**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) During the initial tour of the facility conducted on 10/25/22 at 10:42 AM, Resident #58 was asleep in her bed. The surveyor noted Resident #58 appeared to be very thin and had no teeth present. Clinical records revealed Resident #58 was admitted to the facility on [DATE]. Resident #58 had a medical history significant for Alzheimer's disease and dementia, malnutrition, osteoarthritis, psychosis, and anxiety. Review of the admission Minimum Data Set (MDS) completed on 09/03/22 showed that Resident #58 had a Brief Interview of Mental Status (BIMS) score of 1 out of 15 which indicates she had severe cognitive impairment. This MDS documented that Resident #58 required total dependence of 1 staff member for eating her meals. Review of Resident #58's Care Plan revealed there was a care plan in place regarding her poor dentition, which was created on 08/30/22. Further review revealed there was a care plan in place regarding a history of malnutrition related to inadequate oral intake of calories and protein, which was created on 09/01/22. This care plan also indicated Resident #58 required a mechanically altered diet due to her poor dentition. A care plan was added on 10/25/22 regarding Resident #58 being placed on hospice care. Review of Resident #58's weight history revealed the initial recorded weight was 118 pounds, documented on 08/30/22 as a hospital weight. Resident #58 was weighed on 10/28/22-this weight was 101.2 pounds. This indicated Resident #58 suffered a significant weight loss of 14.24%. During a review of Resident #58's nutrition assessments revealed the dietitian did an initial Nutritional Evaluation on 08/31/22. In this nutrition assessment, the dietitian documented that she used the hospital weight of 118 pounds to complete this assessment instead of obtaining a baseline weight at the facility prior to completing this assessment, which is the facility's policy. During a review of Resident #58's progress notes, it was revealed that the dietitian wrote one note on 10/20/22 which documented a weight of 99 pounds which was taken on 10/03/22. In this note, the dietitian documented that because of the weight loss, she planned to increase Resident #58's ordered house supplement from two times to three times daily. Review of the physician orders revealed she did input this new order on 10/20/22. Further review of Resident #58's notes revealed she had a slow-healing wound on her left arm. The first note regarding this wound was written 09/29/22; this note measures the wound at 2.5 cm(centimeter) x 2 cm x 0.1 cm. The last note regarding this wound was written 10/27/22-this note states the wound has been present for at least 28 days and measures at 1 cm x 0.8 cm x 0.1 cm. Review of Resident #58's meal intake for the date range of 10/02/22 to 10/28/22 revealed there were 50 meals documented at 0-25% consumed or refused. Review of Resident #58's supplement intake for the date range of 10/02/22 to 10/28/22 revealed there were 16 instances where Resident #58 consumed less than 50% of her oral supplement. On 10/25/22 at 1:24 PM, the surveyor observed Resident #58 eating her lunch meal. The resident was assisted by a staff member. The surveyor noted Resident #58 only consumed 10% of this meal. On 10/26/22 at 1:40 PM, observation revealed Resident #58 eating her lunch meal she was assisted by a staff member. The surveyor noted Resident #58 only consumed 15% of this meal. Based on records reviewed, observations and interviews, the facility failed to ensure an accurate nutritional assessment to increase nutrition and to address identified significant weight loss in a timely manner for 5 of 7 residents reviewed for nutrition (Resident #83, Resident #69, Resident #46, and Resident #58). The facility failed to provide nutritional interventions in a timely manner that resulted in significant weight loss and failed to provide protein supplements to aid with a newly developed stage 3 pressure ulcer wound for Resident #41. The findings included: The facility's policy titled: Baseline Weights, revised in September 2018, showed the following: An accurate baseline weight will be obtained upon admission. On admission, the nursing staff will obtain the height and weight of each resident. The admission weight and height will be entered into Point Click Care (PCC). The baseline weight will be determined by the facility dietitian or designee and entered into the resident's electronic medical record as Baseline weight. A new baseline weight will be determined upon readmission to the center. Residents will be weighed weekly x two weeks to monitor the adequacy of intake and identify immediate issues with nutrition and hydration. If the weight remains stable, the weight will be obtained monthly. Significant variances of 5% in a month or 3% in a week are to be reweighed upon completion to verify the