) 2/06/24: 100 lbs. 3/04/24: 92 lbs. (Weight loss of 8% in 28 days, 16.43 % weight loss since 12/05/23) 4/08/24: 91.3 lbs. 5/06/24: 88.9 lbs. (Weight loss of 11.6 % in 4 months, since 1/04/24) 6/11/24: 87.5 lbs. (Weight loss of 20.5 % in 6 months, since 12/05/23) Record review of the care plan for weight loss for Resident 25 indicated it was last revised and updated on 7/10/23, although Resident 25 had continued to lose significant weight after 7/10/23. The interventions included, Add appetite stimulant per MD (Medical Doctor) .Supplement as ordered. It was not specific as to what appetite stimulant was used, or what supplement and how often it should be provided. Record review of facility documents titled, Skin and Weight Review, for 2024, documented by the Dietary Manager, contained a clinical section with clinical interventions to prevent further weight loss which consisted of Multi Vitamin, and health shakes with meals. None of these documents indicated the Registered Dietician was involved in creating them or had provided recommendations to prevent further weight loss. Skin and weight reviews were conducted on the following dates: 1/05/24 at 7:51 p.m. The most recent weight was recorded as 98.4 lbs. 1/11/24 at 2:27 p.m. 1/18/24 at 10:36 a.m. 1/25/24 at 1:41 p.m. 2/02/24 at 9:07 p.m. 2/09/24 at 12:24 p.m. 2/24/24 at 8:49 a.m. 3/01/24 at 1:54 p.m. 3/08/24 at 2:42 p.m. 3/14/24 at 9:07 a.m. 3/29/24 at 2:09 p.m. 4/05/24 at 1:49 p.m. 4/11/24 at 1:23 p.m. 4/17/24 at 10:39 a.m. 4/26/24 at 3:47 p.m. 5/03/24 at 2:19 p.m. 5/10/24 at 2:08 p.m.: The most recent weight was recorded as 88.9 lbs. In this document, the interventions to prevent weight loss continued to be the same as in previous Skin and Weight Review, reports, which were multi vitamin and health shakes, although Resident 25 had suffered a severe weight loss and the interventions had been ineffective in preventing or impeding further weight loss. Record review of Resident 25 physician orders for June 2024, indicated interventions to prevent further weight loss, such as Mirtazapine (A medication to treat depression and increase appetite) 7.5 mg (Milligrams) tab to be administered once a day, fortification (Adding nutrients and calories to food to increase their nutritional value) of meals and health shakes had been in place since 9/30/24, and yet, they had not been effective in preventing weight loss, as noted above. Record review of dietary progress notes documented by the Registered Dietician for Resident 25 indicated only 6 notes had been entered from 1/08/24 to the present (6/10/24). These notes indicated: *1/08/24 at 9:08 a.m.: Weight changes: -9.5#[Minus 9.5 pounds](8.6%[8.6% weight loss]) x 30 days (in 30 days), significant -17.3# (14.9%) x 180 days, significant .Supplement: 4oz healthshake w/meals .Significant weight decline per review. *1/18/24 3:16 p.m.: weight decline continues despite liberalized diet (relaxes restrictions of therapeutic diets, allowing individuals to eat a regular diet that includes foods they enjoy). *2/21/24 2:51 p.m.: weight variances continues .Plan: -CCPOC (Continue with plan of care [Plan of care proved ineffective at preventing further weight loss]). *3/18/24 12:05 p.m.: Hx (history) of significant wt (weight) decline .mirtazapine continues RT (related to) Depression although showed little effect as RT meal consumption .CCPOC. *3/27/24 1:50 p.m.: Weight changes: -5.8#(5.9%)x3 weeks, significant -9.4#(9.3%) x90 days, significant. *4/14/24 3:27 p.m.: Wts. (weights) stable from 3.27.24 (3/27/24), desirable .Plan: CCPOC. Record review of Resident 25's percentage of meals consumed from 5/01/24 to 6/20/24 indicated that on several days, the consumption of only one meal was recorded. For example, on 6/10/24, the only meal recorded was at 9:45 p.m., and indicated Resident 25 consumed 76 % to 100% of her meal. According to this report, on the following days, only one meal consumption was recorded per day, in the month of May 2024: 5/02/24 at 6:00 p.m. Resident 25 refused this meal. Unknown if she ate breakfast or lunch. 5/03/24 at 6:00 p.m. 5/04/24 at 7:16 p.m. 5/06/24 at 10:03 a.m. 5/07/24 at 6:00 p.m. 5/11/24 at 6:00 p.m. 5/12/24 at 6:32 p.m. No meal consumption recorded on 5/14/24. 5/16/24 at 9:58 p.m. 5/18/24 at 6:00 p.m. 5/19/24 at 4:23 p.m. 5/20/24 at 6:00 p.m. 5/21/24 at 6:38 p.m. 5/23/24 at 7:46 p.m. 5/25/24 at 6:00 p.m. 5/26/24 at 6:11 p.m. 5/29/24 at 7:10 p.m. 5/30/24 at 12:55 p.m. Based on record review of this report, on only 12 days out of 31 (May, 2024), staff recorded more than one meal consumption for Resident 25, out of three possible, (breakfast, lunch and dinner), per day (24-hour period). During an interview with the Dietary Manager on 6/20/24 at 4:30 p.m., he stated he had discussed Resident 25's weight loss issues with the Registered Dietician during their weekly phone meetings, since the Registered Dietician only came to the facility once every quarter. The Dietary Manager was asked to provide documentation of those meetings, but he stated he did not know where to find that documentation. The Dietary Manager stated the Registered Dietician or MDS (Minimum Data Set-An assessment tool) nurse were responsible for updating or revising the care