**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident with a Full Code status (resident wants all life saving measures in case of life threatening emergencies) and in distress, received Cardiopulmonary Resuscitation (CPR-an emergency procedure to restart a person's heart, chest compressions) immediately, reducing the residents chances of survival and adverse health outcomes for one of 145 residents with Full Code status (Resident 44). The facility failed to: 1.Ensure Registered Nurse (RN) 2 announced a Code Blue (an announcement that signifies a medical emergency where a patient is experiencing a life-threatening situation) when Resident 44 had no palpable (rhythmic beat of a blood vessel indicating a heartbeat, that can be felt by touch) heartbeat. 2.Ensure RN 2 provided resuscitation and basic life support such as CPR immediately without loss of critical time to Resident 44, when Resident 44 no longer had a palpable pulse on [DATE]. 3.Ensure RN 2 was knowledgeable of the facility's policies and procedures regarding initiating CPR when a full code resident is unresponsive. 4.Ensure RN 2 implemented the facility's policy and procedure (P&P) titled, Emergency Procedure - Cardiopulmonary Resuscitation, revised February 2018, which indicated if an individual was found unresponsive and not breathing normally, a licensed staff, certified in CPR/BLS shall initiate CPR and the American Heart Association ([AHA] the leader in resuscitation science, education, and training, and publisher of the official Guidelines for CPR) guidelines which indicated First responder will call for help, send available staff to call a Code Blue, retrieve emergency medical equipment, assess the residents' level of consciousness, circulation, airway, and breathing and begin CPR, call 911, CPR will continue until the paramedics arrive and assume responsibility. These deficient practices delayed life-saving resuscitation attempts, such as CPR to ensure Resident 44's body had uninterrupted blood, and oxygen circulation, to prevent irreversible damage such as brain damage and or death. The facility had 145 residents, with a Full Code status and at risk of not receiving CPR in case of cardiopulmonary arrest. On [DATE] at 4:43 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) and the Director of Nursing(DON) due to the facility's failure to identify the need for and initiate basic life support to Resident 44, including CPR immediately upon discovering the resident was unresponsive. On [DATE] at 1:34 p.m., the Facility submitted an acceptable IJ removal plan (IJRP- an intervention to immediately correct the deficient practices). After verification the IJRP was implemented through observation, interview, and record review, the IJ was removed while onsite on [DATE] at 4:44 p.m., in the presence of the ADM and the DON. The IJRP included the following: 1.Resident 44 was transferred to the general acute care hospital (GACH) on [DATE] and currently remains hospitalized . 2.On [DATE], the Administrator (ADM) and the Director of Nursing (DON) notified the facility Medical Director of the findings outlined in the IJ removal plan and developed an IJ removal plan. 3.On [DATE] and [DATE], two American Heart Association ([AHA] the leader in resuscitation science, education, and training, and publisher of the official Guidelines for CPR) Instructors provided in-services to nurses on the facility's CPR policy and procedure. The training covered the following: a.Assessment and activation for CPR iUnconsciousness with absence of life ii.Gasping or no observable chest movements (rise and fall) iii.No palpable carotid pulse (the rhythmic beat of a blood vessel that can be felt on either side of the neck), do not use a pulse oximeter (a device that measures how much oxygen is in the blood) to assess for pulse. b.Code for cardiac/respiratory arrest-Code Blue c.CPR Procedures 4.All nursing including part time and overnight shift who was unable to attend the Inservice must be given an in-service prior to returning to work. 5.The DON and Registered Nurse (RN) supervisor reviewed residents who required CPR within the past 30 days and identified one resident aside from Resident 44 with an incident of code blue with not the same deficient practice 6.The AHA instructors will repeat the in services to nursing staff, regarding CPR policy and procedure, every month for 3 months to ensure compliance. 7.The DON and/or designee will review residents who have a change in condition weekly for 4 weeks and monthly thereafter, to ensure that any resident requiring CPR has received the CPR timely, and continually until the paramedics (emergency response team) arrive or there are obvious sign of life. 8.The DON and/or designee will review residents who have change in condition weekly for 4 weeks and monthly thereafter, to ensure that any resident required. Findings: During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Type II Diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), Sepsis (blood infection), and Urinary Tract Infection (UTI- disease causing bacteria in the urinary tract). During a review of Resident 44's Nursing admission Assessment, dated [DATE], the Nursing admission Assessment indicated Resident 44 had an admitting diagnosis of pneumonia (a lung infection that make it difficult to breath). The Nursing admission Assessment indicated Resident 44 had completed antibiotics (medicines that treat bacterial infections by killing bacteria or stopping them from growing) at the GACH prior to admission. During a review of Resident 44's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 44 did not have the capacity to understand and make decisions. During a review of Resident 44's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 44 had severely impaired cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS indicated Resident 44 had functional limitation in range of motion (the distance and direction