**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 37's medical record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses that included diabetes, protein-calorie malnutrition (not enough nutrients to meet the body's needs), and generalized muscle weakness. Resident 37's Admit/Readmit Assessment, dated 4/13/21, indicated that they were total dependence for toilet use, extensive assistance required for personal hygiene, and abrasions and open areas on the skin of the left knee, right lower leg, and right foot. No wounds or skin conditions were noted on the sacral or coccyx areas. A review of a Nurses Progress Note, dated 10/30/21, at 1:42 pm, by Licensed Nurse (LN) 6, indicated that a Certified Nursing Assistant (CNA) alerted LN 6 to some redness on Resident 37's skin during perineal (groin area) care. LN 6 assessed Resident 37's coccyx area and described it as blanching redness (meaning when touched lightly the skin would turn white, then return to its previous color). LN 6 wrote that Resident 37 preferred to sleep on their back and was educated about turning off their back for skin care. Zinc oxide was ordered to apply to the coccyx skin once every shift. A review of an IDT Progress Note, dated 11/4/21, at 12:17 pm, by TN, indicated the Wound Doctor (WD) had seen Resident 37 on 11/2/21, and described a new wound as, distal (furthest from the center of the body) sacrum shear. A review of a Skin/Wound Note, dated 11/7/21, at 8:52 am, by TN, indicated the coccyx wound was macerated (moist and soft). A review of a Weekly Summary, dated 11/7/21, at 3:58 pm, by LN 2, indicated, Skin normal (assessment not indicated). A review of a Health Status Note, dated 11/13/21, at 3:22 am, by a LN, indicated Resident 37's sacral wound was greyish in appearance, malodorous, with reddened edges and painful to touch. Resident 37's laboratory report, dated 11/16/21, indicated a culture report report for the swab of the drainage from Resident 37's sacral wound. The culture produced four types of bacteria, and indicated an infected wound. A review of WD Note, dated 11/16/21, indicated a, shear wound of the distal sacrum - deteriorated due to generalized decline of patient, infection, full thickness. A review of a WD Note, dated 11/23/21, indicated, unstageable DTI of the distal sacrum - deteriorated due to generalized decline of patient, full thickness. Resident 37's WD note, dated 11/30/21, indicated, unstageable DTI of the distal sacrum - improved evidenced by decreased surface area, decreased necrotic (dead) tissue, full thickness. Review of a WD Note, dated 12/7/21, indicated, Stage IV pressure wound of the distal sacrum - improved evidenced by decreased surface, increased granulation (new tissue growth), full thickness. As per the NPIAP and the facility's policy, no staging numbers were assigned to Resident 37's sacral wound until 37-days after it had first appeared as redness, and had progressed to a Stage IV. Review of Resident 37's Care Plan showed no registered dietician evaluation among the interventions listed for the new sacral pressure wound problem. No registered dietician evaluation was completed after the wound was identified. A review of three Weekly Skin Check sheets showed the following descriptions of skin irregularities under Section Two, Condition of Skin. On 11/17/21, shear distal sacrum. On 11/24/21, DTI of the distal sacrum 8 cm x 6.8 cm. On 12/1/21, DTI of the distal sacrum 8.5 cm x 6 cm. Review of Resident 37's Treatment Administration Record (TAR) for the months of 11/21 and 12/21, indicated orders to treat the resident's distal sacrum wound. For orders that were to have been done once a shift (three times a day), there was no documentation for the following dates and shifts: 11/1/21 PM shift; 11/17/21 PM shift; 11/22/21 PM shift; 11/12/21 AM, PM, and NOC (night) shifts; 11/24/21 PM shift; 11/26/21 PM shift; 11/29/21 and 11/30/21 PM shift; 12/1/21 PM shift; 12/4/21 and 12/5/21 PM shift. During a concurrent observation, and interview, on 12/821, at 9:26 am, TN and CNA 8 repositioned Resident 37, and changed the distal sacrum wound dressing. An incontinence brief that was taped closed appeared saturated with urine. A foam dressing covered the wound. The wound was raw, open, with moist pink tissue in the woundbed, and yellow areas that appeared to be subcutaneous tissue in the woundbed. TN stated that the doctor had debrided the wound yesterday. During a concurrent observation, and interview, on 12/09/21, at 10:45 am, the DSD removed a soiled incontinence brief, and changed changed Resident 37's distal sacrum wound dressing. The gauze DSD removed was