plan for weight loss. The Dietary Manager reviewed the May and June, 2024, meal consumption report for Resident 25 and confirmed the documentation was missing and incomplete. During a phone interview with the Registered Dietician on 6/21/24 at 9:13 a.m., she confirmed being aware that Resident 25 was having a severe weight loss. The Registered Dietician stated Resident 25 was provided health shakes, snacks and mirtazapine to prevent further weight loss (however, these interventions had been in place since September of 2023, and Resident 25 had continued to lose weight). When asked the reason the care plan for weight loss for Resident 25 had not been revised or updated despite her weight loss, and no new interventions had been added to prevent further weight loss, the Registered Dietician stated she did not know what other interventions to try. The Registered Dietician confirmed the care plan had not been revised or updated recently. The Registered Dietician was asked if she notified the physician when a resident was identified as having a significant weight loss. The Registered Dietician stated she did not notify the physician, as this was a nursing task. The Registered Dietician was asked how she ensured Licensed Nurses notified the physician of this, and she responded nursing would let her know if there was no follow-up. The facility policy and procedure (P/P) titled, Feeding the Resident, revised 1/2/2021, indicated: . Procedure: . J. Percentage of diet consumed is recorded on the appropriate form in the resident's medical record. K. Any deviation in appetite is reported to the Charge Nurse and recorded in the resident's medical record. L. Update the resident's Care Plan as necessary. The facility P/P titled, Nutrition at Risk (NAR), revised 6/27/2018, indicated, Purpose: To ensure the physical well-being of residents through the management of weight variance. Policy: The weight of residents will be monitored for variance and the NAR Committee (made up by Interdisciplinary Team members) will intervene when appropriate). Procedure: I. The NAR Committee may include, but is not limited to: A. Director of Nursing Services, B. Dietician/Director of Dietary Services, C. Administrator .Prior to each meeting, the Director of Nursing Services or designee will compile a list of residents who are at risk for, or in need of, weight change. Residents that meet the following criteria may be included on the list for discussion: A. Persistent weight loss over a period of three (3) months: B. 2% weight change in 1 week, C. 5% weight change in 1 month, D. 7.5% weight change in 3 months, E. 10% weight change in 6 months, A. Identifying medical or pharmacological conditions, which may be affecting weight changes for the identified residents, B. Assessing changes in diet, food preferences and increased caloric intake, C. Ordering a caloric count, if indicated . VI. Residents on the list will be reviewed weekly until their weight has stabilized. VII. The NAR Committee will document resident based review and recommendations from the meeting on the Point Click Care NAR Assessment form within Point Click Care. The facility P/P titled, Nutritional Assessment, revised 7/11/23, indicated: Purpose: To ensure that residents are properly assessed for dietary needs. Policy: The Dietitian will complete a nutritional assessment initiated by the Dietary Manager upon admission for residents. Nutritional assessments will also be completed upon readmission, annually, and upon change of condition. Procedure: The Dietary Manager will initiate Nutritional Data Assessment in Point Click Care. upon admission utilizing information from the medical record, including: A. Diagnosis, B. Diet order, C. Nutritional supplement, D. Skin condition, E. Ability to chew/swallow, F. Feeding status, G. Meal intake percentage, H. Height, weight, and usual body weight; and I. Birth date, admissions date, room number, and resident name . ll. The Dietitian will review the information provided by the Dietary Manager and revise or update as necessary. The Dietitian is responsible for completing the following information: A. Pertinent medication, B. Laboratory data, C. Ideal body weight, D. Body mass index (BMI), E. Estimated nutritional needs. V. The Dietitian will provide a narrative of recommendations in the Assessment section and identify any weight loss or dehydration risk factors, VI. The Dietitian will complete the Nutritional Assessment within fourteen (14) days of admission. VII. The Nutritional Assessment must be signed and dated by the Dietician on the day of completion. VIII. This process will be repeated each time a Nutritional Assessment is required to be completed. The facility P/P titled, Hydration Program, revised 11/2020, indicated: Purpose: To ensure that residents with medical conditions that can contribute to shifts in water balance are identified and a plan of care is developed based on individual needs. Policy: The Facility will provide residents with fluids to minimize episodes of dehydration or over hydration. Procedure: I. Assessment: A. The Registered Dietitian will determine a recommended baseline daily fluid need for all residents, B. As part of the Comprehensive Resident