a joint can move) on upper extremity (your arm, including your shoulder, elbow, wrist, and hand) and lower extremity (your leg, including your hip, thigh, knee, shin, ankle, and foot), The MDS indicated Resident 44 needed assistance from two or more helpers for the resident to transfer to and from a bed to a wheelchair. During a review of Resident 44's Order Summary Report, as of [DATE], the Order Summary Report indicated there was an order on [DATE] to provide CPR. During a review of Resident 44's Life-Sustaining Treatment (POLST-resident's preferences for medical treatment), dated [DATE], the POLST indicated that facility must attempt CPR if Resident 44 had no pulse and was not breathing. During a review of Resident 44's care plan for Advance Directive (a document that expresses the resident's health care wishes should they be unable to speak for themselves), revised [DATE], the care plan indicated that CPR was to be performed, with interventions including respecting Resident 44's or family's wishes regarding resuscitation efforts. During a review of Resident 44's Change of Condition (COC)/Interact Assessment Form (situation, background, assessment, and recommendation [SBAR] a verbal or written communication tool that helps provide essential, concise information, usually during crucial situations), dated [DATE] at 11p.m., the COC indicated Resident 44's oxygen saturation (amount of oxygen in blood) level was between 88 to 90 percent (%) on room air (RA) (oxygen saturation reference range 95%-100%). The COC indicated facility staff placed Resident 44 on oxygen at 2 Liters (L)/ minute (min) nasal canula (NC) and Resident 44's oxygen saturation went up to 94-95%. The COC indicated Resident 44 was placed on 72-hour monitoring, and her Medical Doctor (MD) was notified on [DATE] at 11:30 p.m. During a review of Resident 44's COC dated [DATE], the COC indicated at 7:30 a.m. on [DATE] Resident 44 was up in her wheelchair. The COC indicated Resident 44's vital signs (VS) were: Blood Pressure 103/64 millimeters of mercury (mmHg- unit of measure. Reference range 120/80 mmHg), Heart Rate 84 (beats) /(per) minute (min-reference range 60 to 100), Oxygen saturation 93% with oxygen 2L/min via NC, Temperature (measure how well the body can make and get rid of heat) 97.9 degree (Reference range 96.8 degree to 98.6 degree) and Respiration Rate 16 (breaths)/min (Reference range 12 to 20 /min) prior to the incident. The COC indicated at 8:40 a.m., Resident 44 was up in her wheelchair, diaphoretic (sweating heavily), eyes closed with VS: HR 40-42/min, oxygen saturation 88% with oxygen at 2L/min via NC. The COC indicated Resident 44 had a palpable (detectable by touch) pulse (heartbeat) of 50 beats/min then Resident 44 was transferred to her bed. The COC indicated Resident 44's heart rate started to fluctuate (vary) from 40-42/min and her oxygen level dropped to 80%. The COC indicated staff did not observe Resident 44's chest rise and fall (indicating breathing), so staff grabbed the Ambu-bag (a handheld device that helps patients' breath when they aren't breathing well or at all) and started providing breaths until the paramedics arrived at 8:45 a.m., and initiated CPR. The COC indicated RN 1 and RN 2 were aware that Resident 44 was full code before calling the paramedics at 8:41 a.m. During a review of the Paramedics Report, dated [DATE], the Paramedics Report indicated Resident 44 had a cardiac arrest (when the heart suddenly stops beating, preventing blood and oxygen from being pumped to the body's organs) on [DATE] at 8:30 a.m., witnessed by staff. The Paramedics Report indicated the emergency medical staff (EMS - Paramedics) arrived at resident's room at.8:44 a.m. and found Resident 44 lying in bed pulseless, apneic (an involuntary pause in breathing), with fixed and dilated pupils (a person's pupils are wide open and do not respond to light, indicating a serious medical condition, often associated with brain damage or severe head injury). The Paramedics Report indicated facility staff noticed Resident 44 was breathing with increased effort, so they began ambuing (the act of using an Ambu-bag) the resident. The Paramedics Report indicated facility staff never initiated chest compressions, even though Resident 44 was observed to be in full cardiac arrest. The Paramedics Report indicated the paramedics immediately initiated CPR on Resident 44 and achieved Resident 44's return to spontaneous circulation (ROSC - when heartbeat and breathing return to normal. During a review of Resident 44's Emergency Documentation-MD notes, from the GACH, dated [DATE], the Emergency Documentation-MD notes indicated EMS brought Resident 44 to the GACH's Emergency Department (ED) from the facility after EMS provided emergency services including CPR at the facility (where Resident 44 resided). The Emergency Documentation-MD notes indicated according to EMS, upon EMS's arrival, Resident 44 was pulseless. The Emergency Documentation-MD note indicated EMS initiated CPR, provided emergency services and Resident 44's ROSC was achieved. The Emergency Documentation-MD note indicated Resident 44's diagnoses at the ED included cardiopulmonary arrest. The note indicated Resident 44 was admitted to the intensive care unit (ICU GACH Unit that cares for seriously ill patients that need constant observation). During an interview on [DATE], at 9:38 a.m., with CNA 1, CNA 1 stated on [DATE] at approximately 8:30 a.m., she entered Resident 44's room to assist Resident 44 with her breakfast and observed Resident 44 sitting in her wheelchair sweating. CNA 1 stated she called CNA 2 to check on Resident 44. CNA 1 stated CNA 2 entered the room, assessed Resident 44, and told her (CNA 1) not to feed Resident 44 her breakfast. CNA 1 stated she stayed with Resident 44 while CNA 2 went to get help. During an interview on [DATE] at 10:17 a.m., with RN 2, RN 2 stated on [DATE] at approximately 8:35 a.m., when she entered