**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one out of 95 residents (Resident 75) received the appropriate services needed to maintain acceptable parameters of nutritional status when: 1. Significant severe weight loss of 14 lbs (pounds, a unit of measurement), 6.7 percent (%) from October 14, 2021 to November 11, 2021, 17 lbs, 8% from September 14, 2021 to December 10 2021, 18 lbs, 8.6% from October 14, 2021 to January 18, 2022, 25 lbs, 11.9% from August 23, 2021 to February 8, 2022, and 34 lbs 16.2% from September 14, 2021 to March 2, 2022 were not addressed in the Interdisciplinary Team (IDT) which may include, Physician (MD), Registered Nurse (RN), Dietary Manager/Dietitian (Registered Dietitian, RD), Social Services, Activity Director/Coordinator .weight variance meeting; nor were interventions implemented to prevent further significant severe weight loss, and 2. There was no documented order for a Physician prescribed weight loss regimen. These failures contributed to on-going unaddressed significant severe weight loss in one, three, and six-month time frames which posed a threat for further medical complications. Findings: A record review for Resident 75 was conducted beginning March 15, 2022. Resident 75 was readmitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, a chronic lung condition that cause breathing difficulties), schizoaffective disorder (a mental illness that can affect a person's thoughts, mood and behavior), anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), hypothyroidism (a medical condition when thyroid gland does not produce enough thyroid hormones to meet one's body's needs, may affect breathing, heart rate, weight, digestion, and mood), hypertension (high blood pressure), Hyperlipidemia (elevated fat levels in the body), polyosteoarthritis (a type of arthritis that affects five or more joints with most common symptoms of joint pain and inflammation), and legal blindness (a form of visual impairment that the glasses or contact lenses cannot correct the vision). Resident 75 was self-responsible. The most recent Minimum Data Set (MDS, a resident assessment tool), dated February 4, 2022, showed Resident 75 had a BIMS (brief interview of mental status) score of six which indicated she had moderate cognitive impairment. A review of the facility document titled, History and Physical Examination, completed on August 22, 2021 by Resident 75's MD, indicated Resident 75 did not have the capacity to understand and make decisions. Section K (Swallowing/Nutritional Status) of the annual MDS assessment, dated November 5, 2021, indicated Resident 75's height was 68 inches () and weight was 194 lbs. Review of a quarterly MDS assessment, dated February 4, 2022, indicated Resident 75's height was 68 and weight was 185 lbs. Both MDS assessments indicated Resident 75 had an unplanned significant weight loss of 5% or more in the last month or loss of 10% or more in the last six months. The MDS assessments further indicated Resident 75 was not on a physician-prescribed weight loss regimen. A review of the facility document titled, Monthly Weight Record, for the year of 2021 and 2022, indicated the following weights for Resident 75: 8/23/21: 210 lbs 9/14/21: 210 lbs 10/14/21: 208 lbs 11/11/21: 194 lbs (a significant severe weight loss of 14 lbs, 6.7% from 10/14/21) 12/10/21: 193 lbs (a significant severe weight loss of 17 lbs, 8% from 9/14/21 to 12/10/21) 1/18/22: 190 lbs (a significant severe weight loss of 18 lbs, 8.6% from 10/14/21 to 1/18/22) 2/8/22: 185 lbs (a significant severe weight loss of 25 lbs, 11.9% from 8/23/21 to 2/8/22) 3/2/22: 176 lbs (a significant severe weight loss of 34 lbs 16.2% from 9/14/21 to 3/2/22) A review of the monthly physician progress notes dated November 5, 2021, December 27, 2021, and February 14, 2022, indicated Resident 75 was being seen by the physician (MD) via telehealth (the use of digital information and communication technologies, such as computers and mobile devices, to access health care services remotely and manage one's health care) with assistance from the facility staff. The notes indicated Resident 75 did not have a recent change in condition, Resident 75's appetite was fair, and to continue skilled nursing care. The significant severe weight loss of 14 lbs, 6.7 % from October 14, 2021 to November 11, 2021, 17 lbs, 8% from September 14, 2021 to December 10 2021, 18 lbs, 8.6% from October 14, 2021 to January 18, 2022, 25 lbs, 11.9% from August 23, 2021 to February 8, 2022, and 34 lbs 16.2% from September 14, 2021 to March 2, 2022 were not addressed in the physician progress notes. On March 16, 2022, at 12:29 p.m., Resident 75's lunch meal observation and a concurrent interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated Resident 75's meal intake average was about 50% but depended on her mood. CNA 3 showed the finished lunch meal tray and stated Resident 75 ate about 50-75% of her meal. CNA 3 further stated Resident 75 sometimes asked for snacks and specific food, which the CNA 3 would give Resident 75. 