saturated with pale green-colored drainage, and the edge of the gauze contained stool. DSD stated that they didn't usually measure the wounds during dressing changes. During an interview, on 12/09/21, at 2:48 pm, the MDS Nurse answered questions about a significant change in status assessment, and whether or not Resident 37's distal sacrum wound would have triggered one to be done since its discovery in early November. MDS stated they weren't sure and were waiting to hear back from the consultant about it. Based on observation, interview, and record review, the facility failed to evaluate, assess, and provide wound care treatments to three of eight sampled resident's (Residents 37, 42, and 211). The facility also failed to use professionally recognized standards for documenting, and staging pressure injuries. These failed practices resulted in the developing of new, or worsening of existing pressure injuries (wounds caused by unrelieved pressure on the skin) for these residents, which could lead to negative clinical outcomes. Findings: According to the National Pressure Injury Advisory Panel (NPIAP an internationally used, and professionally recognized pressure injury resource), revised 2016, Staging pressure injuries are important to ensure appropriate treatment, and the understanding of anatomy is essential when evaluating the type of tissue present in a wound. A review of the facility's policy titled, Pressure Injury and Skin Integrity Treatment, revised 8/12/16, was reviewed, and indicated the following pressure injury staging definitions. Stage 1: Non-blanchable erythema (redness/warmth) of intact skin. Stage 2: Partial thickness skin loss with exposed dermis (layer of skin under the surface). Wound bed is viable, pink or red, moist, and may also present as an intact serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar (dead, black tissue) are not present. Stage 3: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deeper wounds. Undermining, and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament. Cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Deep Tissue Pressure Injury: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This policy indicated that a licensed nurse will initiate a Pressure Injury Progress Report, when a resident is admitted with a pressure injury, or if a pressure injury develops. The Pressure Injury Progress Report will be updated weekly by the licensed nurse. A consultation from a wound care physician will be obtained upon an order from the attending physician. The resident's dietary needs will be evaluated by the Registered Dietitian on admission, and when there is a significant change in the skin condition. The diet should contain adequate calories, nutrients and fluids to support wound healing. The preventive measures may be documented on the Treatment Administration Record (TAR), the Activities of Daily Living (ADL) flowsheet, the Licensed Nurses Progress Note, or the Licensed Nurses Weekly Summary. The licensed nurse will document the status of all skin conditions at least weekly, or as otherwise indicated in the resident's care plan. The licensed nurses will document effectiveness of current treatment for skin integrity problems in the resident's medical record on a weekly basis. The interdisciplinary team (IDT)- Skin Committee will document discussion and recommendations for all skin integrity problems that do not respond to treatment, worsen or increase in size. Complaints of increased pain, discomfort or decrease in mobility by a resident. The presence of exudates, odor or necrosis. The residents refusing treatment, or other problems that may hinder healing. Documentation of all notifications to the family, resident and/or responsible party when there is a change in the resident's skin condition. The resident's care plan will be updated as necessary. The policy further indicated that a risk assessment for developing pressure injuries will be completed upon admission, weekly and for four consecutive weeks after admission, quarterly and when there is a significant change in condition. Regardless of the risk score, the licensed nurse will develop an individualized care plan for the resident's risk factors in consultation with the following; attending physician, IDT, Registered Dietitian, and Director of Rehabilitation Services. The nursing staff will implement interventions identified in the care plan which may include, but are not limited to, the following; pressure redistributing devices for bed and chair, repositioning and turning, bowel and bladder training, scheduled tolieting or incontinence management programs, bed trapeze bar, draw sheets, mechanical lifts, positioning aides, to reduce friction and shear when repositioning. The nursing staff will observe for any signs of potential or active pressure injury daily while providing nursing care. The licensed nurses will document the effectiveness of the pressure injury prevention techniques in the resident's medical record on a weekly basis. Skin assessments are performed on admission, then weekly for four weeks, quarterly and when there is a significant change of condition. The resident's care plan will be initiated on admission, and updated as necessary. 