**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide feeding assistance, implement nutritional recommendations, evaluate nutritional supplement intakes, notify the physician of significant weight loss, and ensure significant weight loss was evaluated by a dietitian for two (R5, R21) of two residents reviewed for nutrition in the sample list of 31. These failures resulted in R5 experiencing a severe weight loss of 16.65% (percent) in six months and R21 experiencing a 15.6% severe weight loss in two months. Findings include: The facility's Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol dated September 2017 documents the physician will be notified of significant weight loss including persistent changes in baseline appetite/food intake, and the physician will help identify medical conditions that may cause the weight change and will consider if any additional diagnostic testing is indicated. This policy documents the staff and physician will identify and implement appropriate interventions to address weight loss and will monitor the resident's nutritional status including response to interventions. 1.) R5's Minimum Data Set (MDS) dated [DATE] documents R5 has moderate cognitive impairment, requires setup assistance for meals, and has had a significant weight loss of 5% or more in one month or 10% or more in six months that was not prescribed. R5's Weight Log documents R5's weight as follows: 107.1 lbs (pounds) on admission of 9/7/23 105.8 lbs on 9/17/23 101.5 lbs on 10/1/23 (5.2% loss since 9/7/23) 100.5 lbs on 11/1/23 96.0 lbs on 12/1/23 (10.4% loss since 9/7/23) 95.2 on 1/1/24 (11.1% loss since 9/7/23) 92.6 lbs on 2/1/24 (13.5% loss since 9/7/23) 90.5 lbs on 3/1/24 (15.5% loss since 9/7/23) 85.7 lbs on 4/1/24 (5.3% since 3/1/23) 84.6 lbs on 4/3/24 (16.65% since 10/1/23) R5's Care Plan dated 1/15/24 documents an intervention for supervision/touching assistance for eating with the helper providing verbal cues/touching/steadying trunk. R5's Care Plan dated 9/20/23 documents R5 is at risk for malnutrition, is underweight, and has a Body Mass Index (BMI) of less than 19. This care plan includes interventions to assist with feeding as needed, encourage oral intake, offer snacks between meals and document acceptance, nutritional supplement 120 ml (milliliters) three times daily (TID), frozen nutritional supplement PRN (as needed), obtain weights as ordered, and notify the physician of significant weight loss. There is no documentation in R5's medical record that any new nutritional interventions were implemented after 12/18/23. R5's Meal Intake with date range 3/12/24-4/10/24 documents of the 88 meals 11 meals had 0-25% consumed, 28 meals had 26-50% consumed, and two meals were refused. R5's March and April Medication Administration Records (MARs) document to administer the frozen nutritional supplement PRN and does not document that R5 was offered this supplement. R5's Nutrition/Dietary Notes document R5 was evaluated by V20 Registered Dietitian (RD) on 9/13/23, 12/18/23, and 3/15/24. On 9/13/23 V20 recommended adding nutritional supplement 60 ml three times daily and a frozen nutritional supplement PRN. On 12/18/23 V20 documented R5's weight loss is likely secondary to decreased appetite and oral intake, and behaviors of refusing meals, supplements, and medications. V20 recommended to increase the nutritional supplement to 120 ml three times daily, continue with the frozen nutritional supplement PRN, and R5's family will encourage the frozen nutritional supplement in the afternoon. On 3/15/24 V20 documented R5 requires varying levels of feeding assistance including independent, supervision, and fully dependence on staff. V20 did not document new recommendations to address R5's continued significant weight loss. There is no documentation that R5's weight is monitored more frequently than on a monthly basis, R5's October significant weight loss was evaluated by V20 Registered Dietitian or that any new nutritional interventions were implemented after 9/13/23 until 12/18/23. There is no documentation that V20 evaluated R5 after 12/18/23 until 3/15/24. There is no documentation that R5's trending significant weight loss that began on 10/1/23 was reported to or evaluated