**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one of 18 sampled residents (Resident 12) when Resident 12 experienced an unplanned insidious weight loss of 10 pounds, 6.8% in three months and 16 pounds 9.8% weight loss in six months. This had the potential to result in muscle wasting, loss of independence, decreased quality of life, and increased disease complications. Findings: A professional reference review of the National Library of Medicine titled, An approach to the management of unintentional weight loss in elderly people, dated March 15, 2005, showed in part, Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period .Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people 65 years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred .Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-10 years or longer, is associated with increased mortality or morbidity or both. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/ 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. A publication from the Academy of Nutrition and Dietetics titled What Resources Are Available to Assist in Assessing Body Weight in Older Adults. July 1, 2025, indicated usual body weight (UBW), an individual's weight throughout adult life or a stable weight over time, is the preferred standard for older adults. Any recent weight changes, especially unintentional weight loss, would also need to be addressed in a care plan. UBW is considered more appropriate than desirable body weight or ideal body weight for weight-related interventions in older adults. 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 a definition for insidious weight loss: 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). Review of the facility Policy and Procedure (P&P) titled Weight Assessment and Intervention dated 2001, showed resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 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. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes but is not limited to the resident's target weight range and the resident's calorie, protein, and other nutrient needs compared with the resident's current intake and the relationship between current medical condition or clinical situation and recent fluctuations in weight; and whether and to what extent weight stabilization or improvement can be anticipated. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia (an eating disorder characterized by a restriction of food intake leading to low body weight), weight loss or increasing risk of weight loss. Interventions for undesirable weight loss are based on careful consideration of the following including but not limited to: Resident choice and preferences; nutrition and hydration needs; the use of supplementation. Review of the admission Record (a document containing the most pertinent information for a resident) for Resident 12, indicated Resident 12 was [AGE] years old. Resident 12 was initially admitted on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to: acute chronic congestive heart failure (worsening of an existing heart failure symptoms), type 2 diabetes (a condition in which the body has trouble controlling blood sugar), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone which can disrupt things such as heart rate, body temperature, and metabolism), Alzheimer's disease (a progressive disease that destroys memory and other important functions), and dementia (a group of thinking and social symptoms that interfere with daily functioning). A record review of Minimum Data Set (MDS, an assessment used to plan care) Section K - Swallowing/Nutritional Status from 5/24/24 to 4/3/25 created for Resident 12 showed: 5/24/24 Quarterly Assessment: Weight 170 pounds, no weight loss of 5% in 1 month or 10% in 6 months; no swallowing issues, received a therapeutic diet. 8/24/24: Quarterly Assessment: Weight 165 pounds, no weight loss of 5% in 1 month or 10% in 6 months; no swallowing issues, received a therapeutic diet. 11/24/24 Quarterly Assessment: Weight 164 pounds, no weight loss of 5% in 1 month or 10% in 6 months; no swallowing issues, received a therapeutic diet. 2/22/25 Annual Assessment: Weight 160 pounds, no weight loss or weight gain of 5% in 1 month or 10% in 6 months, no swallowing issues, received a therapeutic diet. 3/12/25 Significant Change Assessment: Weight 158 pounds, no weight loss of 5% in 1 month or 10% in 6 months, no swallowing issues, received a therapeutic diet. 3/21/25 Discharge Assessment: Weight 158 pounds, no weight loss of 5% in 1 month or 10% in 6 months, no swallowing issues, received a therapeutic diet. 4/3/25 readmission Assessment: Weight 154 pounds, no