accuracy of the weight. Note: both gains and losses should be reweighed. If reweigh determines that the original weight is incorrect, that weight will be struck out. The Weight and Vitals Exception reports from PCC will be utilized to identify residents meeting the significant weight change criteria. The facility's Nutritional Documentation policy, revised in January 2018, showed the following: Nutritional documentation will be completed in appropriate time frames. Residents who exhibit significant nutritional risk factors: Weight loss, Enteral support, Dialysis, or pressure ulcers will be referred to the Registered Dietitian. It further showed that the time frame for weight loss is within five days, the time frame for pressure ulcers is within seven days and the time frame for Initial Assessment is five days. 1) A record review showed that Resident #83 was admitted to the facility on [DATE]. Diagnoses included but not limited to Dysphagia, Dementia, and Muscle weakness. A review of the Minimum Data Set (MDS) dated [DATE] showed that Resident #83 had a Brief Interview of Mental Status (BIMS) score of 0 out of 15, meaning the resident is significantly impaired cognitively. Section M for Skin Conditions of the MDS showed that for pressure ulcer wounds, Resident #83 had 0 wounds noted. During a phone interview conducted on 10/27/22 at 2:00 PM, Resident #83's daughter stated that her father used to be between 136 to 140 pounds before he was admitted to the facility. Her mom used to handle all health-related issues until she took over. She further reported that her father went to the hospital for Urinary Tract Infection and COVID-19 before coming to this facility. The daughter reported that her father had two pressure ulcers in the past on his back. She did not know that her dad had lost so much weight but was aware that he was not eating well. Resident #83's daughter revealed that she spoke to the facility's Speech Language Pathologist, who told her that they would provide her father with a high calories/protein supplement to aid with the poor intake of meals. In an observation conducted on 10/25/22 at 12:38 PM, Resident #83 was noted in his room with the lunch tray at the bedside. Staff N, a Certified Nursing Assistant (CNA), was in the room assisting the Resident with his lunch meal. At 12:54, Staff N removed the tray to the side and said that Resident #83 did not want to eat anymore. Closer observation showed that Resident #83 did not eat the food on his tray but did drink most of his house shake, juice, and ice cream. In this observation, Staff N stated that he needs assistance with his meal daily. A review of the weights showed the following weights recorded for Resident #83: admission weight was taken from the hospital registered at 132 pounds, the next weight was taken on 10/05/22 at 113:4 pounds, and the on 10/17/22 it was recorded at 100.8 pounds. The Initial Nutrition assessment dated [DATE] showed that the facility's Clinical Dietitian used the hospital-recorded weight as the baseline for her assessment. In this note. The facility's Clinical Dietitian stated that Resident #83 had no weight change and estimated his daily needs at 1500-1800 calories a day and his protein need at 60 grams daily. The facility's Clinical Dietitian further wrote that Resident #83 was with poor intake of his meals but did not recommend any nutritional supplements to aid with the poor intake. A review of the progress note written on 10/08/22 by Staff J, the Medical Director's physician Assistance, stated that Resident #83 had a functional decline and poor performance. He is malnourished and has lost 10 lbs. He has developed a stage 3 sacral decubitus (pressure ulcer). In this note, Staff J reported that she spoke to Resident #83's daughter and that she refused tube feeding. The daughter realized that her father was declining and was not making progress in rehab. Staff J further consulted the dietitian for further assistance. It was also noted that Resident #83's daughter was considering hospice for her father. A review of the progress note written on 10/12/22 by Staff J, the Medical Director's physician Assistance, she noted that Resident #83 is with stage 3 pressure ulcers and that she discussed Resident's poor intake of meals with his daughter. The Wound Care Initial assessment dated [DATE] showed that Resident #83 had a stage 3 pressure wound on the sacrum area. It was only when a note dated 10/20/22, completed by the facility's Clinical Dietitian, that she addressed the significant weight loss of 11 percent in 12 days, which was 24 percent weight loss in one month. In this note, she stated that Resident #83 is on a Regular Mechanical Soft diet and that he is tolerating his diet. The Clinical Dietitian said that Resident #83 is eating about 50% of his meals and that he now has a stage 3 pressure ulcer wound. She then recommends ordering a house