by a physician. On 4/08/24 at 11:53 AM R5 was sitting in the dining room and had not taken any bites of food from the meal which consisted barbecued ground beef sandwich, mashed potatoes with gravy, peas, and lemon dessert bar. No staff was sitting with R5 to provide cueing or assistance. At 12:14 PM V24 Certified Nursing Assistant sat next to R5 and offered assistance/cueing. R5 only accepted a few bites of food from V24. V24 asked R5 if R5 wanted something else to eat and R5 did not respond. V24 did not offer R5 a frozen nutritional supplement. At 12:19 PM V13 Registered Nurse (RN) sat down beside R5 and fed R5 bites of food. At 12:26 PM R5 ate half of R5's sandwich and 75% of the mashed potatoes with V13's assistance. On 4/9/24 at 11:30 AM R5's Family (V12) stated R5's family visit often at meal time to feed R5, as R5 eats better when someone assists R5 with meals. V12 stated R5's family are concerned that staff may not be assisting R5 with meals. R5 ate 75% of the noon meal on 4/9/24, with V12's assistance. On 4/10/24 at 11:40 AM R5 was sitting in the dining room with a small cup of the nutritional supplement and a plate of ground meat, green beans and mashed potatoes with gravy. R5 was able to use the fork to take bites of mashed potatoes, but had difficulty getting bites of the ground meat and green beans as they fell off of R5's fork. No staff was sitting with R5 to provide cueing or assistance. V11 Certified Nursing Assistant (CNA) was asked if any residents require eating assistance in this dining room (where R5 was eating). V11 stated there are no residents who require help with eating on a consistent basis. At 12:00 PM V11 began giving R5 bites of food, after it was pointed out that R5 was having difficulty eating. At 12:30 PM V11 was asked how much of the noon meal R5 consumed and V11 stated I don't know, I walked away. On 4/10/24 at 2:15 PM V14 (R5's Family) stated R5 typically does better if someone assists R5 with meals and R5 eats better with a spoon instead of a fork. V14 stated R5 does not show interest in the frozen nutritional supplement and asked if there were alternative options to this supplement and if R5 could be weighed weekly instead of monthly. On 4/10/24 at 10:18 AM V2 DON (Director of Nursing) stated V20 RD reviews the weights monthly and V20's recommendations are given to the physician to review, which is how the physician is notified of weight loss. V2 stated the frozen nutritional supplement is given by the nurses and signed out on the MAR when given. At 12:55 PM V2 confirmed R5's weight loss has not been reported to or evaluated by a physician. At 1:31 PM V2 stated staff should offer assistance if R5 is not eating or having difficulty eating, but R5 does not always accept assistance. V2 stated maybe we should schedule R5's frozen nutritional supplement to be given routinely. On 4/10/24 at 11:57 AM V20 RD stated if there isn't a nutrition note, then V20 likely did not see R5 during the months that were not documented in R5's dietary notes (October 2023, November 2023, January 2024, and February 2024). V20 stated V20 runs a weight report monthly to see if there are any significant weight changes and then V20 follows up on those weight changes. V20 stated V20 originally spoke with R5's family and they were going to give R5's frozen nutritional supplement in the afternoons, and R5 refuses R5's supplements at times. V20 confirmed staff should offer the frozen nutritional supplement at meals if R5 has poor appetite or isn't eating, and this supplement could prevent further weight loss. V20 stated V20 talks with the nurses to determine if supplements are given and accepted. V20 stated the nutritional supplement 60 ml TID was ordered in September 2023 and increased in December 2023 to 120 ml TID. V20 confirmed there were no other nutritional interventions implemented between September 2023 and December 2023. V20 stated V20 gives V20's recommendation forms to the nurses to follow up with the physician. V20 stated a big part of R5's weight loss is R5's poor intakes and poor appetite, and confirmed staff should offer assistance when R5 is having difficulty eating or poor appetite. V20 confirmed if staff do not assist R5 when needed, this could contribute to R5's weight loss. On 4/10/24 at 12:55 PM V20 confirmed there were no new nutritional interventions recommended or implemented for R5 after 12/18/23. 