weight loss of 5% in 1 month or 10% in 6 months, no swallowing issues, received a therapeutic diet. During a record review of Resident 12's Weights and Vitals Summary from 4/3/24 to 6/23/24, the following monthly weights for Resident 12 were shown: 4/3/24: 175 lbs 5/3/24: 163 lbs (6.9 %, - 12 lb weight loss in 30 days [comparison weight 4/3/24 175 lbs]) 6/8/24 164.2 lbs 7/12/24 167.2 lbs 8/5/24 165 lbs 9/2/24 164 lbs 9/30/24 163 lbs 11/11/24 164 lbs 12/4/24: 164 lbs 1/2/25: 162 lbs 2/4/25: 160 lbs 3/3/25: 158 lbs 3/27/25: 154.6 lbs 5/1/25: 154 lbs 6/2/25: 148 lbs Resident 12's documented weights represented an insidious loss in body weight of 16 pounds/9.8% from 12/4/24 to 6/2/24, and 10 pounds, 6.8% in three months from 3/3/25 to 6/2/25. A record review showed on 12/18/24, Resident 12 was prescribed MedPass Sugar Free 90 ml, QD. (MedPass Sugar Free is a nutrition supplement providing extra calories and protein and typically provided during the medication pass. It provides approximately 160 - 180 calories per 90 ml). RD recommended MedPass to be discontinued on 2/20/25 due to resident refusals. The Medication Administration Record [MAR] dated 1/1/25-1/31/25 showed out of 31 days Resident 12 was offered MedPass, he consumed 10% two (2) days, 20% one (1) day, 25% three (3) days, 50% four (4) days, and 100% 7 days. The MAR dated 2/1/25-2/28/25, showed out of the 21 days Resident 12 was offered MedPass, he consumed 100% two (2) days, and 50% three (3) days. A record review for orders showed on 6/19/24 Add snacks BID [twice a day], Document % intake. This order was discontinued on 3/24/24 and was not started again after readmission on [DATE]. On 6/5/25, the RD recommended adding snacks BID. A record review showed Resident 12 was prescribed a No added Salt, Consistent Carbohydrate (CCHO; a diet typically prescribed to maintain blood sugar) diet from 6/8/24 to 3/27/25. A record review showed when Resident 12 was readmitted on [DATE], his diet order was a Cardiac - Low Fat Low Cholesterol, Low Salt, Diabetic No Concentrated Sweets (NCS) diet (a diet restricting foods and drinks with added sugars and simple carbohydrates; According to a progress note dated 6/5/25 RD recommended to change NCS diet to CCHO in house diet). A professional review titled, Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the America Diabetes Association, Diabetes Care 2016 showed, Liberal diets have been associated with improvement in food and beverage intake in the LTC population to better meet caloric and nutrient requirements. While carbohydrate intake should be taken into consideration, no concentrated sweets or no sugar diet orders are ineffective for glycemic management and should not be recommended. Instead, a consistent carbohydrate meal plan that allows for a wide variety of food choices may be more beneficial for both nutritional needs and glycemic control in patients with type 1 diabetes or type 2 diabetes on mealtime insulin. Review of the facility's 2023 Diet Manual for Long Term Care Facilities showed the CCHO diet provided 1900 - 2000 calories per day; and the Low Fat/Low Cholesterol Diet provided 1800 - 2000 calories per day. Calculations in accordance with the Diet Manual show a CCHO diet provided (the combination of a CCHO diet and Low Fat/Low Cholesterol may have provided fewer calories according to the diet manual): 1444- 2000 calories with an intake of 76-100%. 969 - 1500 calories with an intake of 51-75% 494 - 900 calories with an intake of 26-75% Review of Resident 12's record included a physician Progress Note dated 3/30/25, showed Resident 12 was transferred out on 3/21/25 for chest pain and was readmitted to the facility on [DATE]. A record review from December 2024 to June 2025 showed the following RD Nutrition Progress Notes and Assessments: Nutrition Assessment dated 2/20/25 showed Resident 12's weight was 160 pounds, estimated caloric needs were 1818 - 2181 kcals (kilocalories, often referred to as calories), meal intake was 76-100% on average, supplement MedPass Sugar Free 90 ml (milliliters) QD (every day), refusing MedPass supplement on average. No significant weight changes in the last 30, 90, and 180 days. PO intake is meeting ENN [estimated nutrition needs include caloric intake and protein intake]. RD's only recommendation in this assessment was to discontinue the nutritional supplement MedPass due to the resident refusing the supplement. Although the RD documented Resident 12's intake was meeting his ENN in her 2/20/25 Nutrition Assessment, no additional interventions were implemented to address the insidious weight loss of 164 to 160 pounds from 12/4/24 to 2/25. While the RD documented in