Resident 44's room, she observed Resident 44 was lying down, appeared sweaty, and pale. RN 2 stated she checked Resident 44's pulse manually and felt Resident 44's pulse. RN 2 stated the oximeter readings of heartbeat on Resident 44's finger fluctuated between 36 beats/min, to 46 beats/min, and Resident 44's oxygen saturation dropped from 88% to 70%. RN 2 stated she left Resident 44's room and returned with a crash cart (cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate a patient experiencing cardiac arrest). RN 2 stated she suctioned (to suck out or remove something, like thick liquids using a force created by a vacuum) her Resident 44's mouth to remove secretions. RN 2 stated after suctioning Resident 44, she manually checked Resident 44's pulse and it went up to 50/min. RN 2 stated, when Resident 44's pulse was no longer detectable manually, she relied on the oximeter readings of Resident 44's pulse, which still indicated a pulse at 32/min. RN 2 stated she (RN 2) did not initiate CPR because the oximeter indicated Resident 44 had a pulse, although she could not obtain Resident 44's pulse manually. During an interview on [DATE] at 10:14 a.m., with Treatment Nurse (TXN) 1 stated, she was aware Resident 44 was a full code. TXN 1 stated staff should have initiated chest compressions when Resident 44 stopped breathing and had no pulse. During an interview on [DATE] at 10:52 a.m., with RN 2, RN 2 stated she did not initiate chest compressions when she (RN 2) could no longer detect Resident 44's pulse from the resident's carotid artery (the main blood vessels that supply blood to the brain face, and neck). RN 2 stated the oximeter still displayed a pulse reading. RN 2 stated, if the heart rate was not palpable manually, but the oximeter showed numeric values of 30's/min, 40/min and 50/min, it indicated a regular rhythm. RN 2 stated she did not initiate chest compressions when she (RN 2) could no longer detect Resident 44's pulse from the resident's carotid artery (the main blood vessels that supply blood to the brain face, and neck). RN 2 stated she did not announce a Code Blue, because she believed Resident 44 still had a heart rate based on the oximeter reading. During an interview on [DATE] at 12:15 p.m., the Director of Nursing (DON), stated if the COC involved a Resident's unresponsiveness, staff must assess the Resident's lung function and pulse immediately. The DON stated if the resident did not have a detectable pulse staff must start chest compressions immediately, provide breathing support, and call a Code Blue for emergency intervention. The DON stated if an oximeter indicated numbers like 30's/min, 45/min, 50/min without a palpable pulse, it could be an indication that the resident was not okay, and it was important to provide timely CPR. During an interview on [DATE] at 4:17 p.m., Resident 44's primary doctor stated Resident 44 was a full code, and the staff should have provided CPR when Resident 44 experienced a cardiac arrest. During a review of the facility's P&P titled, Emergency Procedure - Cardiopulmonary Resuscitation, revised February 2018, indicated Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. The P&P indicated sudden cardiac arrest (SCA) was a loss of heart function due to abnormal heart rhythms (arrhythmias). 1. Victims of cardiac arrest may initially have gasping respirations or may appear to be having a seizure. Training in BLS includes recognizing presentations of SCA. 2. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 3. Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival. 4. If an individual (resident, visitor, or staff member) was found unresponsive and not breathing normally, a licensed staff certified in CPR/BLS will initiate CPR unless the person had a do not resuscitate (DNR) order, or obvious signs of irreversible death (e.g., rigor mortis). The P&P indicated, if the resident's NR status was unclear, CPR will be initiated until it was determined that there was a DNR or a physician's order not to administer CPR. According to the P&P, if the first responder was not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrived. The P&P indicated Preparation for Cardiopulmonary Resuscitation was as follows: 1. The facility's procedure for administering CPR would incorporate the steps covered in the 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care. 2. Select and identify a CPR team for each shift in the case of an actual cardiac arrest, with a designated team leader who would be responsible for coordinating the CPR. The team The P&P also indicated Preparation for Cardiopulmonary Resuscitation was as follows : 1. If an individual was found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: Instruct a staff member to activate Code Blue and call 911. Verify or instruct a staff member to verify the code status of the individual. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 3. Chest compressions: a Following initial assessment, begin CPR with chest compressions; b Push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute; c Allow full chest recoil after each compression; and d Minimize interruptions in chest compressions. 4. Airway: Tilt head back and lift chin to clear airway. 5. Breathing: After 30 chest compressions provide 2 breaths via ambu-bag or manually (with CPR shield). 6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. 7. Continue with CPR/BLS until emergency medical personnel arrive. During a review of AHA's article titled 11 things to know to save a life with CPR, published [DATE], the article indicated according to research, each minute of delayed CPR, there was a decreased chance of survival by about 10%.