**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review for Resident #137 revealed the resident was admitted to the facility on [DATE] with the following diagnoses that included: Chronic Systolic (Congestive) Heart Failure, Morbid (Severe) Obesity, and Cognitive Communication Deficit. Review of the Minimum Data Set (MDS) for Resident #137 dated 08/11/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment; In Section G for bed mobility, the resident had a self-performance of extensive assistance with support of one person assist, for dressing the resident had a self-performance of total dependence with support of two plus persons assist, and for eating the resident had a self-performance of extensive assistance with support of one person assist. Review of the Physician's orders for Resident #137 revealed an order dated 02/16/23 for regular thin liquids, special instructions none. Review of the Physician's orders for Resident #137 revealed an order dated 02/16/23 for Hydrochlorothiazide 25mg tablet, give 1 tablet by mouth daily and it was discontinued on 02/16/23, same day. Review of the Physician's orders for Resident #137 revealed an order dated 05/18/23 for 'other' snack at bedtime. Review of the Physician's orders for Resident #137 revealed an order dated 06/16/23 for Furosemide 20mg one time order and was discontinued on 06/30/23. Review of the Physician's orders for Resident #137 revealed an order dated 07/27/23 for Ensure plus 240ml by mouth three times daily. Review of the Care Plan for Resident #137 dated 02/06/23 with a problem of resident is at risk for weight loss and/or dehydration related to medications, medical history of chest pain, CHF (Congestive Heart Failure), Dementia, falls, AFIB (Atrial Fibrillation) Morbid Obesity, HTN (Hypertension), Alzheimer's Disease, Gastritis, Thyroid Disorder, Pacemaker, and Dysphagia: abnormal nutrition related to lab values, documented: Patient is within desirable weight range for older adult, has natural / missing teeth in poor condition, skin with abrasion / bruise to left cheek/eye, requires assistance and encouragement with meals and dines in room at this time. The care plan goal was for the resident to be nourished and hydrated as evidenced by: not showing a decrease in 5% or more in weight in less than or equal to 30 days, weight decrease of 10% or more in [NAME] than or equal to 180 days or by showing a weight gain. The care plan interventions included: Provide diet and supplements as ordered by MD (Medical Doctor); Honor food preferences as able; Assess weights as per facility protocol; Notify MD of significant weight change; Assist, feed meals and snacks as needed; Encourage to consume food and fluids offered; Offer meal substitutions PRN (as needed). On 08/07/23, the care plan problem was updated with the following: Quarterly review for Significant weight loss 8# [pounds] (5.1%) x 30 days. Resident with h/o (history of) chronic edema, poor PO (oral) intake, altered nutrition related labs, recent UTI (Urinary Tract Infection). Will be encouraged to have Ensure Plus TID (three times daily) as well as snack. Food preferences updated. Requires encouragement and some assistance with meals. Dines in room. Review of the Certified Nursing Assistant (CNA) Charting for Resident #137 indicated for the month of July 2023, the resident received an AM snack 17 times, received the Noon snack only once, and did not receive the HS (bedtime) snack. For the month of August 2023, the resident received the AM snack 12 times, did not receive the Noon snack and did not receive the HS snack. Review of the Medication Administration Record (MAR) for Resident #137 for the month of July 2023 revealed the resident was offered Ensure Plus 3 times daily since 07/27/23 and majority of the time consumed 25%. The bedtime snack was not documented as given for the entire month of July 2023. Review of the MAR for Resident #137 for the month of August 2023, documented the resident did not receive the Ensure Plus on 08/05/23 or 08/06/23; All other days for the month of August are documented as offered and consumed 0-100%. The bedtime snack is not documented as given for the entire month of August 2023. Review of the weights for Resident #137 revealed the following: 05/12/23, 171.5 pounds 06/14/23, 173 pounds 07/28/23, 157 pounds 08/03/23, 149 pounds 09/06/23, (late entry for 08/07/23) 149 pounds 09/06/23, (late entry for 07/19/23) 157 pounds 09/08/23, 136 pounds. The documented weights indicated that from 06/14/23 to 07/19/23, the resident had lost 16 pounds, indicating a 9% weight loss in 35 days; and from 06/14/23 to 08/03/23, the resident had lost 24 pounds, indicating a 14% weight loss in 50 days. Review of the dietary notes for Resident #137 revealed no dietary notes from 05/19/23 to 