1. On March 16, 2022, at 3:34 p.m., an interview and a concurrent review of Resident 75's monthly weight record was conducted with the Licensed Vocational Nurse (LVN) 1. LVN 1 confirmed the documented weights from August 23, 2021 to March 2, 2022 on Resident 75's monthly weight record. LVN 1 stated she would be concerned the 14 lbs weight loss from October 14, 2021 to November 11, 2021, and the 9 lbs weight loss from February 8, 2022 to March 2, 2022. LVN 1 acknowledged Resident 75 had a 34 lbs weight loss in a six-month time frame from September 14, 2021 to March 2, 2022. LVN 1 further stated gradual weight loss was fine since Resident 75 was over her Ideal body weight range (IBWR). When asked if the 34 lbs weight loss from September 14, 2021 to March 2, 2022, was significant, LVN 1 stated she was not sure if the weight loss was significant. LVN 1 stated all significant weight changes were discussed in the weekly IDT weight variance meeting. When asked for documentation of the IDT weight variance meeting addressing the significant severe weight losses from August 23, 2021 to March 2, 2022, the LVN was unable to confirm documentation in Resident 75's medical record. On March 17, 2022, at 8:14 a.m. an interview was conducted with RN 3. RN 3 confirmed all significant weight changes should be discussed in the IDT weight variance meeting. On March 17, 2022, at 10:00 a.m., an interview and concurrent record review for Resident 75 was conducted with the Dietary Supervisor (DS). The DS stated Resident 75's mental status was about the same as the previous admission. Resident 75 had verbalized she wanted to lose weight on her previous admission. The DS stated Resident 75 did not verbalize she wanted to lose weight or set any weight goal during the present admission because she was not able to answer those questions. The DS stated on the readmission on [DATE], the RD set the goal for Resident 75 to have safe weight loss; one to two lbs per month if medically feasible due to the resident's weight status without any significant weight change. The RD set the target weight goal range (TWGR) of 195 to 200 lbs. The document titled Nutrition Screening and Assessment-OBRA, completed by the DS on November 4, 2021 showed, Resident 75's weight was 194 lbs in November 2021, a 14 lbs, 6.73% significant severe weight loss from October 2021 to November 2021. Resident 75's weight was 208 lbs in October 2021, a 16 lbs, 7.62% significant severe weight loss from August 2021 to November 2021. Resident 75's appetite (meal intake) was 50-74%. The section titled Comments showed, Resident 75's intake was down. The section titled Weight Note showed, resident had a weight loss of 14# (6.73%) x 30 days. Readmit weight on August 22, 2021 was 210#. She continued to be on a planned weight loss of 1-2# per month until TWGR is reached. She is currently at her TWGR. I did explain to resident we want the weight loss to be safe .Will refer to RD due to annual assessment & weight note, at her TWGR. The DS confirmed the 14 lbs, 6.73% weight loss in 30 days was a significant severe weight loss. When asked if the 14 lbs, 6.73% weight loss in 30 days was safe, the DS stated the weight loss was not safe if it was a significant weight loss. The annual nutrition review indicated the DS referred the assessment to the RD. A review of the document titled, Nutrition Screening and Assessment-OBRA, completed by the RD on November 8, 2021, under the Section titled Evaluation showed, Intake meets estimated nutrition needs at this time, Continue POC (plan of care). Under the Section titled Goal showed, TWGR 195-200 lbs, Without significant weight change, as medically feasible and Safe weight loss POC to attain TWGR as medically feasible. The DS confirmed the RD did not change the TWGR and that Resident 75 was below the TWGR. The DS confirmed the goal for Resident 75 was to not experience significant weight change and for safe weight loss to attain TWGR. A review of the document titled, Dietary Note: Weight, Quarterly completed by the DS on February 8, 2022, and electronically signed by the RD on February 10, 2022 showed, Resident 75's TWGR had been reduced to 180-184 lbs, weight was 185 lbs, 22 lbs, 11.9% weight loss in 180 days since August 23, 2021. The section titled, % Meal Intake showed 50-74% for breakfast, lunch and dinner. The section titled, Refer to RD showed, Yes, weight loss, below TWGR, D/C the planned weight loss on 2/8/22. The