supplement (nutritional supplement) twice a day and providing Prostat (protein supplement) once daily to aid with wound healing. The Order Summary Report showed that an order was written for a house supplement two times a day on 10/19/22, and a Prostat supplement once time a day was ordered on 10/21/22, which was a month after Resident #83's was admitted . The care plan for Resident #83 showed that he had a healed stage 2 sacral wound on 10/20/22. He has the potential for the development of pressure ulcers which was initiated on 10/04/22. It further showed that Resident #83 is at risk for malnutrition and that he will maintain a stable weight of fortified foods with meals initiated on 09/22/22. Resident #83 has inadequate intake; reduced cognition, and the goal is to keep his weight at 132 pounds plus or minus 4 percent every month, dated 09/22/22. The facility will provide fortified foods with meals and observe for and report foods; the resident consistently refuses and weigh per protocol. In an interview conducted on 10/27/22 at 11:29 AM, the facility's Clinical Dietitian stated Resident #83, who was admitted on [DATE], had an Initial Nutrition Assessment, which was completed by her on 09/21/22 and then a progress note on 10/20/22. The facility's Clinical Dietitian verified that the documented hospital weight was used for her initial assessment and not the actual verified weight. The facility's Clinical Dietitian stated that she gave Resident #83 fortified foods and mighty shakes (nutritional supplement) initially and then ordered other supplements on 10/20/22 after she realized that Resident #83 was losing weight with the fortified foods and the mighty shakes. The Clinical Dietitian reported that she understands that the hospital weight should not have been used for the initial assessment. 2) Resident #69 was readmitted to the facility on [DATE] with diagnoses of Sepsis, Urinary Tract Infection, Hemiplegia, and Dysphagia. The Minimum Data Set (MDS) dated [DATE] showed that Resident #69 has a BIMS score of 12 out of 15, which indicate the resident is moderately impaired cognitively. A review of the weights showed that the following weights were recorded: readmission weight was noted on 09/09/22 at 174.0 pounds (hospital weight), a weight of 148.6 pounds noted on 10/04/22, and a weight of 148.2. pound noted on 10/06/22. This showed a significant weight loss from 09/09/22 to 10/04/22, 15% in about one month. In an interview conducted on 10/25/22 at 3:50 PM, Resident #69 stated that he has a good appetite and is eating well. A review of the readmission note conducted on 09/13/22 documented by the Clinical Dietitian showed that Resident #69 was on a Diabetic Mechanical Soft diet and was tolerating his diet well. The Clinical Dietitian further noted that Resident #69 had a stage 4 pressure ulcer in the sacrum area and was eating less than 50% of his meals. In this note, the Clinical Dietitian recommended a house supplement twice a day but no protein supplement was noted to aid with wound healing. A wound evaluation report dated 09/15/22 showed that Resident #69 had a stage 4 pressure wound to the sacrum area. Follow-up progress by the Clinical Dietitian was on 10/19/22, which was more than a month later. In this note, she documented that Resident #69 was tolerating his diet and that he had a significant weight loss of 7.16% in 30 days. The Clinical Dietitian recommended speaking to the facility's Speech Language Pathologist regarding a possible diet upgrade to regular consistency because of inadequate intake of calories and protein. No additional supplements or protein supplements are recommended in this note to assist with weight loss, or the pressure ulcer wound. A review of the orders showed an order for weekly weights times two weeks in the morning for significant weight loss, which was dated 10/20/22. The care plan, which was initiated on 08/03/22, showed that Resident #69 is at nutritional risk related to increased intake/protein needs due to a pressure wound. It further showed that Resident #69 would maintain a stable weight with no further weight loss and maintain a stable weight of 161 pounds every month. Interventions are in place: honor preferences for meals and snacks, monitor labs as ordered, serve diet as ordered, supplements as needed, and weight per protocol. In an interview conducted on 10/27/22 at 11:29 AM, the facility's Clinical Dietitian stated Resident #69 was readmitted on [DATE]. The Clinical Dietitian verified that the initial weight for this Resident was from the hospital, and the next weight was not done until 10/04/22. A progress note was written on 09/13/22, which noted the hospital weight and documented a stage 4 wound. In this note, she wrote for house supplement only two times daily but did not address the weight loss until 10/19/22. She requested a speech therapy consult due to inadequate oral intake and updated the Resident's preferences but made no other changes. The Clinical Dietitian agreed that she had no idea how much weight the resident lost in this facility since she used the hospital weight first. 