08/06/23. Review of dietary note for Resident #137 dated 08/07/23 included: 'New weight for August 149 lbs. (pounds) represents a significant weight loss of 8 lbs. (5.1%) in the past 30 days. Weight trend [DATE] #, [DATE]#, Jun 173#, May171.5#, [DATE]#, [DATE]#. Attending APRN (Advanced Practitioner Registered Nurse) aware and is onboard with current interventions.' During an observation conducted on 09/18/23 at 10:50 AM, Resident #137 was lying in bed, was non-verbal and looked thin. During an observation conducted on 09/19/23 at 8:50 AM, Resident #137 was sitting up in bed being fed by staff member and the resident ate about 50% of breakfast. An interview was conducted on 09/20/23 at 8:45 AM with Staff G, MDS (Minimum Data Set) Coordinator, who stated he has been working at the facility for 5 years and 10 months. When asked about care plans in general, he stated the interventions are put in place when a specific care plan is initiated. If interventions are added to the care plan there would be a date in the intervention's column and any interventions above the date would have been added on that date. When asked who would add any interventions, the MDS Coordinator stated the dietician would enter any interventions related to diet. The MDS Coordinator was asked about the weight loss and/or dehydration care plan for Resident #137 and he confirmed there were no added interventions; the only interventions in place were when the care plan was initiated on 05/31/23. The MDS Coordinator was asked about the weight loss and/or dehydration care plan for Resident #137 and he confirmed that 2 interventions were added to the care plan for Resident #137 on 05/18/23. During an interview conducted on 09/20/23 at 12:25 PM with the Clinical Dietary Manager who stated she works twice a week in the facility and daily when training staff members and Staff H Dietician, who stated she works 1 day a week in the facility. When asked about the policy for weights, they stated residents are weighed upon admission and once a week for 4 weeks then once a month. All dieticians are made aware of this policy during training. The nutrition assessment is completed within 3-5 days upon admission or readmission. Residents are considered at high risk for weight loss if the resident has a weight loss in 30, 60, 90 or 180 days and the high-risk residents are kept on monthly weights. They stated it is usually the Restorative Certified Nursing Assistant (Restorative CNA) who takes the weights for the residents. The Restorative CNA will identify new, or readmission residents based on the daily census. For any other resident to be weighed the Dietician will write a list of residents on a piece of paper and give to Restorative CNA to have those residents weighed. The Restorative CNA writes the weight on the same piece of paper, and it is given back to the Dietitian by the end of the same day. The Dietician is responsible to place the weights into the electronic system for each resident. The dietician addresses all significant weight loss/gain within 24 hours. For residents with a significant weight loss the dietician will look at weigh history, diet, medications, and the interventions. They make sure supplements are ordered and they interview the resident, if possible, to see if they like the supplement or would like a different flavor or type and inquire about snacks the resident would like. Certified Nursing Assistants (CNAs)are asked about specific residents and their preferences if resident unable to voice a concern The CNAs document amount of supplement taken. The CNA identifies how the weight was obtained for each resident by the type of scale used (Hoyer lift, wheelchair or standing) but does not always document the type of scale. Weights are not obtained on weekends with the exception of new admissions or readmissions. A significant weight loss is identified as 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. Residents are reweighed if there is a significant weight loss. They stated the scales are calibrated every 3 months. They always had a dietician covering for all residents. They stated there is a Dietary folder shared on each floor, that has the list of all residents who are due to be weighed, so monthly weights are not missed. When asked if they find the system to be effective, the Clinical Dietary Manager stated yes. All weights for the residents are placed in the electronic system the same day the resident is weighed and on occasion placed into the electronic system on the next day. When asked about Resident #137, they stated the resident had a weight, on 06/14/23 of 173 pounds, on 07/19/23, a weight of 157 pounds that was entered into the electronic system on 09/06/23, and on 08/07/23, a weight of 149 pounds that was entered into the