Assessment, a plan of care will be developed for residents who trigger for dehydration or have a potential for fluid overload based on diagnosis or medical history, C. A Licensed Nurse will document the resident's hydration related observations and information (e.g. any clinical signs of dehydration, abnormal labs, edema) in the nursing notes at least weekly if present, D. A Licensed Nurse will notify the Director of Nursing Services or designee, Dietary Department, Attending Physician, and resident's responsible party if the resident refuses fluids for 24 hours, and/or if the resident shows any signs and symptoms of fluid deficit or fluid overload. II. Ensuring Proper Hydration: A. The Nursing Staff will encourage and/or assist each resident to take sufficient fluids each day, unless medically contraindicated . B. If adequate fluid intake is difficult to maintain, Nursing and Dietary Staff will offer alternative approaches (e.g. popsicles, gelatin and/or other similar non-liquid foods). C. Certified Nursing Assistants (CNAs) will make sure that each of their assigned residents has a pitcher of fresh, cool water and a clean glass bedside, unless medically contraindicated: i. Pitchers and glasses will be cleaned at least once a day. They will refill as often as necessary, but at least once during a shift. D. CNAs will also offer the residents additional beverages (depending on the resident's individual preferences) regularly throughout the day and in between meals, if not in conflict with the Attending Physician's orders. E. The Director of Dietary Services will determine the beverage preference of residents and ensure that each resident receives preferred beverage with their meals if possible. F. CNAs will record the resident's percentage of fluid intake at each meal. G. To ensure adequate fluid intake, Nursing Staff will provide and assist residents with thickened liquids in between meals, if indicated. H. Cups will be provided next to the drinking fountains and/or Dietary Services will provide a hydration station accessible to resident when they are thirsty. I. A Licensed Nurse will alert CNAs as to which residents require additional fluids throughout the day or are on a fluid restriction. J. CNAs will alert the Charge Nurse if a resident is not consuming sufficient fluids and/or if resident shows signs and symptoms of dehydration or edema. Ill. Documentation related to hydration status will be maintained in the resident's medical record. A review of the facility job description titled, Director of Nutritional Services, the position of the Dietary Manager, undated, include the following: Dietary Manager was oriented to Dietary Policies, which included the Dietary Medical Record Documents: Nutritional Assessment and Care Plans. It was also noted that despite the lack of professional clinical licensure and lack of professional scope of practice, the Dietary Manager was Initiating/creating/updating a Risk for Nutritional Problems care plan, completing the Dietary part of the Skin and Weight Reviews, completing the K-Section of the MDS, and doing the resident's Quarterly Dietary Assessments. A review of the facility RD'S Dietary Consultant Services Agreement, start date 7/17/23, was vague and had no indication of how often the RD had to do in person visits in order to meet the nutritional needs of residents who have severe weight loss and other Nutritional problems, causing a decline in resident's health. A review of the facility job description titled, CNA, undated, indicated: . General Duties and Responsibilities: General - . Assist in preparing residents for meals (taking to/ from dining room, serving trays, placing bibs, assisting in feeding or cutting food, removal of trays, supervision in dining room, etc.), Serve nourishment in accordance with established facility procedures, Feed residents who cannot feed themselves, Assure that resident's food is accessible and self-help devices are available as needed . Clinical - .Record resident's food and nourishment intake as directed . Chart required information every shift . A review of the job description titled, Charge Nurse, undated, indicated: . General Duties and Responsibilities: . Supervision: . *Check all residents daily to assure that prescribed treatment is being properly administered by nursing personnel/ assistants and to evaluate their physical and emotional status. Record findings in the resident's chart . Based on observation, interview and record review, the facility failed to provide the necessary care and services related to significant and/or severe weight loss or gain for five out of 23 sampled residents (Resident 12, 20, 25, 29 and 227) to ensure the residents maintained an acceptable nutritional status because: 1. The RD (Registered Dietician) was making quarterly visits (once every three months), which led to minimal in person resident assessments, 2. The RD failed to fully tailor the resident's nutritional interventions to the resident's needs and monitor the continued relevance of those interventions such as residents' functional factors and lack of adequate assistance or supervision during meals, 3. The Dietary Manager who has no professional scope of practice was completing