3) Resident #46 was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, Dementia, and Anemia. In an observation conducted on 10/28/22 at 8:18 AM, Resident #46's breakfast tray was brought into the room by Staff D, a Registered Nurse Supervisor. Staff D was observed setting up the breakfast tray, opening the milk container, and walking out of the room to assist with other breakfast trays. In an observation conducted on 10/28/22 at 8:34 AM, Resident #46 was noted in her room with no assistance from Staff. Closer observation showed a meal tray with the following: Pancakes, ground sausage, milk, and orange juice. The tray was noted to be 100% untouched, and no staff was noted in the room. In an observation conducted on 10/28/22 at 8:45 AM, the Resident was noted in her room with no assistance from Staff. Closer observation showed that Resident #46 left her breakfast tray 100% untouched. In an observation conducted on 10/28/22 at 1:00 PM, Resident #46 received her lunch tray with Staff D, the Nurse Supervisor, at the bedside. In this observation, Staff D was feeding Resident #46 a chocolate cream pie which Resident #46 accepted. When attempting to put the Mighty Shake (nutritional supplement) on the tray, Resident #46 made a disliked face and pushed it away. In this observation, Staff D stated Resident #46 could eat independently, but sometimes she sits with her to encourage her and give her company. Staff D further stated that Resident #46 is often brought to the front dining room so other staff members can observe her. Review of the MDS Section G for functional status under eating dated 09/02/22 showed that Resident #46 could eat independently with set up only. The cognitive status section noted her BIMS score was 01 out of 15 to indicate the resident is severely cognitively impaired. Resident #46's weights were recorded as follows: on 03/04/22 at 130.6 pounds, on 03/05/22 at 117.1 pounds, on 03/08/22 at 114.8 pounds, on 04/06/22 at 107.1 pounds, on 05/02/22 at 113.4 pounds, on 06/03/22 at 112.4 pounds, on 08/05/22 at 106.4 pounds, on 10/04/22 at 101.8 pounds. Review of the Nutritional Evaluation Version dated 03/06/22 showed that the Clinical Dietitian used the weight recorded on 03/05/22 for the baseline weight. The Clinical Dietitian documented that Resident #46's son reported appetite and weight declining and that she is at inadequate energy intake. Resident #46 is on a Mechanically altered diet and eats less than 50% of her meals. The Clinical Dietitian recommended fortified foods, but no nutritional supplements were ordered. The subsequent follow-up progress note was on 06/07/22, three months later, and the Clinical Dietitian stated that Resident #46 is eating about 25 to 50 percent of her meals. It further showed that Resident #46 receives fortified foods but no nutritional supplements. Another progress note dated 09/06/22 showed that Resident #46's weight dropped from 112.4 pounds to 106.4 pounds and that her intake is between 25% to 50% of her meals. On this note, the Clinical Dietitian recommended one oral nutritional supplement once a day. A progress note dated 10/25/22 showed that the Resident weight was noted at 101.8 pounds with 4.32 percent weight loss in 30 days. On this note, the Clinical Dietitian recommended increasing the nutritional supplements to two times a day for weight support which was ordered on 10/25/22. A new weight requested by the surveyor on 10/27/22 at 3:18 PM showed that Resident #46's weight was now at 95.4 pounds which showed an additional weight loss from 101.8 pounds to 95.4 pounds (6.2% weight loss in less than a month). Review of the care plan dated 03/06/22 showed that Resident #46 was at nutritional risk related to weight fluctuations as evidenced by disease of dementia, mechanically altered diet, multiple dietary restrictions, and inability to communicate with staff effectively. Record review revealed an Initial Certification hospice note dated 10/07/22, it showed that Resident #46's appetite decreased from 70% to 30% of her last meals. It also showed that the Resident must be spoon-fed and tolerates a small quantity of Pureed diet. It further showed that Resident #46 has severe protein and calorie malnutrition. During an interview conducted on 10/28/22 at 11:55 AM, Staff F, Speech Language Pathologist, stated that Resident #46 is on a Mechanical Soft diet and is eating independently. When asked why the hospice note dated 10/07/22 showed that Resident #46 needed to eat with a spoon and was on a Pureed diet, Staff F reported it must have been a mistake. In an interview conducted on 10/27/22 at 3:20 PM, Staff B and Staff C, Certified Nursing Assistants, stated that the Nurse Manager on the