electronic system on 09/06/23. When asked about why the weights were placed into the electronic system several weeks after they were obtained, they stated that during this period there were 2 dieticians in training that are no longer working at the facility. When asked if the weight loss should have been identified on 07/19/23 or 07/20/23, both agreed the weight loss should have been addressed. They stated that there was an 8-9% weight loss in 30 days from 06/14/23 to 7/19/23 which was a significant weight loss and 13% weight loss in 60 days from 06/14/23 to 08/07/23 which was addressed on 08/07/23. The Dietician may have had the resident reweighed and they would not enter the questionable weight. They were not clear on if the weights in the electronic chart were reweights or the type of scale used. The Dietician addressed the significant weight loss on 08/07/23 making sure the Ensure plus supplement was to be given 3 times daily was currently in place and encouraged resident to drink. The dietician also determined that the resident likes PBJ (peanut butter and jelly) sandwiches and this is conveyed on the menu system (Geri-menu system for the kitchen). Food preferences were updated. On 08/07/23, the only added intervention was food preferences and that she likes PBJ sandwich and would get the PBJ snack at bedtime. The resident had been getting a snack since May 19. The MAR for August 2023 indicates a snack at bedtime. The order for bedtime snack was in place on 05/19/23 and according to dietician she updated the snack preference to a PBJ sandwich which was entered into the kitchen system. When asked how they know if the resident is consuming the snack, and how much is consumed, they stated they would have to ask the night shift nurse and or the night shift CNA. She would look at the CNA snack intake log for the bedtime snack and they acknowledged the snack log did not have an entry for the snack every night. On 09/08/23, the RD assessment did not reflect any documentation about the intake for the PBJ bedtime snack. The resident was on a regular diet, and she would have added ice cream or fortified foods for the resident. Based on observations, interviews, and record review, the facility failed to identify and provide nutritional interventions in a timely manner to prevent avoidable, severe weight loss for 4 of 7 sampled residents reviewed for nutrition, Residents #138, #42, #363, and #137. The findings included: Review of the facility's policy, titled, Weight Management, dated March 2017, showed, in part, the following: The dietitian or authorized clinical designee, in conjunction with the facility interdisciplinary team (IDT), will monitor and evaluate resident weights for significant changes or other changes that may indicate changing nutritional status. Resident weights will be obtained per facility policy and recorded in the medical record. Each resident will be weighed monthly (every 30 days) or more frequently (weekly, daily) per physician's order, nursing, or dietitian recommendation. For new admissions, weekly weights for four weeks are recommended. A reweigh must be obtained within 48 hours (or per unit policy) if a weight change that meets the following criteria is noted: If the resident is over 100 pounds, loss or gain of 5 pounds if the resident is less than 100 pounds, loss or gain of 3 pounds. The dietitian and authorized designee will assist the clinical team with identifying significant weight changes and pertinent trends as needed based on the facility process. The percent of Body Weight Change Interval is 2% one week, 5% one month, 7.5% three months, and 10% six months. Nutrition reassessment and modifications to existing plan of care may indicate. The dietitian will reassess the nutritional needs and intake of the resident with a weight change. Appropriate recommendations will be documented in the medical record and Dietitian Communication Log. Review of the facility's policy, titled, Nutrition Assessment and Progress Notes, dated March 2017, showed, in part, the following: All residents will receive a comprehensive nutrition assessment by a registered dietitian or authorized designee. Evaluation and documentation of nutritional concerns are recorded in a timely manner in the medical record. The nutrition assessments are an in-depth evaluation of objective and subjective data related to an individual's food and nutrient intake, lifestyle, and medical history. The assessment is the first step to be completed using the Nutrition Care Process. Progress notes are completed for intermittent documentation as needed according to facility policy and with nutrition status or care changes. Review of the facility's policy, titled, Resident Weights, reviewed on 08/14/23, showed, in part, the following: The