the resident's Annual and Quarterly Dietary Progress Notes which included recommendations and initiating resident's Nutritional Risk care plan, 4. The Dietary Manager incorrectly coded residents who had either lost or gained a significant amount of weight in their MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) under Section K (Swallowing/Nutritional Status). The coding for Residents 20 indicated, a physician-prescribed weight gain regimen when the physician had not written an order. The coding for Resident 12 indicated, not on physician-prescribed weight-loss regimen when there was a physician's order for a weight loss regimen, 5. The weekly Weight Variance Meeting document titled, Skin and Weight Review, the Clinical section, which was supposed to filled out by the RN (Registered Nurse) on the committee, was not consistently completed, 6. Residents' meal and fluid intake was not being monitored closely, and 7. Residents who needed supervision with their meals and fluid intake were not consistently supervised. These failures had the potential to place Resident 12, Resident 20. Resident 25, Resident 29, and Resident 227 at risk for altered nutritional status and/or dehydration (occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions) that could lead to further health complications, hospitalization and even death. Findings: Review of a Practice Paper published by the American Dietetic Association, dated 2010, indicated In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost.that may trigger sarcopenia [a condition characterized by loss of skeletal muscle mass and function] and functional decline [a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living]. (American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, October 2010 Journal of the American Dietetic Association). Involuntary weight loss can lead to muscle wasting depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. (February 15, 2002/Volume 65, Number 4 www.aafp.org/afp American Family Physician) A publication titled, Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated the goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight. During a review of the Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines (2007-2009), indicated: the Registered Dietitian (RD) should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT). The State Operations Manual (SOM) provides these parameters for significant weight loss: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% Gradual unintended weight loss over time is known as insidious weight loss. This can be where an older adult loses only 1-2 pounds per month, but for a continued period. When addressing unintentional weight loss, one needs to figure out why, if possible, the root cause of unintended weight loss (Geriatric Dietitian, 3/31/22). A Nutrition-focused physical findings assessment, often referred to as clinical assessment, are findings from evaluation of body systems, muscle and subcutaneous fat wasting, oral health, hair, skin and nails, signs of edema, suck/swallow/breath ability, appetite and affect. The intent of this assessment is to intervene in findings that are relevant to patient care. (Journal of the Academy of Nutrition and Dietetics, 2013). The National Library of Medicine defines the care planning process as a systematic process to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. The assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. Critical thinking skills are essential to assessment. Patient assessment is reserved for those professionals who have a legal scope of practice. The Certified Dietary Manager does not have a scope of practice in California Law. CMS (Centers for Medicare/Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 indicates under Section K: Swallowing/Nutritional Status states The assessor should collaborate with the dietitian .to ensure that items in the section have been assessed and calculated accurately . 1. A review of Resident 29's Administration Record, indicated Resident 29 was admitted [DATE], with a diagnosis of sequelae of cerebral infarction (stroke caused by disruption of blood flow to the brain), convulsions (involuntary contracture of the muscles), feeding difficulties, muscle weakness, blindness right and left eye, dementia (more confused and forgetful), psychotic disturbances (confused thinking, delusions - false beliefs that are not shared by others, hallucinations - hearing, seeing, smelling or tasting something that isn't there, changed behaviors and feelings), anxiety, major depression, and hemiplegia (paralysis of one side of the body), amongst others. Resident 29's Primary language was Spanish. A review of Resident 29's Quarterly MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 2/12/24, indicated Resident 29 could not complete a BIM (Brief Interview of Mental Status), had a memory problem and cognitive skills for daily decision making was severely impaired, one upper extremity and both lower extremities had functional limitation of range of motion, Resident 29 needed supervision or touching assistance with eating (The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or once the meal is placed before the resident), and