section titled, Meeting care plan goal, if no reason? showed, yes. The section titled, RDN Recommendations: showed, to continue POC, Res (Resident 75) is obese, has a weight loss POC (plan of care) and meeting weight goal. Monitor. A review of facility document titled, Nurse Assistant Notes: A.M. Shift and Night Shift, from October 1, 2021 to February 28, 2022, indicated there were 453 meals (Breakfast, Lunch, and dinner) served between October 1, 2021, and February 28, 2022. Resident 75 refused eight% of her meals and consumed 50% or less 41.5% of the time. The DS confirmed she tried to communicate with Resident 75 about her weight loss with the goal of one to two lbs per month but Resident 75 was not able to interview about the weight. The DS stated she suggested to discontinue the weight loss plan at that time and referred to the RD. The DS stated the RD wanted to continue the same plan of care and lowered Resident 75's target weight goal to 180-184 lbs. The DS stated she did not remember if she talked to the RD about the change of Resident 75's target weight goal, but she changed the care plan per the RD's assessment plan. The DS confirmed Resident 75 was not involved in the decision to reduce her TWGR but should have been. The DS confirmed Resident 75's significant severe weight loss of 14 lbs, 6.73% weight loss in 30 days and the significant severe weight loss of 16 lbs, 7.62% in 90 days, and 22 lbs, 11.9% weight loss in 180 days were not discussed in the IDT weight variance meeting. She stated the nurses or herself (the DS) determined which residents should be followed in the IDT weight variance meeting. She confirmed that she did not know why Resident 75 was not included in the weight variance for monitoring the significant weight loss since November 2021. A concurrent review of Resident 75's weight record dated March 2, 2022, was conducted with the DS. Resident 75 had another weight loss of nine lbs in a month, and weight loss of 34 lbs, 16.2% in six months. The DS stated the weight loss should have been discussed in the IDT weight variance meeting and she did not know why it was not discussed until March 16, 2022. The DS stated she did not attend the IDT weight variance meeting on March 16, 2022, but she signed it because the nurse went over what they discussed in the meeting. During an interview on March 17, 2022, at 11:55 a.m., RN 4 stated she entered the February 2022, and March 2022 weights on Resident 75's monthly weight record. On February 22, 2022, Resident 75's weight was 185 lbs with a weight loss of five lbs in a month. RN 4 stated she did not calculate the weight change percentage. RN 4 stated dietary was responsible to calculate the weight percentages and put in a form. RN 4 explained the process of significant weight loss if identified. She stated she would check resident's meal intake, and if the residents had any edema or medical conditions. RN 4 stated she would notify the MD and the RD. She stated for Resident 75, the February 2022, and March 2022 weights were still within Resident 75's IBWR but she still notified the MD because the weight loss was a significant change. RN 4 stated she did not document on the nursing progress notes that she notified the MD. RN 4 stated she documented NNO which meant no new order from the MD next to the weight change on the comment column in Resident 75's monthly weight record. When asked what the appropriate time frame to address a significant weight change was or if significant weight loss was considered safe, the RN 4 did not answer. During a follow up interview on March 17, 2022, at 2:11 p.m., the DS explained the process of identifying significant weight changes. The DS stated the Restorative Nurse Assistant (RNA) weighed the residents on the first of each month and took four to five days to complete. The residents' weights were entered in the computer and a form with the weight changes was generated. The DS stated she would go over the weights with the nurse, usually with the Assistant Director of Nursing (ADON). The DS stated if a resident was on a planned weight loss regimen, the facility would monitor the weight monthly. The DS stated if the resident was on a weight loss plan but had a significant weight loss, the facility would monitor weights weekly. The DS would communicate with the RD and initiate the weight loss assessment form which was emailed to the RD. She stated the RD would email the completed assessment back to the DS. During an interview and a concurrent record review with the Director of Nursing (DON) on March 17, 2022, 3:02 p.m., when asked if Resident 75's significant weight loss from November 2021 to March 2022 was discussed in the IDT weight variance meeting, the DON did not answer. The DON