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident, who was receiving feeding through a gastrostomy tube ([GT] a soft tube surgically placed into the stomach to provide nutrition and medications), did not have a severe weight loss (a weight loss greater than five percent (%) in one month, or greater than 7.5% in three months, and greater than 10% in six months) for one of 48 residents receiving GT feeding (Resident 188). The facility failed to ensure: 1.The licensed nurses conducted a change of condition (COC) assessment and monitored Resident 188 closely including weekly weights, signs and symptoms of malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function), and dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake), when the resident had A.Significant weight loss of (nine pounds ([lbs.] a unit of weight measurement) in one month (12/6/2024 [119 lbs.]-1/3/2024 [110lbs]) which was 7.6 % of Resident 188's admission body weight of 119 lbs., B.Weight loss of 24 lbs. in two months (12/6/2024 [119 lbs.]-1/31/2025 [95 lbs.]) on 1/31/2025 which was 20.1% of Resident 188's admission body weight of 119 lbs. C.Weight loss of 25.8 lbs. on 2/6/2025 (12/6/2024 [119 lbs.] - 2/6/2025 93.2 lbs.]) which was 21.6% of Resident 188's admission body weight of 119 lbs. 2. The licensed nurses notified Resident 188's physician and responsible party (RP) of Resident 188's 7.6% significant weight loss identified on 1/3/2025 and 20.1% weight loss in two months identified on 1/31/2025 in accordance with Resident 188's untitled care plan dated 12/23/2024. 3. Resident 188's assigned nurse (unknown) notified the Registered Dietician (RD) to evaluate Resident 1 when the resident had a nine lbs. weight loss on 1/3/2025. 4. Registered Nurse (RN) 3 notified the RD on 1/31/2025 for the RD to evaluate Resident 188's 20.1% weight loss, in accordance with the untitled care plan dated 12/23/2024 when Resident 188 was noted to have continued weight loss. 5. The Interdisciplinary Team ([IDT] a team of different health care professionals working together to develop care interventions for a resident), including the RD met after Resident 188's significant weight loss was first identified on 1/3/2025, and then on 1/31/2025, to develop interventions to prevent further weight loss. 6. The IDT developed an individualized care plan with measurable goals to address Resident 188's weight loss identified on 1/3/2025 and 1/31/2025. 7. Restorative Nursing Assistant ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) 1 documented Resident 188's weight right after weighing Resident 188 on 1/31/2025 on the RNA Monthly Weight Report. 8. The RD did not wait until 2/6/2025 (30 days later) to reassess the effectiveness of Resident 188's nutritional interventions recommended on 1/7/2025, including increasing Resident 188's GT feeding 10 additional cubic centimeter ([cc], a unit of measurement) per hour (hr.) to 55 cc/hr, once his diarrhea (loose stool) subsided, per IDT/ care plan review, continue to monitor weight trends (unknown frequency), and reassess as needed (unknown frequency) the interventions recommended (on 1/7/2025). As a result of these deficient practices, Resident 188 had severe weight loss of 25.8 lbs. equal to 21.6% in 60 days. These deficient practices placed Resident 188 and 48 facility residents recieving enteral feeding at risk for malnutrition, dehydration, and possible death. On 2/8/2025 at 4:44 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Director of Nursing (DON) and the administrator (ADM) due to the facility's failure to implement interventions to prevent Resident 188's severe weight loss, and placed 48 residents recieving enteral feeding at risk for malnutrition, dehydration, and possible death. On 2/9/2025 at 1:13 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 2/9/2025 at 3:10 p.m., in the presence of the DON and ADM. The IJRP included the following immediate actions: a. A change of condition assessment, Situation Background Assessment Recommendation ([SBAR] a communication tool used to share information in a structured way) for severe weight loss was completed on 2/6/2025, which included vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's basic body functions), pain, laboratory (medical procedure that involves testing a sample of blood, urine, or other substance from the body) results reviewed and obtained new physician orders on 2/6/2025 for adding Liquacel (protein supplement) and to increase GT feeding to 55cc/hr. b. On 2/8/2025, the assistant director of nursing (ADON) conducted another assessment, indicating the Resident 188 remained at his baseline (starting point used for comparisons) condition with normal vital signs, and without any sign of distress. c. On 2/8/2025, the IDT members, including the RD, conducted an IDT care plan meeting. During the meeting, the IDT members addressed Resident 188's overall condition with severe weight loss of 12/6/2024 119Ibs, 1/3/2025 ll0lbs (-9 lbs.), 2/6/2025 93.2Ibs. (25.8 lbs.) The physician instructed to start weekly weight for four weeks and repeat the comprehensive metabolic panel ([CMP] a blood test to check liver, kidney, and metabolic health) on 2/10/2025. d. RNA 1 will receive a performance correction notice, and a one-on-one in-service by the DON regarding weight documentation, emphasizing the importance of recording the weight on the same day it was measured. e. On 2/8/2025, the weights management in-service was initiated until all licensed nurses, including part-time and night ([NOC] 11 p.m. to 7 a.m. shift) will be completed. In-service will be expected to be completed by 2/10/2025. Any licensed nurse unable to attend the in-service due to part time status, emergency or leave of absence has been removed from the schedule and must be given an in-service prior to returning to work. Weight Management in-service includes: e1. Conducting a change of condition assessment for significant or severe weight change: loss or gain of 3 lbs. within a month, 5% a loss or gain of at least 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. e2. Licensed nurses will notify RD and physician of the significant or severe weight changes. e3. Conduct significant weight