Weight Team will be responsible for weighing Residents and entering weight into the Electronic System. Weight fluctuations shall be re-weighed and then reported to the Nurse / Dietitian / Diet Tech if there is a +l - 5-pound change in weight. Appropriate documentation shall be entered into the Resident's Medical Record, and proper interventions shall be implemented. To accurately report and record weights for monitoring and documenting residents' weight variances. Residents shall be weighed within 24 hours of admission and re-admission. All admissions and re-admissions are to be weighed for four consecutive weeks after 4. All residents will be weighed monthly unless a more frequent schedule is required, as noted. Any resident that the Physician / Nurse Manager / Dietitian / Diet Tech judge needs to have their weight checked more frequently may be placed on a weekly weight schedule. Significant weight deviations of +/- 5 pounds shall be re-weighed within 24 hours and then shall be notified to the Nurse Manager / Dietitian / Diet Tech via Resident weight loss form. All Resident weight gains or losses shall be properly documented in the Electronic System. Proper interventions shall be put into place and monitored. Calibration of scales is to be done quarterly by a company that is under contract. 1. Record review revealed that Resident #138 was initially admitted to the facility on [DATE]. He was discharged on 05/27/23 and returned to the facility on [DATE]. Resident #138 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The hospital consultation report dated 08/12/23 revealed that Resident #138 is a [AGE] year-old with a history of Diabetes, Stroke, and Seizures. Resident #138 was diagnosed with aspiration pneumonia (food or liquid is breathed into the airways or lungs) and to provide tube feeding with goal for optimal caloric intake. Resident #138 is also non-verbal and has altered mental status. The physician's orders, dated 08/16/23 and discontinued on 08/18/23, showed the following tube feeding history: Nepro (tube feeding formulary) at 55 milliliters (ml) an hour for 12 hours, starting at 6:00 PM and off at 6:00 AM. This tube feeding order provided 1183 calories daily and 53 grams of protein daily. A new physician order was noted, which began on 08/18/23 and discontinued on 08/25/23, for Nepro 60 ml an hour for 15 hours starting at 7:00 PM and off at 10:00 AM. This order provided 1620 calories a day and 73 grams of protein daily. A new physician order, starting on 08/25/23 and stopped on 09/15/23, was noted for Nepro at 45 ml an hour for 18 hours, starting at 4:00 PM and stopping at 10:00 AM. This tube feeding provided 1485 calories and 66 grams of protein a day. On 09/15/23, a new physician order for tube feeding was noted for Nepro at 50 ml an hour for 20 hours starting at 2:00 PM and stopping at 10:00 AM, providing 1800 calories a day and 81 grams of protein a day. The pressure ulcer skin report dated 08/17/23 revealed that Resident #138 has a stage 4 pressure ulcer, exposing muscle and noted to the sacrum area. In an observation conducted on 09/18/23 at 7:58 AM, Resident #138 was observed in his bed with the tube feeding Nepro running at 50 ml an hour. Closer observation showed a tube feeding with Nepro, which started on 09/17/23 the day before at 2:00 PM. The tube feeding bottle was marked on the 300 ml level on the 1000 ml capacity bottle. The tube feeding, which started at 2:00 PM the day before, running at 50 ml an hour, should have been on the 100 ml mark on the 1000 ml capacity bottle. Continued observation conducted on 09/18/23 at 10:00 AM showed Resident #138 was noted in his bed with the tube feeding running at 50 ml an hour. Closer observation showed a tube feeding with Nepro, which started at 2:00 PM the day before. The tube feeding level was on the 200 ml mark on the 1000 ml capacity bottle. The tube feeding bottle, which started at 2 PM the day before and ran at 50 hours, should have been completed at this time. An observation conducted on 09/18/23 at 2:45 PM showed that a new tube feeding bag was started at 2:00 PM with Nepro at 50 ml an hour. The tube feeding was at the 1000 mark on the 1000 capacity bottle. In an interview conducted on 09/19/23 at 7:00 AM, Staff D, Registered Nurse (RN), stated Resident #138 is tolerating his tube feeding well with no issues. In another observation conducted on 09/19/23 at 9:00 AM, Resident #138 was noted in the bed with the tube feeding on hold. The tube feeding showed that it was the same tube feeding bottle that started the day before at 2:00 PM. The tube feeding was on the 450 level on the 1000 ml bottle. The tube feeding that started the day before at 2:00 PM should have been at around the 50 ml mark on the 1000 ml bottle. In an observation conducted on 