1. Resident 211's medical record was reviewed. Resident 211 was admitted to the facility on [DATE], with diagnoses that included the repair of a broken left hip, a bladder infection, dementia, high blood pressure and COVID-19 (a serious respiratory virus). Resident 211's most recent MDS (Minimum Data Set, a standardized assessment tool), dated 11/19/21, indicated that Resident 211 was dependent on staff for bed mobility, transfers, eating, dressing, bathing, grooming, incontinent of bowel and bladder, and that she had one Deep Tissue Injury present. On 11/12/21 at 10:26 am, Resident 211's Admit/Readmit Assessment, skin assessment was done. Section C titled, Skin Integrity, contained a picture of human body with numbered pressure area sites where the nurse documents all skin concerns upon admission, including pressure injuries. This area was blank with a notation that read, See admit note for skin assessment. The Admit Note, did not included an actual assessment either. The hospital transfer record dated 11/12/21, indicated that Resident 211 did not have any pressure injuries at the time she was discharged from the hospital. Therefore, Resident 211's pressure injuries were considered acquired, in this facility. A review of Resident 211's Progress Notes, indicated that the first documented skin assessment was on 11/12/21 at 12 pm, when a licensed nurse documented that she had superficial shearing to coccyx (tailbone area). On 11/14/21 at 8:38 am, two days later, the Treatment Nurse (TN) documented that Resident 211 had a pressure injury to her sacrum [area above the tailbone] that measured 4 centimeters (cm), and the wound bed was 100% slough (a yellowish-white material in the wound bed that consists of dead cells, and delays wound healing). The pressure injury was not staged and according to the facility's Pressure Injury Prevention policy, this would have been considered an Unstageable Pressure Injury. At 11:06 am, the same day, TN identified a second pressure injury to Resident 211's right buttock that measured 1 cm x 1 cm. The TN described the wound as, shearing [from skin rubbing on sheets or sliding down in bed]. According to the policy, this was a Stage 2 pressure injury. There was only one weekly Skin/Wound, progress note, done on 12/7/21 at 7:29 am, three weeks after the pressure injuries were identified. The TN documented that the sacral wound then measured 3 cm x 3.5 cm and had started out as a sheer, but worsened because Resident 211 was scooting herself all over her bed. There were no documented or care planned interventions in place that addressed how Resident 211's constant movement impacted the healing of her pressure injuries. There were only two Weekly Skin Check, assessments done on 11/14/21, and 11/27/21. The skin assessment on 11/14/21, was still identifying shearing, to the right buttock and had not mentioned the sacrum. The skin assessment on 11/27/21, included an open wound, on the sacrum but was still not staged after two weeks. Only one Weekly Nursing Summary, was done on 12/3/21, three weeks after admission, and the general skin condition, was left blank. On 11/17, and 11/18/21, nursing progress notes, incorrectly reflected that Resident 211's skin was not being assessed when the licensed nurses documented only redness or shearing to the buttock area. On 11/16, 11/29, 12/1, and 12/3/21, the licensed nurse's documentation indicated that Resident 211 was anxious, extremely restless, in pain, agitated and constantly moving in bed. There was no evidence that the IDT had met to discuss, evaluate and develop a plan of care to resolve Resident 211's acquired pressure injuries. There was no evidence that a Registered Dietitian (RD) had evaluated Resident 211's nutritional needs, as their policy directed. A review of Resident 211's Physician's Orders, indicated that there had been an order since 11/12/21, to obtain a consultation by a wound physician. The wound physician had not been asked to evaluate Resident 211, even though he was in the