floor would be assigned to take on specific days. They will be given a list of residents who need weights for the day and will give it back to the Unit Manager when they are done. They further revealed that weights are done monthly or as needed. An interview was conducted with the facility's Director of Nursing (DON) on 10/27/22 at 11:03 AM. The DON stated she had been the DON in this facility for six months. She reported that the current full-time Dietitian has been in the facility for eight months. The DON stated that there were gaps and no full coverage of dietitians prior to this Dietitian. The Corporate Dietitian filled in remotely through their electronic system. When asked who is responsible for taking the resident's weights, she stated, the CNAs are responsible for taking the weights. The Unit Managers are responsible for assigning which residents the CNAs are supposed to weigh daily. All residents are supposed to have monthly weights, and only one CNA is assigned to complete these weights. The Dietitian verbally gives the Unit Manager a list of residents, and the Unit Managers provide the list of the assigned CNAs for the day. The DON further stated that an issue was identified last month that staff was using hospital-recorded weights instead of taking admission weights in the facility. Staff F stated that she had to talk to the Dietitian about the need to do admission weights in the facility. Staff F reported that they also identified that no 3-day weights were being done. When asked what staff is responsible for putting the resident's weights in the computer system, she stated only a few CNAs are trained to put the weights in the computer system. Staff F further clarified that the CNAs who are trained as Unit Secretaries are trained to put the weights in the system. An interview was conducted with the Regional Nurse on 10/27/22 at 11:14 AM. She stated she was this facility's previous Director of Nursing (DON) for two years. She reported that while she was the DON, she would communicate with the Corporate Dietitian via phone calls and emails regarding residents who required weights. An interview was conducted with the facility's, Registered Dietitian on 10/27/22 at 11:29 AM. She revealed that during her training at the facility, she was not taught the facility policy about doing weights on new admission. When asked what the guidelines are for timing or weights and timing of nutritional assessment, she did not know. According to her, the facility used to have a Restorative program that included assigned CNAs who took the weights regularly, but that has ended. She said she knows the staff has been documenting the hospital weights in their admission assessment, and she had been using the hospital weights to document her baseline assessments. The staff has been asked to take admission weights on residents but has not been done. She stated the resident's first weights are usually done two weeks to one month after admission. She stated that she had noticed a significant discrepancy between the hospital weights and the weights taken by the staff. When asked who is responsible for documenting the resident's weights in the electronic system, she said, the unit managers. For supplements, she will first use fortified foods and magic cups (nutritional supplements), and if that does not work, she will intervene with other dietary supplements. The Weight and Vital Report is reviewed daily to trend any weight loss for the residents. When asked how she decides to intervene if a resident has a change (significant weight loss or new wound), she stated she intervenes if a change is brought to her attention. When asked if she writes for a protein supplement for any residents with stage three and stages four wounds, she said only if the protein needs are not met for the resident. An interview was conducted with the facility's DON and the Corporate Nurse on 10/27/22 at 5:30 PM. They stated that since the admitting nurse needs to close the admission assessment within 24 hours, sometimes the hospital recorded weights are used, especially if residents get admitted late at night. It is later crossed out by the Clinical Dietitian when she does her initial assessment, and a new weight needs to be taken. They both acknowledged that before September 2022, most of the admission weights were not taken by the staff. 