Section K - Swallowing/Nutritional Status, indicated Resident 29 had weight loss of 5% or more in the past month or loss of 10 % or more in the last six months. and Resident 29 was not on a physician-prescribed weight loss regimen. Weight Review A review of Resident 29's Weights and Vital s Summary, documented from 11/9/23 through 6/3/24, indicated the following: 11/9/2023: 141.9 lbs. 12/5/2023: 142.5 lbs. 1/4/2024: 139.6 lbs. 2/6/24: 130 lbs. 2/8/24: 127.1 lbs. 2/12/24: 126.4 lbs. 2/20/24: 131.1lbs. 2/26/24: 131.7 lbs. 3/4/2024: 130.0 lbs. 3/1/2024: 131.7 lbs. 3/11/2024: 129.5 lbs. 3/19/2024: 130.4 lbs. 4/8/2024: 121.5 lbs. 4/15/2024: 122.3 lbs. 4/22/2024: 118.4 lbs. 4/29/2024: 120.6 lbs. 5/6/2024: 120.5 lbs. 5/13/2024: 119.4 lbs. 5/22/2024: 113.5 lbs. 5/28/2024: 114.0 lb. 6/3/2024: 115.1 lbs. A review of Resident 29's Weights and Vitals Summary, indicated Resident 29 weighed 141.9 pounds (lbs.) on 11/9/23. On 5/13/24 (six months later), Resident 29's weight was recorded as 119.4 lbs., indicating a 15.86 % (percent) weight loss, which is considered severe. Resident 29's weight on 6/3/24 was 115.1 lbs. an additional loss of 4.3 pounds in three weeks. Residents 29's cumulative weight loss in 7 months was 26.8 lbs. or 18.8% During an observation on 6/11/24 at 9:53 a.m., Resident 29, who was in bed, had no straw in her water pitcher and no cup next to her water pitcher, preventing her from being able to drink her water. During an observation on 6/12/24 at 12:40 p.m., there were two staff members (Unlicensed Staff C and a nurse) for nine residents in the Total Assisted Dining (TAD) Room. Resident 29 was trying to communicate in Spanish but was being ignored. Unlicensed Staff C and the nurse in the TAD Room did not speak Spanish, so Unlicensed Staff C and the nurse could not understand Resident 29 in order to meet her dining needs. Unlicensed Staff C nor the nurse got someone who could communicate in Spanish with Resident 29. Resident 29 was legally blind. There was no staff member sitting next to Resident 29 to guide her on where her food was on her plate. Unlicensed Staff C and the nurse were both sitting at the other end of the table feeding a resident. Unlicensed Staff C did place a plate guard (helps prevent food from accidentally being pushed off the plate while eating, minimizing spills at mealtime) on Resident 29's plate and handed her a fork. Resident 29 started eating her pasta with her fingers. Resident 29 did not receive staff assistance to guide her with using her fork or where food items were on her plate. During an observation on 6/14/24 at 11:15 a.m., Resident 29 was in bed with her head covered with a blanket. There was a light yogurt with a spoon in it, container indicated worth 100 calories, zero consumed, and a chocolate shake with a straw, container indicated worth 200 calories, 75% consumed. There was no straw in Resident 29's water pitcher, which felt almost empty and no cup to pour water into. Resident 29 was legally blind and her overbed table was at the side of her bed out of reach. Through multiple observations while Resident 29 was in bed from 6/11/24-6/13/24, never observed a nurse or CNA go into Resident 29's room and offer her fluids. A review of Resident 29's Nutritional Data Collection and Assessment, dated 5/8/24 (6 months after the resident began to lose weight) was completed by the RD. Resident 29's estimated needs were listed as 1917 calories, 68 grams of protein and 1373-1585 cc's of fluid (cubic centimeters-a metric unit of measure). The assessment indicated Resident 29 was on a nutritional supplement three times/day, with meals which was initiated on 2/20/24, and was receiving Mirtazapine (an antidepressant which may increase appetite), which was initiated on 2/2/24. The assessment: acknowledged an unplanned weight change, however did not recognize it as a severe weight change and included the need for adaptive equipment (a divided plate and plate guard). The assessment indicated Resident 29 had inadequate intakes. The RD also commented Resident 29 liked coffee. There were no additional recommendations or assessment of the effectiveness of current interventions. There was no plan to develop nutritional implementations that emphasized Resident 29's preference for coffee, such as coffee flavored high calorie beverages. The note also indicated Resident 29 thinks the food is poisoned, refuses everything, however there was no indication the facility attempted to assess the rationale of these comments. The RD indicated a referral to the physician regarding Resident 29's statements, however the facility was unable to validate the referral. There was no additional follow up from the Registered Dietitian despite continued weight loss. A review of Resident 29's At Risk for Nutritional Problems, care plan, the Focus section was created and initiated by the Dietary Manager on 4/3/2019. There was no revision of the nutritional risk care plan by the RD (Registered Dietitian) until 5/9/24 (six months after the start of severe weight loss). Interventions initiated by the Dietary Manager, dated 4/3/19 were as follows: encourage fluids and encourage oral intake. The Dietary Manager continued to initiate interventions [TRUNCATED]