09/20/23 at 7:00 AM, Resident #138 was noted in his bed with the tube feeding running at 50ml an hour. Closer observation showed that the tube feeding was started at 8:00 PM the night before, dated 09/19/23. The tube feeding was noted at the 1000 ml mark on the 1000 ml capacity bottle. The tube feeding that started the night before at 8:00 PM should have been around the 450 ml mark (550 ml should have been infused) at 7:00 AM the next day. An interview conducted on 09/20/23 at 7:10 AM with Staff E, Licensed Practical Nurse LPN), stated that the 3:00 PM to 11:00 PM nurse started the tube feeding and that it was started at 8:00 PM. She further noted that the tube feeding was running all night and that Resident #138 was tolerating the tube feeding well. An interview conducted on 09/20/23 at 12:20 PM with Staff H (Clinical Dietitian) and the Clinical Dietary Manager. They stated that weights are taken upon admission, once a week for four weeks, until they become monthly, and then they weigh them once a month. All residents on tube feedings are considered high-risk residents, and weights are taken monthly. The weights are taken by Restorative Certified Nursing Assistants, who oversee taking the weights on all residents. New admission weights are based on the census that is printed for the day and given to the staff responsible for obtaining weights. For the monthly weight, the Dietitian will write the list of residents who need a monthly weight and give it to the designated staff. Staff H will write the list of residents who need a weight on a piece of paper, which is later given back to her with the weights taken. Staff H reported that the Dietitian working for that day will input the weights into the electronic system. For all significant weight loss that is identified, they will be addressed with interventions within 24 hours. When asked if the type of scale used is also documented with the weights in the electronic system, they said no. According to the Clinical Dietary Manger, for all severe weight loss identified, they will do a complete nutritional assessment. They will review their weight history, diet, medication, and any supplements they are provided. They will also try and interview the residents to see if they like the supplements or update their food preferences for other food items. For weight loss, they reported that severe weight loss is any weight loss of 5% or more in one month, 7.5 % or more in 90 days, and 10% or more in 180 days. A reweigh will be done if they notice a 5% weight discrepancy, and they will ask the staff to take another weight to ensure the correct weights are taken. When asked about scale calibration, they were told it is done every three months on all Hoyer lift scales. When asked about the communication between the different dietitians in the facility, they said they share a folder that has the list of all residents who are due for the monthly weights or weekly weights. There is always ongoing communication between the different dietitians, and they find it effective. Rarely do they not put residents' weight into the electronic system the same day they are taken or the following day. The surveyor asked the Clinical Dietary Manager why it took three weeks for Staff I, the Clinical Dietitian, to increase the tube feeding rate to meet estimated needs, but she did not know. The Clinical Manager said that Resident #138 should have been followed up a few days later to address any further vomiting or intolerance to the tube feeding and, if not, to increase the tube feeding back to goal rate. In an observation conducted on 09/20/23 at 4:50 PM, Resident #138 was noted in bed with the tube feeding 'on hold'. Closer observation showed that the tube feeding was started on 09/20/23 at 3:00 PM with Nepro at 50 ml an hour. Closer observation showed that the tube feeding was still at the 1000 ml mark on the 1000 ml capacity bottle. An interview was conducted on 09/20/23 at 4:56 PM with Staff K, RN, who said that she was the one who placed the tube feeding 'on hold' because the resident was moved from the chair to his bed. Record review of the weights log showed the following: readmission weight noted at 147.2 pounds on 08/18/23, two days after his readmission, and 137.8 pounds on 09/15/23. This showed a 6.8% severe weight loss in less than a month, from 147.2 pounds to 137.8 pounds. Record review of the dietary readmission dated 08/18/23 revealed that Resident #138's estimated caloric daily needs to be between 1700-2000 calories and 80 grams to 100 grams daily protein needs. The resident's Body Mass Index (BMI) was noted at 23.7, within the normal level. In this note, the clinical dietitian reported that Resident #138 was on a tube feeding regimen that provided 69% of the lower end of caloric needs