facility every Tuesday. On 11/14/21, an order to put Zinc (a thick white barrier cream like Desitin diaper rash cream) on Resident 211's right buttock for shearing, but the right buttock actually had a Stage 2 pressure injury. Incorrect staging of pressure injuries can result in obtaining the wrong treatments. An order for an air mattress, was not written until 12/9/21, nearly one month, after the facility had identified Resident 211's acquired pressure injuries. On 12/08/21 at 9:00 am, an observation, and concurrent interview, of Resident 211's pressure injuries was conducted with TN. Resident 211 was asleep and lying on her left side. She was on a standard house mattress. Both the right buttock and sacral pressure injury wounds were missing their dressings. The right buttock Stage 2 pressure injury contained 100% slough therefore, it had worsened to an Unstageable pressure injury. The sacrum wound was deep and contained 25% slough and according to the pressure staging guidelines, would be considered a Stage 3. The TN stated, The wounds appear to have worsened since three days ago. TN confirmed that she still has not asked the wound physician to see Resident 211. On 12/08/21 at 4:23 pm, TN was interviewed, in the conference room. TN stated that she has been in this position since 7/2021, and only received two-days of training. The TN stated, I don't know what I am doing. I don't have a clue what I am looking at on these wounds. I stage everything as a DTI [deep tissue injury] because I don't know how to stage wounds. I wait for the wound doctor to do the rest. TN confirmed that she had not evaluated Resident 211's skin until two-days after she was admitted , and had incorrectly staged her pressure injuries, but then so did the other nurses. TN stated, that Resident 211 should have already been placed on an air bed, and seen the wound doctor by now. TN confirmed that the weekly Skin/Wound assessments were not done, I am very behind on documentation. TN confirmed that the RD had not evaluated Resident 211 for nutritional needs, and stated, we haven't had one for a few months. TN confirmed that these combined failures and her lack of knowledge most likely contributed to the worsening of Resident 211's pressure injuries. On 12/09/21 at 8:35 am, an interview, and concurrent record review, was conducted with the Director of Nursing (DON). The DON confirmed that there was no record that any physician had evaluated Resident 211's pressure injuries since she was admitted . The DON stated that a request should have been sent to the wound physician on 11/14/21, when the pressure injuries were first identified. The DON confirmed that the admission Skin Assessment was blank. The DON confirmed that there were several missing Weekly Skin Check, Weekly Nursing Summary and Skin/Wound assessments and stated, those should have been done every week, either by the treatment nurse, or the floor nurse. The DON confirmed that it is the policy of the facility for the registered dietician to evaluate and participate in recommending dietary supplements such as vitamins, minerals and protein for residents with pressure injuries, and that was not done. The DON confirmed that there had been no wound IDT meetings to discuss Resident 211's pressure injuries, and added, up to now, I thought she just had some shearing, this is all very confusing. On 12/9/21 at 11:15 am, an observation, of Resident 211's pressure injuries and concurrent interview, was conducted with the Director of Staff Development (DSD). The DSD stated that she considered herself experienced and knowledgeable about pressure injuries, and staging. The observation revealed that the right buttock wound was covered in slough 100%, the DSD stated, that would be considered an Unstageable pressure injury because you can't tell how deep it is until the slough is gone, then it will most likely be a stage 3 or 4. The sacral wound had full thickness skin loss and exposed fat with 25% slough, the DSD stated, this would be a Stage 3. The DSD added, these wounds are definitely not DTI's, and the staff need training. 