loss IDT care plan to include useful interventions based on assessment. f. The DON and ADON initiated review of all residents' weight records (180 residents) for the past 30 days to ensure that all significant or severe weight changes had proper assessments, RD recommendations, MD notifications, and updated plan of care. All reviews will be completed by 2/10/2025. g. The DON and the ADON will conduct monthly in-services to licensed nurses regarding weight management for 3-months, covering the following details: Conducting a change of condition assessment for significant or severe weight change: loss or gain of 3 lbs. within a month, 5% a loss or gain of at least 5% in 30 days, 7 .5% in 90 days, or 10% in 180 days. DON and/or designee will notify RD and physician of the significant or severe weight changes. Conduct significant or severe weight loss IDT care plan to include useful interventions based on assessment. Note that education on oral gratification is not considered a useful intervention for promoting weight gain. h. The DON and/or designee will repeat a monthly in-service for three months to RNA responsible for weights documentation, to ensure all weights are recorded on the same day it is measured. i. On 2/8/2025, the DON created a weight management monitoring log, including significant or severe weight loss. j. The DON/ADON will meet with the RNA weekly for four weeks, then monthly for three months to ensure timely weight documentation. k. The DON/ADON will participate in weekly weight management meeting and document the findings with corrective actions in the monitoring log. L. The DON/ADON will monitor weight variance through weekly weight meeting to ensure all residents with weight variance (significant or severe) will be addressed. The DON will discuss weight management related findings during the monthly QA meeting for three months to ensure ongoing compliance with the state and federal regulations. (cross reference: F553, F580, F656, and F865) Findings: During a review of Resident 188's admission Record, the admission Record indicated Resident 188 was admitted to the facility 12/6/2024 with diagnoses including muscle wasting (the shrinking and weakening of muscles), non-Hodgkin lymphoma (cancer [invasive growth of disease causing organisms]), tracheostomy tube (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), and multiple pressure ulcers (Injury to skin and underlying tissue resulting from prolonged pressure on the skin) and had a GT. During a review of Resident 188's Minimum Data Set ([MDS] a resident assessment tool) dated 12/13/2024, the MDS indicated Resident 188 had severe cognitive impairment (a significant decline in cognitive abilities that significantly impact daily functioning and independence) for daily decision making. The MDS indicated Resident 188's current weight as of 12/6/2024 was 119 lbs. The MDS indicated Resident 188 was receiving a therapeutic (a meal plan that controls the intake of certain foods or nutrients) diet and was receiving 51% or more of his total calories through a feeding tube. During a review of Resident 188's untitled Care Plan initiated on 12/23/2024, the Care Plan indicated Resident 188 had cancer with an increased risk for weight loss secondary to non-Hodgkin's lymphoma. The untitled Care Plan indicated Resident 188's goal was not to have a weight loss exceeding 5% per month. The Care Plan interventions included RD evaluations and to notify the physician and Resident 188's responsible party of any change of conditions. During a review of a document titled, Weekly-Weights- Station Subacute (a level of care needed by a patient who does not require hospital level acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) Summary dated 12/2024, the document indicated Resident 188's admitting weight was 119 lbs. and was weighed weekly after admission on [DATE]. Resident 188's weight was as follows: 1. On 12/11/2024 Resident 188's weight was 115 lbs. There was four lbs. weight loss in five days since admission on [DATE]. 2. On 12/18/2024 Resident 188's weight was 112 lbs. There was another three lbs. weight loss in a week from 12/11/2024. 3. On 12/27/2024 Resident 188's weight was 110 lbs. There was another two lbs. weight loss in a week from 12/28/2024. 4. On 1/3/2025 Resident 188's weight was 110 lbs. The Weekly Weights and Vitals Summary did not indicate the aforementioned weekly weights were recorded and addressed in Resident 188's electronic medical record (EMR) and the resident's weekly weight loss was addressed. During a review of Resident 188's Weights and Vitals Summary, dated 12/6/2024, the Weekly Weights and Vitals Summary indicated Resident 188 weighed 119 lbs. The Weights and Vitals Summary dated 1/3/2025 indicated Resident 188's weight was 110 lbs., a nine lbs. (7.6%) weight loss since admission. The Weights and Vitals Summary did not indicate Resident 188's weekly weight measurements were continued when the weight loss was identified on 1/3/2025. During a review of Resident 188's Weights and Vitals Summary dated 2/6/2025, the Weights and Vitals Summary indicated Resident 188 weighed 93.2 lbs., which was a 25.8 lb. (21.7%) weight loss since admission. During a review of Resident 188's Order Summary Report (physician's orders), the Order Summary Report indicated an order was placed on 12/6/2024 to monitor Resident 188's weight weekly for four weeks and then monthly. The Order Summary Report indicated an order for monthly weights was placed on 12/6/2024. The Order Summary Report indicated there was an order placed on 12/6/2024 for GT feeding with Glucerna (diabetes-specific nutritional formula) 1.5 calorie ([cal] a unit of energy derived from nutrition) at 45 cubic centimeters (cc) per hour (hr) for 20 hours via GT pump (device to administer feeding formula) to provide 900 cc equal to1350 kilocalories (kcals) per day and discontinued on 1/7/2025. During a review of Resident 188's change