and only 59% of the higher end of caloric needs. It further showed that it only offered 66% of the lower-end protein needs and 53% of the higher-end protein needs. It was then recommended to change the tube feeding regimen to Nepro at 60 ml an hour for 15 hours, providing 1620 calories and 73 grams of protein. The clinical dietitian further recommended providing protein supplements twice a day, which provided an extra 34 grams of protein. The tube feeding Nepro at 60 ml an hour for 15 hours met 100% of the estimated lower end of caloric needs and 88% of the higher end of estimated caloric needs. Record review of the dietary progress note dated 08/25/23 revealed the following: Resident #138 had an episode of emesis (vomiting) and was given Zofran medication. In this note, the clinical dietitian changed the tube feeding recommendations and adjusted the feedings for Nepro at 45 ml an hour running for 18 hours, providing 1458 calories a day and 66 grams of protein daily. This tube feeding order met 94% of the estimated lower end of caloric needs and 79% of the higher end. This tube feeding order was running from 08/25/23 and was only discontinued on 09/15/23, three weeks later. The dietary progress note dated 09/15/23 revealed the following: Resident #138 has a BMI score of 21, which dropped from 23.7 to 21.0. In this note, the clinical dietitian reassessed the calories needed between 1802 and 2080 daily. She increased the tube feeding Nepro from 45 ml to 50 ml an hour for 20 hours to provide 1800 calories a day and 81 grams of protein. This change provided 93% of the higher end of caloric need for Resident #138. The care plan, which was initiated on 09/15/23, showed that Resident #138 had a significant weight loss of 6.7% in 30 days with a stage 4 pressure ulcer. It was recommended to adjust the tube feeding to meet estimated needs. The goal noted for the nutrition and hydration to be meet the needs and not show a weight decrease of 5% or more in 30 days or a decrease of 10% or more in 180 days. The Minimum Data Set (MDS), 180 days, which was dated 09/15/23, showed that Resident #138 had a Brief Interview of Mental Status (BIMS) score of 00, indicating high cognitive impairment. In an observation conducted on 09/20/23 at 9:38 AM, Staff A and Staff B (Certified Nursing Assistants) were asked to take the weight of Resident #138. A Hoyer lift scale was used to take the weight of Resident #138. Continued observation showed that the current weight taken on Resident #138 was noted at 132.2 pounds. This showed an additional weight loss from 137.8 pounds on 09/15/23 to 132.2 pounds in 5 days-a total severe weight loss of 10.12% in about one month. In an interview conducted on 09/20/23 at 9:50 AM, Staff A and Staff B, they stated that they get a list of residents daily from the dietitians. The list lists all the residents whose weights must be taken for that specific day. When taking the weights, they will write on that piece of paper the scale type that was used each time for taking the weights. That list is later given back to the dietitians, who input the weights into the electronic system. A tour was conducted on 09/20/23 at 10:13 AM with Staff C, Materials Manager, which observed the following: The 3rd floor was observed with 3 Hoyer lifts, which showed that the last scale calibrating was on 05/15/2023 and the next due date for calibration was on 08/20/23. The 4th floor was observed with 3 Hoyer lifts that showed the previous scale calibrating was on 05/15/23, and the next due date was on 08/20/23. The 2nd floor showed 3 Hoyer lifts that showed that the last scale calibrating was on 05/15/23, and the next due date was 08/2023. In an interview with Staff C on 09/20/23 at 11:35 AM, he stated that one company comes once a year to ensure that the Hoyer lifts in the facility are in working condition. When asked when the last time the outside scale company came to calibrate the Hoyer lift, he did not know. When asked when the next due date for the scale calibration was, Staff C stated he didn't know. When the Surveyor pointed to the stickers noted on the Hoyer lifts regarding the calibration of the scales, he said, I think that another company comes to the facility every quarter to calibrate the scales and make sure that the scales are weighing property. When asked by the surveyor for copies of all visitation invoices in the last year, he said that he needed to contact the company for the visitation invoices. Record review of the scale preventative maintenance and calibration agreement effective 08/01/2021 revealed quarterly visitations by the scale company to ensure that the scales are maintained for accuracy and balance; and to inspect and test with certified test weights to confirm national standards. In a phone interview