3. Resident 42's medical record was reviewed. Resident 42 was admitted on [DATE], with diagnoses that included a Stage 4 pressure injury, and stroke. On 5/7/21, another diagnosis of adult failure to thrive (those with multiple chronic medical conditions resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability) was added. Resident 42 had a left trochanter (bony prominence near the end of the thighbone) Stage 4 pressure injury for which he was receiving treatment. During an interview, on 12/08/21 at 10:05 am, the TN said a physician who specializes in wound care was treating Resident 42's wound. She said this was a long term wound greater than two-years that had shown slow improvement during that time. On 12/09/21, wound treatment records were reviewed for 9/2021 through 11/2021. Treatments had been ordered twice per day in 9/21. On 9/3/21, 9/4/21, 9/6/21, and 9/7/21, only one treatment, instead of two treatments, per day was documented as done. The order was then changed, on 9/8/21, to a weekly treatment, and no treatment was documented 9/15/21. In 10/21, treatments were changed to Tuesday, Thursday, and Saturday in 10/21. Treatments were not documented as done, on 10/19/21, and 10/23/21. Treatments were then changed to daily, on 10/24/21, and his treatment was not documented on 10/27/21. Daily treatments continued in 11/21. Treatments were not documented on 11/12/21, 11/13/21, 11/19/21, and 11/24/21. During a concurrent record review, and interview, on 12/09/21 at 11:35 am, the missing treatments were discussed with the Director of Nurses (DON) who confirmed the above. She said when the treatment nurse was not working, the nurses assigned to pass medications does the residents' treatments. The DON said if she found any more documentation or other information regarding these missing treatments she would let me know, but nothing additional was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 47's medical record was reviewed. Resident 47's was admitted to the facility on [DATE], from an acute care hospital following a hip fracture. She had a history of high blood pressure and diabetes mellitus (elevated blood sugars) without complications. On admission her height was 63 inches, weight 183 pounds (lbs). Resident 47's weight on 9/20/21 was 178.8 lbs. On 10/2/21, Resident 47 was hospitalized with pneumonia/COVID-19, and was placed on a ventilator. Resident 47 returned to the facility on [DATE]. readmission weight dated 10/25/21, was 134.6 lbs. Her weight continued to decline, reaching 125.4 lbs on 11/29/21, an additional 9.2 pounds/ 7% loss in 6 weeks. A review of the Facility Matrix document on 12/07/21 at 9:30 am, indicated that Resident 47 exhibited excessive weight loss without a physician-ordered weight loss program. A review of the MDS (Minimum Data Set, a resident assessment tool, with information sent from facility to CMS data base) dated 12/1/21, indicated that Resident 47 had no swallowing issues, and had weight loss of 5% or more in the last month, or 10% or more in the last 6-months, and was not on a physician-prescribed weight loss regimen. During an interview with Resident 47 on 12/07/21 at 9:40 am, she stated that her usual weight was 170 pounds (lbs), Now I weigh 140 lbs. She stated she got COVID-19 at this facility, lost her sense of taste, was sent to a hospital, and was put on a ventilator. When asked about her continued weight loss Resident 47 stated, I don't like their food. It has no flavor. It is terrible. It has no flavor, and no taste. I have no teeth, and so they think everything needs to be like baby food. I don't need it pureed. I usually order out from a restaurant tacos, or pizza. The following, Weights and Vitals Summary, for Resident 47 indicated: 10/25/21 Weight 134.6 lbs 11/08/21 Weight 128.2 lbs 11/15/21 Weight 127.1 lbs 11/22/21 Weight 126.7 lbs 11/29/21 Weight 125.4 lbs This represented a 6.8% weight loss in one month which is considered severe. Resident 47's nursing notes titled, re-admission Note/Care Conference dated 10/21/21, noted that the facility was not using a current weight, rather utilized a weight prior to hospitalization. Progress Notes, dated 10/29/21, titled Weekly Assessment, failed to mention the 4.75 lb weight loss, since readmission. A follow up IDT note, dated 11/04/21, titled IDT Progress Note - Behavior Management, noted the current admission weight, however failed to recognize the weight loss during hospitalization. An IDT progress note, dated 11/18/21 at 9:09 am, indicated a review of a fall. There was no mention of resident's weight loss, or of poor meal intakes. Remaining Progress Notes, dated 10/18/21 through 12/8/21, made no mention of weight loss since re-admission. A review of the Dietary Profile performed by the Dietary Services Supervisor (DSS) showed Effective Date 9/2/21, Signature by the DSS on 9/22/21, and admission [DATE]. The DSS documented, Resident states she can tolerate regular texture, informed SLP (Speech and Language Pathologist). Review of the Nutritional Risk Assessment, completed by the Regional RD on 11/5/21 indicated: * Resident 47 had a diet order for a CCHO, mechanical soft ground texture, thin