her 2/20/25 Nutrition Assessment, Resident 12's average meal intake was 76-100%, no time frame was specified. A record review of the Meal intake Documentation Nutrition - Amount Eaten for Resident 12, from 12/1/24 to 2/19/25, showed: from 12/21/24-12/31/24, Resident 12 consumed 76-100% for 62% of meals (56 out of 90 meals); from 1/1/25 to 1/31/25, Resident 12 consumed 76-100% for 59% of meals (54 out of 92 meals); and from 2/1/25 to 2/19/25, Resident 12 consumed 76-100 % for 58% of meals (32 out of 55 meals). Progress Note dated 3/20/25 showed Resident 12 weighed 158 pounds, average meal intake was 84%, average snack intake was 50%. No significant weight changes in the last 30, 90, 180 days. PO (by mouth) intake meeting ENN . no new recommendations at this time . Although the RD stated Resident 12 was meeting his ENN in her 3/20/25 progress note, Resident 12 experienced an insidious weight loss of 6 pounds between 12/4/24 and 3/3/25. While RD documented in her 3/20/25 progress note, Resident 12's average meal intake was 84%, no time frame was specified. A record review of the Meal intake Documentation Nutrition - Amount Eaten for Resident 12, from 2/21/25 to 3/19/25 (dates between RD nutrition assessment on 2/20/25 and RD progress note on 3/20/25), showed: from 2/21/25-2/28/25, Resident 12 consumed 76-100% for 67% of meals (16 out of 28 meals); and from 3/1/25 to 3/19/25; Resident 12 consumed 76-1 00% for 48% of meals (25 out of 52 meals). Nutrition Assessment dated 4/3/25 showed Resident 12 weighed 154 pounds, estimated caloric needs were 1750 - 2100, average meal intake was 50-75%, and no supplements. PO intake meeting ENN. No new recommendations at this time. While RD documented Resident 12's intake was meeting ENN in her 4/3/35 Nutrition Assessment, calculations including percent intake and calories provided by the diet manual, showed Resident 12 did not meet ENN. RD stated Resident 12's average meal intake was 50-75%, but no time frame was specified. RD did not show how many calories 50-75% intake provided. According to the diet manual 50-75% intake of a CCHO diet provided [PHONE NUMBER] calories which did not meet Resident 12's ENN of 1750-2100 calories per RD's assessment dated [DATE]. Resident 12 experienced insidious weight loss of 9.4 pounds between 12/4/24 and 3/27/25. Progress Note dated 6/5/25, showed Weight changes: -3.9%/-6# x 30 days, -6.3%/-10# x 90 days, -9.8%/-16# x 180 days . [AGE] year old male noted with significant weight loss of -6 # [pounds] x 30 days . Weight loss is undesirable as resident is meeting only 93% of IBW [Ideal Body Weight] . Resident may benefit from resuming snacks BID to increase calorie and protein intake and monitor on weekly weights x 4 weeks. RD did not recommend interventions to address weight loss until Resident 12 experienced an unplanned weight loss of 6 pounds between 5/1/25 and 6/2/25, 10 pounds between 3/3/25 and 6/2/25, and 16 pounds between 12/4/24 and 6/2/25. During a concurrent phone interview and record review with Registered Dietitian (RD) on 6/25/25 at 9:53 a.m., Resident 12's weight log, progress notes, assessments, and physicians' orders from 3/5/2024 to present, were reviewed. RD stated she began working at the facility in January 2025. RD confirmed Resident 12 continuously lost weight from 12/4/24 to 6/2/25. RD stated she considered Resident 12's weight loss to be insidious. RD stated insidious weight loss was a weight loss that was slowly down trending. RD stated she did not consider interventions for weight loss from January to June 2025 because Resident 12's meal intake was meeting his estimated nutrient needs (ENN) according to PO nutrition intake documentation. RD confirmed she did not recommend an intervention for weight loss until 6/5/25 when she documented Resident 12 had significant weight loss of 6 pounds between 5/1/25 and 6/2/25. In addition, RD stated she was not involved with Interdisciplinary Team (IDT) meetings. RD stated she did not know what was discussed in the IDT meetings. RD also stated she did not speak to resident representatives (RPs), it was up to the dietary manager to speak with RPs to determine resident weight goals, and she did not attend IDT meetings since she worked at the facility only four hours a week. During a meal observation on 6/25/25 at 11:54 p.m., Resident 12 ate his lunch in the dining room. Resident 12 consumed 50% of his milk (8 ounce cup), 100% his juice (6 ounce cup), 100% of his dessert (which he ate first), less than 25% of his vegetables, and 25% of his fish filet. Resident 12 appeared agitated and yelled at staff no when staff asked if he wanted anything else to eat. In an interview on 