conducted on 09/21/23 at 8:50 AM with the scale calibration outside company's technician, he stated that he had previously been to this facility to calibrate their scales. He further said that it is essential to calibrate the scales every three months because this facility does not have a way to verify or to make sure that the scales are accurate and calibrating them verifies their accuracy. He further reported that the last calibration visit was on 05/15/23, and the following visit was due in August 2023. According to him, the facility will remind them that it is time to come in if they run behind. In an observation conducted on 09/21/23 at 10:00 AM, the tube feeding was noted in the room, with a bottle of Nepro, which was started the day before, on 09/20/23, at 3:00 PM. Further observation showed the tube feeding was on the 450 ml mark on the 1000 ml capacity bottle. A tube feeding that started at 3:00 PM and ended at 10:00 AM should have been on the 50 ml mark. In an interview with the Assistant Director of Nursing (ADON) on 09/21/23 at 10:10 AM, she was asked what the protocol was for hanging a new tube feeding bottle. The sticker on the tube feeding bottle will have the tube feeding formulary, the date, and the time that the tube feeding was started. The nurse documents tolerance for the tube feeding or if it was held for any reason in the nurse's note. When asked what is documented in the Medication Administration Record (MAR) regarding the tube feeding, she said that nursing staff put the time with initial, and if the tube feeding is held for any reason, they will put in the option of the hold, but there is nowhere in the MAR to put the time it was held. She further verified that the tube feeding order for Resident #138 was supposed to be started at 2:00 PM and stopped at 10 AM the next day. The ADON was also asked if the tube feeding was held for any reason and restarted again and if the nursing staff ran it past the stop time to compensate for the missing hours for Resident #138, but she did not know. In an interview conducted on 09/21/23 at 10:28 AM with Staff L, Licensed Practical Nurse, she stated that she stopped the tube feeding this morning at 10:00 AM and has kept the tube feeding bottle the same since it started yesterday. In an interview conducted on 09/21/23 at 10:40 AM, the facility's medical director stated that Resident #138 was his patient. The tube feeding was placed on hold yesterday for a few hours because of nausea and vomiting and was restarted a few hours later. He further said that Resident #138 has had issues with nausea and vomiting in the past, and the tube feeding needed to be stopped for a few hours. In an interview conducted on 09/21/23 at 10:45 AM, Staff M, Licensed Practical Nurse, stated that when a new bottle of tube feeding is hung, the date and time that the tube feeding was started is recorded on the bottle's sticker. If the tube feeding is not tolerated, she would stop the feeding, check the residuals, and call the doctor for further orders. That would all be documented in the nurses' notes. Staff M further said that there is a section in the MAR that says 'other'. In that section, you can comment on why the tube feeding was stopped or held for any reason. Staff M also reported that if tube feeding is stopped and then restarted again, it will be stop[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow physicians' orders regarding tube feeding for 1 of 2 sampled residents, Resident #124. The findings included: Review of the facility's policy, titled, Enteral Nutrition Products, dated 08/22/22, showed in part the following: The facility supplies residents with enteral nutrition support as ordered by the Physician. It further showed that all enteral nutrition products must be labeled with the Resident's name, date it was prepared, product name, concentration, and volume. Resident #124 was admitted to the facility initially on 06/01/23 with diagnoses to include Hyperlipidemia, Dementia, and Left Hip Fracture. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #124 had a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of the diet order, dated 09/01/23, noted for tube feeding, Jevity 1.5 (tube feeding formulary) at 65 milliliters (ml) an hour times 15 hours to start at 6:00 PM and off at 9:00 AM. The weight log for Resident #124 showed the following: 90.6 pounds on 06/20/23, 88.3 pounds on 07/11/23, 83.2 pounds on 07/27/23, 84.6 pounds on 08/09/23, 81.3 pounds on 08/10/23, 82.1 pounds on 09/01/23, 85 pounds on 09/20/23, and 81 pounds on 09/21/23. That is a 10.5% weight loss in 3 months. In an observation conducted on 09/18/23 at 8:02 AM, Resident #124 was noted in her room with the tube feeding running at 65 ml an hour. Closer observation showed that it started the day