**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: a) protect a resident from neglect when they failed to maintain acceptable nutritional and hydration parameters for a non-verbal resident with a diagnosis of dysphagia for 1 (R1) of 3 residents reviewed for abuse and neglect in a sample of 12. This failure resulted in R1 experiencing a significant weight loss of 5% in 1 week due to not receiving nutrition for 16 days, with subsequent hospitalization for malnutrition, critically low potassium levels, dehydration, and electrolyte imbalance; and b) failed to ensure a resident was free from abuse for 1 (R2) of 3 residents reviewed for abuse and neglect in a sample of 9. The findings include: a.) R1's Face Sheet in the medical record documents that R1 was admitted to the facility on [DATE] with diagnoses including hemiplegia, unspecified affecting unspecified side, dysphagia (oropharyngeal phase) following other cerebrovascular disease, aphasia, and Gastro-esophageal Reflux Disease. R1's June 2023 Physician's Order Sheet (POS) documents an order dated 1/20/23 for a pureed diet with NTL (nectar thickened liquids) and assist with meals as needed. R1's MDS assessment dated [DATE] in Section B, Hearing, Speech & Vision documents R1's speech clarity as No speech - absence of spoken words. Subsequent MDS assessments dated 4/14/23 and 5/30/23 document R1's speech clarity as Unclear Speech - slurred or mumbled words. R1's MDS (Minimum Data Set) dated 5/30/23 documents in Section C, Cognitive Patterns, that R1 has a BIMS (Brief Interview of Mental Status) of 99, indicating R1 was unable to complete the interview. The same MDS assessment documents in Section G, Functional Status, documents that the self-performance and support provided under the section Eating as Activity did not occur-activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7 day period. A Nurse's Note in R1's medical record authored by V30 (Licensed Practical Nurse) dated 5/20/23 at 1:54 PM documents in part Resident (R1) started coughing during breakfast and lunch today that caused her to expel her food up both meals and for the past couple days she needed to be suctioned following 2 meals which she was and tolerated well. I called primary care today and talked to the Dr (doctor) on call which is (V35- Nurse Practitioner) she said to send to the emergency room. Ambulance called and was transported to (local hospital #1). R1's ED (Emergency Department) Discharge Instructions dated 5/21/23, authored by V24 (emergency room Physician) documents a final diagnosis of dysphagia, concern for aspiration. Discharge Instructions document that R1 is on 125 cc (cubic centimeters) of D5 (Dextrose 5%) 1/2 NS (Normal Saline) 20 KCl (Potassium Chloride), needs swallow evaluation, please contact the facility physician to order swallow evaluation, this needs to be done tomorrow morning, keep the patient NPO (nothing by mouth) until the swallow eval is done, check blood sugar, fingerstick, every 6 hours, and follow up with PCP (Primary Care Physician) in 24 hours. A Miscellaneous Nursing Note from the hospital records dated 5/21/23 documents spoke with (name of facility). Nurse reports that they have the capability to do swallow evals in their facility Monday through Friday. (Name of facility) also, has the capability to give IV fluids. I spoke with provider and he is willing to send (R1) back to (name of facility) as long as they are comfortable with the IV fluids and NPO status. Attempting to return call to (name of the facility). The Nursing Note further documents pt (patient) to be discharged back to the facility. Report called to (V18- Licensed Practical Nurse). A Nurse's Note dated 5/21/23 at 11:52 AM documents in part that (R1) returned from (local hospital #1) at 2050. New orders for IV fluids. A Nurse's Note dated 5/22/23 at 2:00 AM documents in part Resting in bed at this time. HOB (head of bed) elevated 30 degrees. #20 gauge IV patent in left hand. No redness or swelling noted, flushes without difficulty. N.O. (new order) from (local Hospital #1) to start D5 ½ NS 20KCl at 125 mL (milliliters) per hr (hour) until morning. IV fluids running per orders. Keep NPO until swallow eval ordered and done. R1's June 2023 POS documents orders dated 5/22/23 for a swallow eval next available Dx (diagnosis): dysphagia, keep NPO until swallow eval is done, and check blood glucose Q (every) 6 hours and an order dated 5/23/23 for Dextrose 5%- 0.45%NaCl (Sodium Chloride) IV (Intravenous) solution at 125mL/ hour. On 6/21/23 at 8:30 AM, V18 (Licensed Practical Nurse) said that she admitted R1 back to the facility after the 5/21/23 trip to the emergency room. V18 said she was specifically told a swallow exam by the hospital. V18 said that she told them that they could do a bedside swallow test but could not do a barium swallow or a video test. V18 said that she put R1 on the doctors list for rounds. V18 said that R1 was ordered to be NPO at that time. V18 said the doctor does rounds on Wednesdays and Fridays and sometimes the