of condition (COC)- Licensed Nurse Note dated 12/14/2024, the note indicated Resident 188 was having frequent loose stools (diarrhea). During review of Resident 188's Order Summary Report the Order Summary Report indicated on 1/7/2025, an order was placed for Imodium A-D (antidiarrhea medication) 2 milligrams (mg) via GT every four hours as needed for loose stool for seven days. During a review of Resident 188's Nutrition/ Dietary Note dated 1/7/2025 at 10:56 a.m., the Nutrition/Dietary Note indicated the RD documented Resident 188's weight was 110 lbs. with a nine lbs. weight loss in one month. The RD documented Resident 188's ideal body weight ([IBW] the healthiest weight per height) range was 117 lbs. to 143 lbs., and Resident 188's nine lbs. weight loss was significant. The Nutrition/Dietary Note indicated the RD recommended to increase the Glucerna 1.5 from 45 cc/hr to 55 cc/hr to provide 1100cc/1650 kcal per day. The Nutrition/Dietary Note indicated the RD recommended to monitor the resident's weight trends (frequency not specified) and she (RD) documented she would reassess the resident's nutritional needs as needed. There was an addendum (additional information) added on 1/7/2025 to the Nutrition/ Dietary Note indicating Resident 188 was able to tolerate the GT feeding well and had no nausea (feeling sick to your stomach), vomiting (throwing-up forces the contents of the stomach up through the food pipe) or diarrhea. During a review of Resident 188's Nutrition/ Dietary Note dated 1/7/2025 at 1:13 p.m., the Nutrition/ Dietary Note indicated the RD discussed Resident 188's frequent loose stools with a nurse (unknown) and to hold the order to increase the GT feeding to 55 cc/hr due to Resident 188's diarrhea. The Nutrition/ Dietary Note indicated the GT feeding would be increased once the diarrhea resolved. During a review of Resident 188's Medication Administration Record (MAR) for January 2025, the MAR indicated Imodium A-D was last given to the resident on 1/13/2025 for loose stool. During a review of Resident 188's Order Summary Report for January 2024, the Order Summary Report indicated an order dated 1/7/2025 to increase Glucerna 1.5 to 55 cc/hr. to administer for 20 hours via GT pump to provide 900 cc/1350 kcal per day. This order was discontinued three days later on 1/10/2025. The Order Summary Report indicated on 1/10/2025 an order was placed to decrease the Glucerna 1.5 back down to 45 cc/hr to administer for 20 hours to provide 900 cc/1350 kcal per day. The Order Summary Report indicated there were no new orders placed until 2/7/2025. On 2/7/2025 there was a new order to increase the GT feeding with Glucerna 1.5 at 55 cc per hour for 20 hours via GT pump to provide 1100 cc/1650 kcal per day. During a review of Resident 188's Licensed Nurses Progress Notes dated 1/7/2025, the Licensed Nurses Progress Notes indicated Resident 188's physician (MD 1) was informed Resident 188 was having loose stool and the RD recommended to increase Resident 188's GT water flush (water given through the GT for hydration) to 50cc/hr related to elevated (no result specified) blood urea nitrogen ([BUN] a kidney function laboratory test). The Licensed Nurses Progress Notes did not indicate MD 1 was informed of Resident 188's nine lbs. weight loss. During a review of Resident 188's Care Plan (untitled) initiated on 1/7/2025, the Care Plan indicated Resident 188 was identified to be at risk for dehydration secondary to diarrhea. The Care Plan indicated the goal for Resident 188 was to reduce the risk of unplanned weight changes. The Care Plan interventions included monitoring Resident 188's weight (frequency not identified) and report (unspecified to whom) any change of plus or minus (+/-) of three pounds per week or +/- five pounds per month per policy (policy not identified). This Care Plan did not include Resident 188's actual weight loss of 7.5% (nine lbs.) that had been identified on 1/3/2025 or the interventions to reduce the risk of continued weight loss from occurring. During a concurrent observation and interview on 2/5/2025 at 12 p.m., with Resident 188, in Resident 188's room, the resident was observed receiving Glucerna 1.5 through GT at rate of 45 cc/hr. Resident 188 stated he had been losing weight recently but was hopeful he would gain some weight back because he passed his swallow evaluation (checks how well a resident swallows) on 2/4/2025 and was now able to eat a little food along with his tube feeding for oral gratification (the pleasure derived from oral activities such as eating). Resident 188 stated he hoped to gain some weight because his legs looked like bones. Resident 188 was observed pulling his bed sheets away from his legs. Resident 188 legs were observed being very thin with prominent bones. Resident 188 stated he wanted to be stronger to participate in therapy. During an interview on 2/5/2025 at 12:03 p.m., Licensed Vocational Nurse (LVN) 6 stated RNA 1 was responsible for measuring and recording weights. LVN 6 stated RNA 1 had not reported any recent weight changes for Resident 188. During an interview on 2/5/2025 at 2:49 p.m., Registered Nurse (RN) 2 stated as of 2/5/2025, the last weight recorded for Resident 188 was on 1/3/2025. RN 2 stated RNA 1 was supposed to turn monthly weights in by the fifth day of every month but they were not yet completed. RN 2 stated the facility usually did not complete a COC for weight loss unless it was a lot of weight, like a 40 lbs. weight loss. RN 2 agreed that a nine lbs. (7.6%) weight loss was a lot of weight to lose in one month. RN 2 stated that a COC did not need to be completed for a 7.5% weight loss. RN 2 stated if Resident 188 had been weighed weekly for four weeks after he was admitted on [DATE], per physician's order, the RD could have assessed Resident 188 sooner than 1/7/2025 and identified the gradual weight decrease. RN 2 stated she reviewed Resident 188's electronic medical record