before, on 09/17/23, at 6:00 PM. The tube feeding was noted at the 850 ml mark on the 1500 ml capacity bottle. The tube feeding running at 65 ml an hour should have been at the 600 ml mark out of the 1500 ml capacity bottle. In an observation conducted on 09/18/23 at 11:45 AM, Resident #124 was in her room with the tube feeding off. In an observation conducted on 09/18/23 at 2:50 PM, Resident #124 was in her room with the tube feeding off. In an observation conducted on 09/19/23 at 9:00 AM, Resident #124 was noted in her room with the tube feeding running at 65 ml an hour. Further observation showed that the tube feeding was started the day before, on 09/18/23, at 6:00 PM. The tube feeding was noted at the 1200 ml mark on the 1500 ml capacity bottle. The tube feeding, which started the day before, running at 65 ml an hour, should have been around the 500 mark out of a 1500 ml capacity bottle. In an observation conducted on 09/20/23 at 7:05 AM, Resident #124 was noted in bed with the tube feeding running at 65 ml an hour. Closer observation showed that the tube feeding started on 09/19/23 at 6:00 PM. The tube feeding was noted at the 1150 ml mark on the 1500 ml capacity bottle. The bottle that started at 6:00 PM the night before should have been at around the 655 ml mark on the 1500 ml capacity bottle. About 845 ml of formulary should have been infused during the night. An interview was conducted on 09/20/23 at 7:10 AM with Staff E, Licensed Practical Nurse/LPN. Staff E stated that Resident #124's tube feeding was infusing all night and was well tolerated with no issues. In an observation conducted on 09/21/23 at 10:32 AM, the resident's weight was taken as requested by the surveyor. The facility used a standing scale to take the weight of the Resident, who was fully clothed with her shoes on before going on the standing scale. The first reading showed 80 pounds, and the second weight reading showed 81 pounds. The staff did not subtract the weight of the shoes from the total number of 81 pounds. This new weight had a 4-pound discrepancy from yesterday's (09/20/23) weight. The dietary progress note dated 07/07/23 showed that the Clinical Dietitian recommended placing Resident on Jevity 1.5 at 45 ml an hour for 18 hours, providing 1215 calories and 52 grams of protein daily. This order was changed on 07/07/23 and discontinued on 07/12/23. The dietary progress note dated 07/27/23 showed that Resident #124 had 7% weight loss within the month and was receiving tube feeding Jevity 1.5 at 35 ml an hour for 18 hours, which was ordered from 07/12/23 to 07/27/23. This tube feeding order provided 945 calories a day and met 89% of the estimated lower end of caloric needs and 75% of the estimated higher end of caloric needs a day. On this note, the Clinical Dietitian recommended changing the tube feeding to a bolus feeding regimen with three cans of Jevity 1.5, providing 1065 calories and 45 grams of protein daily. Resident #124's estimated caloric needs was between 1051 and 1261 and protein needs between 43 grams and 56 grams. Resident #124 had a Body Mass Index (BMI) of 19.6 (normal limits) on admission and was dropped to 17.6, which is underweight. Record review of the dietary progress note dated 08/03/23 revealed that the tube feeding order was changed again to Jevity 1.5 at 65 ml an hour running for 13 hours, providing 1265 calories and 54 grams of protein daily. On 08/10/23, the tube feeding was changed again to Jevity 1.5 at 65 running for 14 hours, which provided 1365 calories and 58 grams of protein. Continued record review revealed that on a dietary note dated 09/01/23, the tube feeding was increased again with Jevity 1.5 at 65 ml an hour for 15 hours, providing 1460 calories and 62 grams of protein a day. The care plan dated 07/07/23 showed Resident #124 was at risk for weight loss and dehydration related to swallowing problems and dementia. It further showed the resident will be nourished and hydrated as evidenced by not showing a decrease in 5% or more in weight in less than or equal to 30 days, weight decrease to 10% or more in less than or equal to 180 days, or by showing weight gain. The Physician's orders revealed that Resident #124 was on a diet by mouth before 07/06/23 but was totally dependent on tube feeding as the only source of nutrition after 07/06/23. In an interview conducted on 09/21/23 at 12:42 PM with the Assistant Director of Nursing (ADON), she was asked what the protocol is if a resident has a weight loss on tube feeding and at what point she would be concerned. She said that they would contact the doctor, and if this continues throughout the week, and the doctor will contact the dietitian for any changes. The ADON said this is also the protocol for any residents on tube feeding that is not tolerated.