weekend and they usually clip the hospital orders on the list and put them in a folder labeled MD (Medical Doctor) rounds. V18 said that R1 came back on IV fluids and the hospital sent a bag of fluids with her. V18 said the fluids were D5 1/2 NS. V18 said that when she hears swallow evaluation to her that means to have a speech therapy evaluation not video or barium swallow test. V18 said when she received report from the hospital, a video or barium swallow test was never mentioned. V18 said the folder for physician rounds, that included R1's hospital records, was left at the nurse's station. V18 said that on 5/18/23 she had to suction R1. V18 said that there was no food in what she suctioned. V18 said it was clear frothy phlegm. Nurse's Notes dated 5/21/23, 5/22/23, 5/23/23, 5/24/23, 5/25/23, 5/26/23 and 5/27/23 all document that R1 continues to be NPO until the swallow evaluation is completed. A Nurse's Note dated 5/30/23 at 9:26 AM, documents that R1 has left the facility to have a swallow eval done. A hospital Fluoroscopy Esophagram Report (from local hospital #2) documents the reason for the exam as dysphagia with an order dated 5/22/23 by V21 (Physician). The Fluoroscopy Esophagram results dated 5/30/23 at 9:48 AM, documents under findings that the patient was unable to swallow barium. There is a history of aspiration. This is a non-diagnostic exam. Is suggested that the patient be scheduled for a video swallow with speech pathologist to evaluate which consistencies the patient can tolerate without aspiration. On 6/14/23 at 7:00am, V3 (DON/Director of Nurses) said that they tried to get a barium swallow done for R1 but the 2 local hospitals could not do it. V3 said they did get an appointment for 5/30 but that R1 would not swallow the barium so it could not be completed. V3 said that V21 saw R1 at the facility on 5/31/23 in the morning and was unsure what the family's choice would be- hospice or feeding tube and then the family made the decision to get a feeding tube that same afternoon. V3 said they were following physician orders by keeping R1 NPO since that is what he ordered. A Nurse's Note by V3 dated 5/31/23 at 12:56 AM documents (R1) remains NPO. She was unable to complete swallow eval today. (V21) is aware of study failure. Awaiting further orders. IV site to left upper arm patent and clear without evidence of infiltration. D5 0.45%NS infusing at 125mL per hour. Glucose readings wnl (within normal limits). Oral care provided. A facility Progress Note dated 5/31/23 by V21 (Physician) documents under plan that Orders reviewed and signed and continue current regimen. Patient (R1) has been in and out of the hospital emergency room several times over the last couple weeks. (R1) was diagnosed with progressively worsening dysphagia to the point that she is been kept NPO due to constant aspiration. We would attempt esophagram and she was unable to do due to dysphagia. Staff has been in contact with (V36 Power of Attorney-POA/ Family). (V36) is contemplating hospice versus PEG (percutaneous endoscopic gastrostomy) tube feeding. Patient has been on IV fluids. Patient is non-verbal but does not show any signs of discomfort or pain. As soon as the family decides we will proceed with orders. A Nurse's Note dated 5/31/23 at 11:43 AM documents TC (telephone call) to (V36) in regards to being placed on hospice service or have a feeding tube placed. (V36) said she wants a feeding tube placed and doesn't want her on hospice care. A Wound/ Weight Meeting Note authored by V32 (Licensed Practical Nurse) dated 6/1/23 at 10:34 AM documents in part Current weight 113.6 lbs (pounds) which is 6.2 lbs loss since being placed on NPO status with IV D5 1/2NS continuous at 125 mL/hr, pending swallow study, which she failed. Call placed to (V36) regarding options of feeding tube placement or hospice care. (V36) has opted for feeding tube. MD notified and PEG tube placement is pending . A Nurse's Note dated 6/1/23 at 2:06 PM documents June 8th at 2 PM (local hospital #3) for G (gastrostomy) tube placement. On 6/25/23 at 9:00am, V3 (DON) said that they were able to get another appointment at another local hospital for G tube placement on 6/8/23. V3 said that V21 was able to find a surgeon to place the feeding tube and sent R1 to the hospital on 6/6/23. R1's admission History and Physical (from local hospital #3) dated 6/6/23 under the section HPI (history of present illness)/ Subjective documents in part that R1 presents with traumatic brain injury, aphasia, dysphagia, spastic right hemiparesis was brought into ER (Emergency Room) today from the nursing home for possible PEG tube placement .