6/25/25 at 12:01 p.m., Licensed Vocational Nurse (LVN) D stated Resident 12 ate in his room or the dining room depending on his mood. LVN D stated his food intake at meals was inconsistent. During an interview on 6/25/25 at 2:30 p.m., RD stated weight loss was discussed with nursing only when residents trigger for significant weight loss. During an interview with the Interim Director of Nursing (IDON) on 6/25/25 at 3:02 p.m., IDON stated RD came into the facility weekly and reviewed resident weights. Resident weights were discussed in weight variance IDT meetings only when there is a significant weight change. IDON confirmed the RD was not present in the IDT meetings. During a consecutive interview and document review with IDON on 6/26/25 at 9:59 a.m., weight variance IDT meeting documentation was reviewed. From 12/2024 to 6/2025, weight variance IDT meeting documentation showed there were no weight variance IDT meetings to address Resident 12's insidious weight loss of 10 pounds from 12/4/24 to 5/1/25. An IDT meeting was not held until 6/6/2025 after the RD documented Resident 12 had a significant weight loss of 6 pounds from 5/1/25 and 6/2/25. The documentation showed the only staff present in the meeting were the Certified Dietary Manager (CDM), IDON, and a Minimum Data Set (MDS) staff. Only information repeated from RD 6/5/25 progress was documented in the weight variance IDT meeting minutes, such as Resident 12's weight at 148 pounds, a weight loss of 6 pounds in a month, recommend snacks twice a day, and start weekly weights. IDON confirmed the RD was not present for IDT meetings. IDON stated dietary manager presents the RD recommendations from the RD assessments/progress notes, but possible causes of weight loss were not discussed. IDON confirmed she could not find documentation to show the Resident 12 was on a planned/prescribed weight loss program. During an interview and concurrent record review on 6/26/25 at 10:43 a.m., the MDS Coordinator (MDSC) reviewed MDS Section K - Swallowing/Nutritional Status dated 5/24/24 for Resident 12. MDSC confirmed stated Resident 12's significant weight loss of 6.9% in one month (4/3/24 to 5/3/24) was not reflected on the 5/24/24 MDS section K but the weight loss should have been reflected. MDSC stated a Registered Nurse (RN) reviewed section K for accuracy. During an interview and concurrent document review on 6/26/25 at 11:19 a.m., IDON reviewed MDS Section K - Swallowing/Nutritional Status dated 5/24/24 for Resident 12. IDON confirmed an RN was to review section K of the MDS for accuracy. IDON confirmed Resident 12's 5/24/24 MDS section K should show Yes [loss of 5% or more in the last month .] not on a physician-prescribed weight-loss regimen because Resident 12 lost more than 5% weight in one month from 4/3/24 to 5/3/34 and he was not on a physician prescribed weight loss program. On 6/26/25 at 11:40 a.m., Resident 12's Responsible Party (RP) was interviewed. RP stated his father (Resident 12) was always overweight before he was admitted to the facility. RP stated his father began losing weight when he was admitted to the facility. RP stated he visited the facility on the weekends, and his father expressed he did not like the facility food, that it had no taste. RP stated his father mainly liked Filipino food. During a dining observation on 6/26/25 at 12 p.m., Resident 12 at lunch in his room. Resident 12 consumed 100% of his milk, 80% of his juice, 25% of rice, 75% of chicken, 100% of dessert, did not eat any vegetables, and did not eat his bread. During an interview and concurrent record review with RD on 6/26/25 at 12:21 p.m., RD confirmed weight maintenance was her goal for Resident 12. RD stated weight loss due to PO intake was not desirable for Resident 12. RD stated weight loss can be caused by other things other than food intake, such as skin breakdown and medication. RD confirmed she did not discuss possible causes of weight loss with IDT. RD also stated prescribed snacks equal about 100 to 150 calories, so snacks BID would add about 200 to 300 calories a day. During an interview on 6/26/25 at 2:04 pm., CDM stated she did not talk to family members or RP regarding Resident 12's food preferences, instead she spoke to Resident 12. CDM stated Resident 12 was not picky with food and liked coffee. CDM stated currently Filipino food was not served at the facility. While CDM stated she could speak to Resident 12, a record review of the MDS for Resident 12, dated 4/3/25, indicated Resident 12 had a score of 4 on the Brief Interview for Mental Status (BIMS, an assessment of a resident's cognition skills; a score of 0-7 indicates severe cognitive impairment).