liquids diet. Meal and fluid intakes averaged 50-75%. * Estimated energy needs were 1550-1850 kcal (kilocalories)/day, and 68-74 grams protein/day. * The RRD noted Resident 47 had no swallowing difficulty, but needed mechanical soft ground texture food due to no teeth or dentures. * The RRD also commented that fasting serum blood sugars were in good control, resident would likely benefit from liberalizing the CCHO diet, and resident had specific ethnic or religious food preferences/ likes & dislikes - refer to the dietary profile . kitchen has been honoring food preferences and providing pudding as HS (evening) snack. * The RRD summarized that Resident 47 had inadequate nutrient intake related to acute illness, meal intake 25-100%, 44.2 lbs/24.7% weight loss in 16 days of hospitalization. Resident 47 was willing to be weighed and accept a nutrition supplement with her medications. * The goals for Resident 47 were to consume greater than 50% of meals, and achieve body weight 135 lbs +/- 5% for 3 months. A recommendation was made to liberalize the diet to regular (no restrictions) but continue current texture modifications, add nutrition supplement with medication pass, and record amount taken, and consider lab tests. A review of an SBAR (Situation, Background, Assessment, Recommendation) form dated 11/12/21, indicated that RD recommendation - liberalizing CCHO (diet) to Reg (Regular diet), add Med Plus 1.7 90 mL (milliliter) TID (three times a day) - record % consumes. In a response, dated 11/15/21, the doctor wrote, No, and Continues with elevated blood sugar! regarding liberalizing the diet, and OK to the Med Plus Nutrition Supplement. A verbal order for speech therapy was obtained 11/9/21. Review of the Speech Therapy SLP Evaluation and Plan of Treatment, document dated 11/9/21, and signed by the physician 11/16/21, indicated that Resident 47 had some dysphagia (difficulty swallowing) but had good rehab potential. Diet textures were not changed. Patient needs further progress in the area of oral functions and strength of swallow to improve nutritional intake. The patient is at risk for aspiration and decreased leisure task participation. Patient has severe decreased food intake and needs further evaluation in this area to determine reason for discomfort. A review of the ADL (Activities of Daily Living) Flowsheet for Resident 47 indicated in October 2021 Resident 47's meal consumption averaged 39%, of the 33 meals documented. In 11/21 21, Resident 47's meal consumption averaged 47% of the 85 meals documented. Based on the caloric content of the facility's CCHO diet, Resident 47 would have needed to consume an average of 82% to 93%, of her meals, in order to meet her estimated energy needs. The facility's policy titled, Food Intake - Recording Percentage & Nutritional Assessment, revised 1/12, was reviewed and indicated that if any resident refuses a meal, or the food eaten is less than 50%, a nourishment (snack) or meal replacement will be offered. The amount of supplement or nourishment taken as a meal replacement will be recorded on the resident food intake record after each meal. A review of the Nutrition Care Plan for Resident 47 indicated: 9/27/21 a weekly weight loss of 5.5 lbs, 3.1%, 3-month weight loss of 20.2%. The goals initiated on 9/6/21 were to maintain admission weight (183 lbs) +/- 5%, resident to consume at least 75% of meals x 3 months, resident will tolerate diet without chewing difficulty, swallowing difficulty or GI distress x 3 months. Interventions initiated on 9/6/21, were to offer substitutes if intake less than or equal to 75%, provide and honor preferences. On 11/5/21, the RRD added interventions requesting lab work and 1.7 calorie/mL nutrition supplement three times daily with nursing medication pass, record % taken. The provision of snacks were not included in the care plan. A review of the facility's policy titled, Nutritional Assessment, revised 2/1/14, was reviewed and indicated that its purpose was to ensure that residents are properly assessed for dietary needs. The Dietitian will complete the Nutritional Assessment within fourteen (14) days of admission. The Nutritional Assessment must be signed and dated by the Dietitian on the day of completion. During an interview, with the RD, and Dietary Services Supervisor (DSS) on 12/8/21 at 11:20 am, it was reported that the previous RD had been gone from this facility since mid-September, and there was no facility RD until the previous Friday, 12/3/21. The DSS stated if problems came up she would communicate with the nurse or doctor. They would consult the Regional Registered