5) Resident #41 was initially observed during the initial tour of the facility on 10/25/22 at 10:23 AM. The resident was observed on a pressure reducing mattress, sleeping. At 11:00 AM this surveyor returned to her room and attempted to initiate a conversation and was unable to do so. Record review of Resident #41 medical records revealed she is Russian speaking. Initial admission to the facility was on 8/10/13 and readmitted [DATE] with Quadriplegia, Chronic Obstructive Pulmonary Disease, and Diabetes Type 2. A review of Resident #41's Brief Interview for Mental Status (BIMS) on the Quarterly Minimum Data Set with an assessment reference date of 08/25/22 revealed a score of 99 which indicated that she was unable to complete the BIMS. The medical records also revealed the resident had a Stage 3 pressure wound on her sacrum which indicated the wound is down to the fat layer and may have dead tissue and drainage. On 10/27/22 an additional observation of the resident was made at 10:26 AM. She was lying in bed with her eyes closed. An interview was conducted with Staff B, a Certified Nurses Assistant (CNA) on 10/27/22 at 10:30 AM. Staff B was asked how much the resident eats and if she needs to be fed. Staff B stated that how much she eats depends on her mood and if she does not want to eat she will eat 50-75%. Today she ate 75% of her breakfast. She always needs assistance to eat. Staff B was asked if she is the person who weighs Resident #41. Staff B replied that she used to weigh all of the residents on the second floor until about 2 months ago when that stopped. Staff B reported that she would report the weight to the unit manager who would report to dietary. Three consecutive weights is the policy. The unit manager would hand her the weights that needed to be done. She does not know why she is not weighing every resident anymore. On 10/27/22 at approximately 10:45 AM, an interview was conducted with Staff E, Unit Manager, a Licensed Practical Nurse (LPN). Staff E revealed a CNA is assigned to do the weights and it is done from the first to the fifth of the month. A census is printed up so they weigh everyone. Staff E puts in the weight or the nurses will put the weight in the computer. The dietitian looks at the weights in the computer and she will tell them or write an order for weekly weights. Review of the weights for Resident #41 are as follows: 10/27/22 140.8 pounds (Lbs) 10/4/2022 16:10 143.4 Lbs Mechanical Lift 9/1/2022 20:34 146.3 Lbs Bath 8/1/2022 15:18 148.8 Lbs Mechanical Lift 7/5/2022 12:40 143.2 Lbs Mechanical Lift 7/2/2022 15:58 143.2 Lbs Mechanical Lift 6/3/2022 07:49 145.0 Lbs Mechanical Lift 5/2/2022 18:57 153.4 Lbs Mechanical Lift 4/4/2022 09:25 155.0 Lbs Mechanical Lift Review of the electronic health record for Resident #41 revealed no nutrition assessment was done when the physician ordered a dietary consult on 07/07/22 when a Stage 3 wound was identified. An assessment was done on 06/07/22 and house supplement twice a day was ordered and again on 08/29/22 when the dietitian decreased the house supplement to daily due to weight gain. An interview was conducted with the Registered Dietitian (RD) on 10/27/22 at 11:29 AM. Regarding Resident #41 who was readmitted on [DATE], the RD verified the resident had a significant weight loss noted earlier in June and she started the resident on a house supplement 2 times daily. She ultimately wrote to decrease the supplement because the resident gained weight, but she admitted she did not do interventions regarding the resident having a new stage 3 wound which was identified on 07/07/22. During this interview, it was noted in the wound care doctors note that the doctor wanted a dietary consultation. When asked how is she notified of a new consult for a resident, the RD stated that she does not know. An interview was conducted with Staff A, the wound care nurse, on 10/27/22 at 12:48 PM. Staff A stated the wound care doctor comes to the facility one time per week and writes notes. Staff A reported that she does the measurements and the daily wound care, and updates the doctor if there is a decline in the condition of the wound. When asked if she knows how dietary is updated on the status of resident's wounds, Staff A stated she does not know. When asked about Resident #41's wound status, Staff A revealed that the resident had an old ulcer which reopened due to the resident being a quadriplegic and being difficult to reposition off bony prominences, having severely impaired movement, mentation, and weight loss. Interview via telephone with the wound doctor on 10/28/22 at 9:51 AM revealed that he started with wound care for Resident #41 July of this year. He scans the notes into the electronic health record within 2 hours of his visit. He looks at the protein needs for the patients and expects the dietician to follow up with the wound and pick up if any supplements are needed. An additional interview conducted with Staff A, wound care nurse on 10/28/22 at 11:15 AM revealed that the wound care notes are not sent to her directly. Staff A reveled she does look at them related to the size of the wound and any dressing change the doctor may make. She expects the dietician to view the notes for any supplements that may be needed or vitamins. Observation of lunch on 10/28/22 at 1:17 PM revealed Resident #41 was being fed by Staff F, the speech therapist. Resident #41 had a mechanical soft diet and ate 100% of her lunch.