2.) R21's Physician Order dated 3/9/24 documents to administer (nutritional supplement) twice daily (does not specify Original or Plus version) and may substitute with (comparable alternate nutritional supplement) 120 ml TID. R21's March and April 2024 MARs document administration of this order, but do not document if or when the alternate supplement was given or the amount of (nutritional supplement) given. R21's Weight Log documents R21's weight as follows: 81.5 lbs (admission weight) on 12/12/23 78.4 lbs on 12/31/23 75.6 lbs on 1/1/24 (7.2% loss since 12/12/23) 74.1 lbs on 1/14/24 68.8 lbs on 2/1/24 (15.6% loss since 12/12/23 and 9% loss since 1/7/24) 69.8 lbs on 3/1/24 74.6 lbs on 4/1/24 and 70.1 lbs on 4/3/24 R21's Dietary/Nutrition Note dated 12/19/23 documents R21's BMI is 15.1, R21 is underweight related to inadequate oral intake and poor appetite. This note documents V20's recommendation of (nutritional supplement) Plus twice daily that is provided by R21's family, and give (comparable alternate nutritional supplement) 120 ml TID when unavailable. This note documents R21's family requested to be notified when supplement is running low. R21's Dietary/Nutrition Note dated 3/7/24 documents R21 accepts the comparable alternate nutritional supplement when the ordered supplement is unavailable. This note documents R21's meal intakes average 50-75%, but vary with occasional poor intakes and refusal of meals. This note documents the recommendation to continue with the same supplement amount and frequency noted on 12/19/23. There is no documentation in R21's medical record that R21's trending weight loss that began on 12/31/23 was reported to or evaluated by a physician. On 4/08/24 at 11:48 AM R21 was eating independently in the dining room. At 12:26 PM R21 ate approximately 75% of R21's meal. On 4/08/24 at 12:35 PM R21 stated R21's weight was down to 62 lbs at one time, and R21 didn't like that. R21 stated R21 has difficulty gaining weight and last week R21 weighed 70 lbs. R21 stated R21's appetite is pretty good and R21 has an upcoming doctor appointment to have R21's esophagus stretched, which usually helps with R21's eating. R21 stated the nurses give R21 a nutritional supplement that R21 likes. On 4/10/24 at 9:44 AM V7 Registered Nurse stated R21 gets (nutritional supplement) per orders and (comparable alternate nutritional supplement) can be given if the (nutritional supplement) is unavailable. V7 entered the medication room and showed the nutritional supplement bottles that are administered to R21. This supplement was not the Plus version of the (nutritional supplement) as ordered. On 4/10/24 at 1:31 PM V2 confirmed there is no documentation that R21's physician was notified of R21's weight loss. On 4/10/24 at 11:57 AM V20 RD stated there is a difference in the Original and Plus versions of (R21's ordered nutritional supplement). V20 stated (nutritional supplement) Plus is R21's preferred supplement that R21 was taking at home, and R21 should receive one bottle (237 ml) twice daily. V20 confirmed (nutritional supplement) Plus is ordered for R21 and provided by R21's family. V20 stated V20 was not aware that R21 was not receiving the ordered supplement and V20 will need to follow up on this right away as the Original and Plus supplements do not have equivalent nutritional content. V20 stated more of the Original will need to be given to equal the amount of Plus ordered. V20 confirmed the order should specify Plus, and not receiving the ordered supplement could have contributed to R21's weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to utilize the safest assistive devices for one resident (R1) of three residents reviewed for falls in a sample list of three residents. This failure resulted in (R1) slipping from a sit to stand lift and sustaining a dislocated shoulder requiring closed reduction. Findings Include: 1. R1's Care Plan updated 3/5/24 includes the following diagnoses: Fall, Chronic kidney Disease Type III, Congestive Heart Failure, Muscle Weakness, Difficulty Walking, Unsteadiness on Feet, Abnormal Gait, Lack of Coordination, and Abnormal Postures. This Care Plan documents R1 is High Risk for Falls. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is moderately cognitively impaired, has functional limitations to all four extremities, uses a manual wheelchair and is totally dependent to roll wheelchair 150 Feet. This MDS also documents R1 is dependent for Sit to Stand, Toilet Transfer, and Toilet hygiene. R1's Care Profile Audit Report printed 3/26/24 documents: On 2/21/24 at 11:26AM Sit-to-Stand (lift). On 2/21/24 at 2:43PM (Sling type mechanical lift). On 2/27/24 at 7:36AM (Sling type mechanical lift). R1's Physical Therapy Note dated 3/10/24 by V12, Physical Therapy Assistant (PTA) documents Precautions/Contraindications: Fall risk, Lower extremity Edema, Low Activity tolerance, (sling type Mechanical Lift) transfer, Left Lower Extremity Numbness, Limited bilateral shoulder flexion, Bilateral Hand and Wrist Edema, and Left Quadriceps Weakness. R1's Incident Note dated 03/11/2024 at 12:39PM by V6, Registered Nurse (RN) documents (R1) assisted to toilet with Sit to stand lift, two CNAs used sit to stand trial to clean (R1) when (R1) slid out of sling and was lowered by CNA to floor. Range of Motion Within Normal Limits, (R1) complains of pain in Right upper arm. (R1) assisted by three staff and (sling type mechanical lift) to bed. (R1) complains of increasing pain in Right shoulder and inability to move. Grip equal and pulses even bilaterally. Power of Attorney present and requesting (R1) to be seen. Ambulance called and R1 sent to emergency room at approximately 11:45AM. R1's emergency room report from 3/11/24 at 4:11PM documents reports to Emergency Department status post fall with obvious right shoulder deformity. R1's X-ray dated 3/11/24 at 1:45PM documents Comparison to 2/12/24 (Chest X-Ray) Impression: Right Glenohumeral Shoulder Dislocation. Further notes by emergency room staff document R1 required closed reduction for shoulder dislocation. On 3/26/24 at 2:00PM V6, RN stated I was (R1's) nurse the day (R1) slid out of the sit-to-stand. I hadn't worked that hall for a while and I thought (R1) was using a sit to stand so I told the CNAs they could use the sit-to-stand to clean (R1) after a bowel movement. (V8 and V9) Certified Nurse's Aides (CNAs) transferred (R1) from the chair to the toilet using a (sling type mechanical lift). (R1) had a bowel movement and so they could clean (R1), the CNA's used a sit to stand lift. They reported to me that when they stood (R1), (R1) was weak and began to slip so they eased (R1) to the floor. (R1) was in between the toilet and the door on the floor when I got to the room. (R1) was moaning a little and said her right shoulder hurt. We got the (sling type mechanical lift) and put (R1) in bed. I didn't see any redness or swelling. I put ice on the shoulder and elevated (R1's) right arm on a pillow. R1's power of attorney was here and requested we send (R1) to the hospital. I notified (V3, Assistant Director of Nursing) and we sent (R1) to the hospital. On 3/26/24 at 2:30PM V8, Certified Nurse's Aide (CNA) stated I was with (R1) when (R1) fell (3/11/24). We moved (R1) to the toilet with a (sling type mechanical lift). We thought we could clean (R1) easier with the (sit to stand lift) so we stood (R1) up from the toilet with the sit-to-stand lift. (R1) was too weak and slipped out of the sit to stand sling. (V9) Certified Nurse's Aide and I assisted (R1) to the floor. Once we had (R1) on the floor (R1) was moaning in pain and I thought (R1's) shoulder looked a little crooked. (V6) came in and the three of us got (R1) in the (Sling type mechanical lift) and took (R1) back to bed so (V6) could look at (R1). (R1's) family member was here and asked (R1) be sent to the hospital and that is what we did. On 3/26/24 at 3:00PM V4, Occupational Therapist, Director of Therapy verified the Physical Therapy noted 3/10/24 documents (R1) required a (sling type mechanical lift) for transfer. On 3/26/24 at 4:00PM V10, Nurse Practitioner, stated I wasn't there so I couldn't say for certain the fall from the lift caused (R1's) shoulder dislocation, but (R1) was a larger person and slipping out of a lift, would have put pressure on (R1's) shoulders.