Dietitian (RRD) for more complicated residents. She was not sure who did the initial nutrition assessments. When asked how often the RRD came to the facility the DSS replied she wasn't sure. She thought the RRD maybe came every 2-weeks, but she didn't always connect with the kitchen. During an interview, with the Director of Nursing (DON) on 12/8/21 at 3:15 pm, she acknowledged their previous RD left mid-September, the new RD started Friday 12/3. The DON stated the RRD had been at the facility twice since the previous RD left in September. The DON acknowledged that nutrition needs of Resident 47 were not met when resident weight loss, and poor meal intakes were not addressed timely and per policy. Based on interview, and record review, the facility failed to ensure that two of 22 sampled residents (Residents 37, and 47), whose weights were not within acceptable parameters of nutritional status, received adequate evaluations, interventions, and monitoring. These failures resulted in significant weight loss for these residents, and had the potential to lead to a decline in their overall health condition. Findings: The facility's policy titled, Evaluation of Weight and Nutritional Status, dated 1/19, was reviewed, and indicated that its purpose was to ensure that residents maintain acceptable parameters of nutritional status through evaluation of their weight and diet. The facility will work to maintain an acceptable nutritional status for residents, and will do this by monitoring the following: A. The resident's nutritional status and the factors that put the resident at risk of not maintaining acceptable parameters of nutritional status. B. Analyzing the assessment information to identify the medical condition, causes and/or problems related to the resident's condition and needs. C. Defining and implementing interventions for maintaining, or improving nutritional status that are consistent with resident needs, goals and recognized standards of practice. D. Monitoring and evaluating the resident's response, or lack of response to the interventions. E. Revising or discontinuing the approaches as appropriate, or justifying the continuation of current approaches. This policy provided the following definitions: weight loss - significant weight loss 2% in one week, 5% &/or 5 lb [pounds] in one month, 7.5% in three months, or 10% in six months, as well as unplanned weight loss that occurs over time that does not meet the guidelines for significant weight loss, and does not trigger review of the Nutritional Status CAA [care area assessment]. Avoidable - the resident did not maintain acceptable parameters of nutritional status and the facility did not do one or more of the following: 1. Evaluate the resident's clinical condition and nutritional risk factors; 2. Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; 3. Monitor and evaluate the impact of interventions; or 4. Revise the interventions as appropriate. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days, 10% in 180 days, will be evaluated by the IDT (Interdisciplinary Team)- Nutrition & Weight Variance Committee to determine the cause of weight loss/gain and the intervention(s) required. Once weight gain, or loss as described above is identified, the IDT - Nutrition & Weight Variance Committee will: a. Identify and implement appropriate interventions; b. Update and revise the care plan, as appropriate; c. Notify the responsible party; d. Notify the Attending Physician; and e. Notify the Registered Dietitian (RD). The Centers for Medicare and Medicaid (CMS) included the following in their interpretive guidelines for this regulation; Failure to identify residents at risk for compromised nutrition and hydration may be associated with an increased risk of mortality and other negative outcomes, such as impairment of anticipated wound healing, decline in function, fluid and electrolyte imbalance/dehydration, and unplanned weight change. 1. Resident 37's medical record was reviewed. Resident 37 was admitted on [DATE], with diagnoses that included cerebrovascular disease (condition that affects blood flow to the brain), metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), high blood pressure, heart disease, and diabetes. In the past three months (from 9/7/21 to 12/8/21), Resident 37 had a weight loss of 19.8%, or 36.9 pounds. The facility's Weights Vitals Summary form documented the following weights, and comparisons for Resident 37: 5/3/21: 186 lbs (pounds) 6/7/21: 179.6 lbs 7/6/21: 178.2 lbs 8/3/21: 184.1 lbs 9/7/21: 185.9 lbs There was no weight for 10/2021. 