stated the facility should address the significant weight loss after the weights were entered in the medical record. The process would be to notify the MD and the RD. She stated then she would carry out any order from the MD. She reviewed Resident 75's record and stated there was no MD order for Resident 75's weight loss plan. The DON stated the facility should have addressed the significant weight loss on February 8, 2022, even though Resident 75 was on weight loss plan. She stated Resident 75 should be included in the IDT weight variance meeting and monitored Resident 75's weights closely. The DON acknowledged the goal from the RD was to have safe weight loss of one to two lbs per month, but she did not answer when asked if 14 lbs weight loss in a month on November 11, 2021, was consider safe. The DON stated that she would monitor weights weekly for a resident who had a significant weight loss even though he or she was on a weight loss program. A concurrent review of the facility document titled, Dietary Care Plan for Nutrition Status, for Resident 75, initiated on August 22, 2021, and updated on November 4, 2021, was conducted with the DON. The DON confirmed the plan of care did not reflect a weight loss plan until Resident 75's TWGR was reduced to 180-184 lbs on February 10, 2022. A phone interview was conducted with the RD on March 18, 2022, at 10:08 a.m. The RD confirmed significant severe weight loss parameters of 5% in a month, 7.5% in three months and 10% in six months. The RD stated she was aware of the consequences of significant severe weight loss. When asked if Resident 75's significant severe weight loss between November 2021 to March 2022 was safe the RD stated obesity was more important to deal with than significant severe weight loss. When asked if she involved Resident 75 in the weight loss plan, the RD stated she could not remember if she spoke to Resident 75. When asked if a resident on a weight loss plan should have a Physician's order, the RD stated nursing was responsible to get an order from the MD for a physician prescribed weight loss plan. The RD stated she did not enter a recommendation for a physician prescribed weight loss regimen for Resident 75 on the RD recommendation form. A concurrent review of Resident 75's annual nutrition assessment completed on November 8, 2021, was conducted with the RD during the phone interview. The RD was asked if the significant severe weight loss of 14 lbs, 6.73% in one month was safe weight loss. The RD did not answer the question but stated the November 2021 weight was an outliner weight. The RD further stated, we cannot control how many pounds people lose and how they eat. A concurrent review of Resident 75's quarterly nutrition assessment completed on February 10, 2022, was conducted with the RD during the phone interview. Resident 75's weight in February 2022 was 185 lbs, a significant severe weight loss of 22 lbs, 11.9% weight loss in 180 days since August 23, 2021. The DS had a comment to hold the weight loss plan due to the weight loss and she referred to the RD. The RD disagreed and adjusted and reduced the TWGR to 180-184 lbs. When asked why the TWGR was decreased after Resident 75 had experienced a significant severe weight loss in the past 180 days, the RD stated she adjusted the weight goal as Resident 75 lost the weight. She added she would stop the weight loss plan now and the facility would start to follow Resident 75 more closely. A phone interview was conducted with Resident 75's MD on March 18, 2022, at 11:59 a.m. When asked what Resident 75's nutrition plan was since admission, the MD stated he did not remember. When asked if he remembered Resident 75 was on a weight loss regimen, he stated the RD would be the one to make those recommendations. When asked if he wrote an order for a physician-prescribed weight loss regimen, the MD stated he believe he gave the RD a verbal order for a planned weight loss regimen. The MD was asked if Resident 75's significant severe weight loss of 25 lbs, 11.9% in five months in February 2022 and the significant severe weight loss of 34 lbs, 16.2% in six months in March 2022 was safe, the MD stated he could not answer that question without reviewing Resident 75's medical record. A review of facility document titled, RDN (Registered Dietitian Nutritionist) Recommendations, dated August 2, 2021, to March 10, 2022, indicated the RD did not have any recommendations or interventions for Resident 75's significant weight losses which occurred between November 11, 2021 and March 2, 2022. A review of facility document titled, Dietary Care Plan for Nutritional Status, initiated on August 22, 2021, and updated on November 4, 2021, it indicated the plan of planned weight loss did not