and could not find any documentation that Resident 188 was weighed weekly as RD recommended. During an interview on 2/6/2025 at 10:22 a.m., RNA 1 stated she weighed Resident 188 on Friday 1/31/2025 and the resident weighed 95 lbs. RNA 1 stated she did not document the weight for 1/31/2025 in Resident 188's chart but I knew Resident 188 had lost a lot of weight so she (RNA 1) verbally informed RN 3 about the weight loss on 1/31/2025. RNA 1 stated RN 3 stated that the weight loss identified on 1/31/2025 was okay, and that Resident 188 would start gaining weight because he passed his swallow evaluation and was able to eat (for oral gratification) as well as receive tube feedings. RNA 1 could not produce any documentation that the resident's weight of 95 lbs. on 1/31/2025 was documented. RNA 1 pointed to her head and stated, it is all in here. RNA 1 stated the residents' monthly weights on the sub-acute unit were not entered into the computer yet because she had yet to complete taking all the weights for the month and would finish by 2/7/2025. During an interview on 2/6/2025 at 11:48 a.m., RN 3 stated on 1/31/2025, RNA 1 did inform her Resident 188 lost a lot of weight (did not know exact amount). RN 3 stated she did not inform the physician because she was admitting another resident at the time. RN 3 stated she assumed Resident 188 would start gaining weight now that he was able to eat by mouth and was continuing to receive tube feeding. RN 3 stated Resident 188's diarrhea had stopped sometime mid-January 2025 (exact date unknown). During an observation on 2/6/2025 at 12:02 p.m., RNA 1 and LVN 3 were observed weighing Resident 188 using a mechanical lift (device used to assist with transfers [from one surface to another] and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) containing a scale. Resident 188 weighed 93.2 lbs. (total of 25.8 lbs. weight loss from admission weight of 119 lbs. on 12/6/2024). During an interview on 2/6/2025 at 12:21 p.m., the RD stated the nursing staff did not notify her of Resident 188's identified weight loss on 1/3/2025. The RD stated residents' monthly weights were documented in the residents' medical records and were printed out for her review every Monday or Thursday (in general). The RD stated on 1/7/2025, she reviewed Resident 188's weight report dated 1/3/2025 which indicated the resident weighed 110 lbs. and had a weight loss of nine lbs. The RD stated she assessed Resident 188 on 1/7/2025. The RD stated she had not reassessed Resident 188 since 1/7/2025 (30 days ago) when she evaluated him for significant weight loss and did not implement any interventions such as measuring his weight weekly because she (RD) did not feel Resident 188 required weekly weights for close monitoring. The RD stated she was unable to increase Resident 188's GT feeding on 1/7/2025 because Resident 188 had diarrhea. The RD stated she did not reassess Resident 188 after the diarrhea subsided on 1/13/2025. The RD stated she did not feel it was necessary to monitor Resident 188's significant weight loss of 7.6% more frequently than monthly. The RD stated it was important to monitor severe weight loss closely to ensure the residents health status did not decline. The RD stated the potential outcome of severe weight loss was malnutrition. During an interview on 2/6/2025 at 2:04 p.m., MD 1 stated he should have been notified as soon as possible of Resident 188's severe weight loss. MD 1 stated it was important he was notified so he could decide on new interventions and ensure the RD was assessing the resident's nutritional needs. During a review of Resident 188's Nutrition/ Dietary Note dated 2/6/2025, the Nutrition/ Dietary Note indicated Resident 188 weighed 93 lbs., and had a 17 lbs. (15%) weight loss in one month from 1/3/2025 to 2/6/2025 and had 26 lbs. weight loss in three months from 12/6/2025 to 2/6/2025. The Nutrition/ Dietary Note indicated the weight loss was significant and was likely related to pressure ulcer healing, diarrhea, and respiratory failure (a serious condition that makes it difficult to breathe on your own). The Nutrition/ Dietary Note indicated Resident 188 was tolerating GT feeding well and was not experiencing diarrhea at the time on 2/6/2025. The Nutrition/ Dietary Note indicated the RD recommended to increase the GT feeding to Glucerna 1.5 at 55cc/hr for 20 hrs. to provide 1100 cc/1650 kcal daily. During a review of Resident 188's COC/ Interact Assessment form (SBAR) dated 2/7/2024, the COC indicated Resident 188 had a 26 lbs. weight loss. The COC indicated MD 1 was notified of the weight loss. During a review of Resident 188's COC/ Interact Assessment forms (SBAR), the COC/Interact Assessment forms did not indicate there were any other COCs from admission (on 12/6/2024) to 2/7/2025 in Resident 188's chart regarding weight loss or that MD 1 or Resident 188's responsible party (RP), family member (FM)1were informed of the resident's severe weight loss. During an interview on 2/7/2025 at 12:41 p.m., Resident 188's FM 1 stated nursing staff (unknown) told her in passing Resident 188 was losing weight, but no one informed her how much weight. FM 1 stated on 2/7/2025, the morning nurse (unknown) called her about Resident 188's weight loss and informed her that Resident 188 had lost weight. FM 1 stated they did not inform her of the actual amount of weight he lost but now she was feeling worried about Resident 188's health. During an interview on 2/8/2025 at 1:23 p.m., the ADON stated a COC was important documentation including monitoring when an issue outside of the resident's baseline occurred. The ADON stated a significant weight loss was outside of Resident 188's baseline and a COC should have been initiated. The ADON stated he reviewed Resident 188's medical record and did not find a COC completed for weight loss or any documentation indicating the physician or FM 1 was notified of the weight loss. The ADON stated