11/8/21: 157.2 lbs (comparison weight 9/7/21, 185.9 lbs, -16.2%, -30.1 lbs) 11/15/21: 155.8 lbs (comparison weight 9/7/21, 185.9 lbs, -15.6%, -28.7 lbs) 11/22/21: 152.7 lbs (comparison weight 9/7/21, 185.9 lbs, -17.9%, -33.2 lbs) 11/29/21: 148.8 lbs (comparison weight 9/7/21, 185.9 lbs, - 20%, 37.1 lbs) 12/8/21: 149 lbs (comparison weight 9/7/21, 185.9 lbs, -19.8%, 36.9 lbs) Further review, of Resident 37's record indicated that he had been on a Consistent Carbohydrate Diet (CCHO, focus is to eat the same amount of carbohydrates every day to keep blood sugar stable). A copy of the Activities of Daily Living (ADL, daily routine activities that people do such as eating) flowsheets, where the nursing assistants charted the amount of each meal eaten by the resident, were provided. For half of all meals for the months of 10/2021 and 11/2021, Resident 37 had refused or eaten less than 25% of recorded meals, for these two months. No additional supplements for weight loss were added until frozen shakes were added twice per day on 11/28/21 (by this time he had lost 20% of his weight, and this was three weeks since facility staff knew of the severe weight loss noted on 11/8/21). There was a draft note (note made in the electronic record but not yet signed as complete), by the RD, on 11/5/21. There were no nutritional supplements recommended at that time, as the RD noted his last weight of 185.9 lbs on 9/7/21. There was no RD evaluation, or assessment of Resident 37's weight loss, after the facility knew of the weight loss on 11/8/21. There was also no IDT note in the record relating to his weight loss. During an interview, on 12/09/21 at 1:30 pm, the Director of Nurses (DON) was asked to provide any information she had regarding Resident 37's weight loss, and nutrition provided to him for this weight loss. During an interview, on 12/09/21 at 2:30 pm, the DON said this resident had Vitamin C ordered, and given in October for his wound. She provided a physician's order for Vitamin C starting on 10/2/21, and ending on 10/17/21, fifteen days. She provided a copy of the facility's December monthly weights (not part of the record) and for this resident, it indicated he had refused weights in October and November. She said he had COVID-19 (a serious respiratory virus) in October and lost weight. The weights documented in the resident's electronic record were then reviewed with the DON, which showed he did not refuse weights in November, and, in fact, had been weighed weekly, and lost 28-pounds from 9/7/21 to 11/8/21, and had continued weight loss after that. During the above continued interview, starting at 2:30 pm on 12/9/21, the DON confirmed the facility's prior RD left in mid-September 2021 and the facility's new RD started last week, on 12/3/21. She said, a corporate regional RD came to the facility twice during this period of time (mid-September to 12/3/2021). The draft note from the corporate regional RD, dated 11/5/21, which listed the September weight of 185.9 lbs, was then reviewed with the DON. DON said this note had been made by the corporate RD during one of the times she came to the facility. The DON was asked if she thought the RD may have changed, or added recommendations to her note, had she been told there was a 28-pound weight loss, documented on 11/8, three days after she made her note. The DON confirmed there was no RD evaluation after Resident 37's weight loss, and said she would check for further information. She provided a nourishment roster that indicated a sandwich was passed to Resident 37 in the morning, and at bedtime. A review of the ADL sheets indicated a space for nourishment three times each day. For November, there was documentation that he accepted nourishment 10 out of 90 possible times, but only consumed 100% of the nourishment on two days. During a concurrent record review, and interview, on 12/09/21 at 3:46 pm, the DON said she had no other information, and she had checked for physician notes that addressed the weight loss but could find none, and also no IDT notes. The nutrition care plan which was started on 4/14/21, was reviewed. The focus was updated to include weight loss on 12/8/21 (after the start of the survey) but the interventions, which had been started on 4/14/21 (when Resident 37 had been first admitted ), had not been updated. These interventions included reporting to the physician signs and symptoms of malnutrition and specified 3-pounds in one week, greater than 5% in one month, greater than 7.5% in three months and greater then 10% in six months, and RD evaluation as needed. The DON confirmed no new interventions for weight loss had been added to Resident 37's care plan.