start until February 10, 2022, with one to two lbs weight loss per month to the goal of 180-184 lbs. The other goal was for Resident 75 to consume meals at least 75% of meals and minimize the risk for significant weight loss of five lbs per month. The care plan indicated the approach plan for the facility to encourage Resident 75 to consume 75-100% of her meal, the facility should monitor weight and report + or - five lbs or more per month to the MD, and to notify the MD for any significant weight loss. A review of the facility policy and procedure titled, Weight Monitoring, revised 2022, indicated, .the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range .the facility will utilize a system approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors. b. Evaluating/analyzing the assessment information. c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary .nutrition assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns .the care plan should address the following .a. identified causes of impaired nutritional status .c. Identify resident-specific interventions; d. Time frame and parameters for monitoring; e. Updated as needed such as when the resident's condition changes .interventions are determines to be ineffective or a new causes of nutrition-related problems are identified; f. If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate .Interventions will be identified, implemented, monitored, and modified, consistent with the resident's assessed needs .to maintain acceptable parameters of nutritional status .Residents with weight loss - monitor weight weekly .A significant change in weight is defined as: a. 5% change in weight in 1 month .b. 7.5% change in weight in 3 months .c. 10% change in weight in 6 months .Documentation: .the physician should be informed of a significant change in weight and may order nutritional interventions; b. The physician should be encouraged to document the diagnosis or clinical conditions that may contributing to the weight loss .e. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes .g. The interdisciplinary plan of care communicates care instructions to staff . 2. On March 17, 2022, at 9:30 a.m., an interview and concurrent record review with the MDS Coordinator (MC) was conducted regarding Section K of Resident 75's annual assessment dated [DATE], and the quarterly assessment dated [DATE]. Section K for both the annual and quarterly assessments indicated Resident 75 experienced a significant unplanned weight loss of 5% or more in the last 30 days, or a significant unplanned weight loss of 10% or more in the last 180 days. The MC confirmed the significant unplanned weight loss in the quarterly and annual assessments for Resident 75 was not a physician-prescribed weight loss regimen. The MC stated physician-prescribed means a physician's order. The MC further stated he was aware Resident 75 was on a weight loss program with a weight loss goal of one to two lbs per month. The MC stated Resident 75 weight losses for the annual and quarterly assessments were more than one to two lbs per month and therefore not considered a physician-prescribed weight loss. The MC stated the MD should be aware of a planned weight loss regimen. The MD was responsible for any new orders or a change of the planned weight loss regimen. The MC confirmed Resident 75 did not have a physician order for the planned weight loss regimen of one to two lbs in a month. During an interview and a concurrent record review with the DON on March 17, 2022, at 3:02 p.m., the DON confirmed there was not a physician order for a weight loss regimen. During a phone interview with the RD on March 18, 2022, at 10:08 a.m., the RD stated nursing was responsible to get an order from the MD for a physician prescribed weight loss plan. The RD stated she did not enter a recommendation for a physician prescribed weight loss regimen for Resident 75 on the RD recommendation form. On March 18, 2022, at 10:50 a.m., an interview was conducted with the RN 2. When asked who was responsible to get a physician order for a physician prescribed weight loss regimen, the RN 2 stated a weight loss regimen was based on the RD recommendations. The RN 2 was unable to confirm the MD order for a weight loss regime for Resident 75. A phone interview was conducted with Resident 75's MD on March 18, 2022, at 11:59 a.m. When asked if he wrote an order for a physician-prescribed weight loss regimen, the MD stated he believe he gave the RD a verbal order for a planned weight loss regimen. A review of facility document titled, RDN (Registered Dietitian Nutritionist) Recommendations, dated August 2, 2021, to March 10, 2022, indicated the RD did not have any recommendations for a planned weight loss regimen.