the RD needed to be made aware of significant weight loss but so did the physician because the physician had more options for addressing the weight loss, more interventions, and modalities to address the weight loss. The ADON stated a care plan should have been created for the weight loss as a change of condition. The ADON stated it was important to create a care plan, so all staff involved knew the new interventions, new goals, and the problem the resident was having. The ADON stated he reviewed Resident 188's medical record and did not find a care plan for the resident's severe weight loss. The ADON stated it was important to monitor interventions for a COC to see if interventions were effective. The ADON stated the IDT should have met and discussed Resident 188's weight loss so that they could collaborate and come up with new solutions for the weight loss and recommend them to the physician. The ADON stated the IDT was to be done as soon as the RP and resident were available to be involved in the care planning. The ADON stated as soon as Resident 188's diarrhea subsided on 1/13/2025 the RD should have reassessed the resident and the physician should have been notified so they could decide if GT feeding could have been increased. The ADON stated the potential outcome of not monitoring severe weight loss or reassessing the resident's interventions was further weight loss. The ADON stated based on Resident 188's current weight of 93.2 lbs., the interventions were not working and the IDT meeting should have been conducted to address the resident's progressive weight loss. During an interview on 2/8/2025 at 1:57 p.m., the RD stated she did not attend IDT meetings for weight loss. The RD stated the IDT discussed Resident 188's case but the notes of the IDT discussion were not written down. The RD stated if it was not documented, it was not done. The RD stated RNA 1 did not write down any weights on 1/31/2025, she (RNA 1) just told her (RD) the weight verbally on 2/6/2025. The RD stated the potential outcome of not being notified right away of weight loss was a delay of interventions to prevent further weight loss. The RD stated she based her assessment of Resident 188's chart and information obtained from nurses but did not assess or speak to the resident himself. During an interview on 2/8/2025 at 2:33 p.m., the DON stated facility staff cannot assume a weight loss was expected based on the resident's diagnosis. The DON stated they must closely monitor the resident's weight trends (via weekly weights) to see if any other interventions could be implemented for the resident. The DON stated she was not made aware Resident 188 had severe weight loss and that his weight loss was not discussed during an IDT meeting. The DON stated communication among the care team was important so weights can be addressed appropriately. The DON stated it was important to reassess the interventions to see if the interventions were working and revise and add new interventions as needed. During an interview on 2/8/2025 at 3:02 p.m., the director of staff development (DSD) stated the weights should be documented in the resident's chart right away after obtaining the weight. The DSD stated, we are all human and the RNAs could forget a weight or mix up the weights of different residents if they did not write them down right away. The DSD stated accurate weights were important so an accurate nutritional assessment could be done, and weights could be accurately monitored. During an interview on 2/8/2025 at 3:26 p.m., the medical director (MD 2) stated the physician needed to be informed as soon as weight loss was identified. MD 2 stated any significant weight fluctuations needed to be addressed. MD 2 stated continued weight loss was not good and affected a resident's well-being, could lead to malnutrition and slow pressure sore healing. During a review of the facility's policy and procedure (P/P) titled Nutritional Assessment dated 10/2017, the P/P indicated as part of the comprehensive assessment, the nutritional assessment was to be a systematic, multidisciplinary process that included gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk of impaired nutrition. During a review of the facility's P/P titled Weight Assessment and Intervention dated 3/2022, the P/P indicated weights were to be recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since last weight assessment was retaken the next day for confirmation and if the weight is verified, the nursing team was to immediately notify the RD in writing. Residents were to be weighed at an interval determined by the IDT. The threshold for significant unplanned and undesired weight loss was to be based on the following criteria [ where percentage of body weight loss = (usual weight - actual weight)/ (usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe. 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 for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate (RP). Individualized care plans shall address to the extent possible: the identified causes of weight loss; goals and benchmarks for improvement; and time frames and parameters for monitoring and reassessment. During a review of the facility's P/P titled Change in Resident's Condition or Status dated 3/2022, the P/P indicated the nurse was to notify the physician and RP when there has been a significant change in the resident's physical condition. Notifications were to be made within 24 hours. The nurse was to record information relative to changes in the resident's record. During a review of the facility's Registered Dietician (RD) Consultant job description dated 4/2022, the job description indicated the RD was to work with the ADM, nursing, and other department heads on planning resident care issues, and quality assessment monitoring and reporting. The RD was responsible for evaluating the nutritional needs of the residents and documenting in the nutritional record.