(V36) stated that (R1) has been without food for 2 weeks since an episode of aspiration. She has been awaiting evaluation by speech therapist .Routine labs obtained today show severe hypokalemia 1.8. UA (urinalysis) is pending. Chest X-rays unremarkable for cardiopulmonary pathology. Under the section Plan it documents traumatic brain injury with spastic right hemiparesis, aphasia, dysphagia on puree with inconsistent swallow and history of aspiration with poor oral intake, anorexia and dehydration with severe electrolyte derangement, hypokalemia, monitor on telemetry, check magnesium as well and replete all electrolytes, Speech and Swallow eval, NPO, D5NS with KCL (potassium) at 100 mL/hr. General surgery consulted for a PEG tube placement. A document titled ST (Speech Therapy) Bedside Swallow Evaluation from the hospital records dated 6/7/23 by V14 (Hospital Speech Therapist at local hospital #3) document an impression of moderate oral dysphagia and pharyngeal dysphagia suspected. A pureed diet with nectar thickened liquids was recommended and a goal of R1 participating in dysphagia treatment in order to further determine safest and least restrictive diet level. An inpatient speech therapy note by V14 dated 6/12/23 documents that R1 swallowed nectar thickened liquids and pureed consistencies with no overt signs and symptoms of aspiration and speech therapy was not needed at this time due to R1's goals were met and a recommendation was made for discharge to a skilled nursing facility. A Nutritional Assessment in the hospital records dated 6/9/23 document that R1 meets ASPEN (American Society for Parental and Enteral Nutrition) criteria for severe protein calorie malnutrition related to inability to consume adequate nutrition as evidenced by patient with aspiration two weeks ago and reportedly uncooperative with previous SLP (Speech and Language Pathologist) evaluation who has been without food for two weeks and presents with critical hypokalemia 1.8 and critical hypophosphatemia 0.7 as well as (by mouth) intake 0% of estimated needs for 2 weeks, significant fat wasting noted per NFPE (Nutrition Focused Physical Exam): moderate orbital pad, significant muscle wasting per NFPE: moderate clavicular, moderate dorsal hand/interosseous. Under the section Evaluation it documents that R1 is tolerating diet order of pureed diet and nectar thickened liquids as recommended by SLP (Speech-Language Pathologist) based on bedside evaluation, ate 75% of lunch and dinner yesterday (6/8/23), and ate 100% of breakfast this morning (6/9/23). On 6/15/23 at 10:46 AM, V14 (Hospital Speech Therapist at local hospital #3) said that speech therapy makes the recommendation for a resident to be NPO (nothing by mouth). V14 said you cannot leave someone without eating for that long. V14 said she did a bedside swallow evaluation on R1 when she was admitted to the hospital and that R1 was safe for PO (by mouth) intake and could have eaten if R1 was seen by speech therapy. V14 said she is not sure why R1 was not seen at the facility. V14 said they were going to put a feeding tube in a lady that did not need it. V14 said that R1 is still in the hospital and is on a full pureed diet and is doing great and has had no feeding tube. On 6/15/23 at 10:30 AM, V12 (Contracted Speech Therapist for facility) said that she could have done a bedside swallow evaluation on R1 if it was ordered by the Physician but that she never received any order or information for R1. On 6/15/23 at 10:35 AM, V13 (Director of Rehabilitation/COTA/Certified Occupational Therapist) said a bedside swallow evaluation could have been done but was not ordered by the physician. On 6/20/23 at 11:35am, V3 said that the Dietician saw R1 at the facility on 5/19/23. V3 said that the dietician was not here while R1 was NPO, therefore did not see R1. V3 also said that R1 received her medications crushed in applesauce and did not receive any of them while she was NPO. V3 said that V21 was aware. A facility document labeled Vital Signs Grid documents that R1 weighed 119.8 on 5/24/23 and 113.6 on 5/29/23, a weight loss 6.2 pounds (5.2%), in 5 days. There were no interventions or dietary notes documented in R1's medical record to address this weight loss. On 6/20/23 at 2:06 PM, V23 (RD/Registered Dietician) said she was not aware of R1's weight loss during that time. V23 said unfortunately she was not made aware that R1 was NPO for 16 days. V23 said she saw R1 on 5/19/23 and she was eating. V23 said she would have expected to have been notified that R1 was going that long without eating since R1 needed a liquid nutrition rather than just IV fluids for hydration. On 6/20/23 at 8:25am, V21 (Physician) said that R1 had had 2-3 episodes of aspiration. V21 said he sent R1 to a local hospital emergency room and doesn't understand if they were unable to do any kind of swallow testing, then why did they not send her to a facility where it could be done? V21 said he tried and tried to find someone to place a feeding tube with no success and finally found one and that is why they sent R1 out on 6/6/23. V21 said he did not realize that R1 went 16 days without eating and said he is not surprised about the weight loss. V21 said he doesn't know what else he could have done. V21 said that as soon as V36 made the choice of putting in the feeding tube, they called all over southern Illinois trying to get someone to put the tube in. V21 said no one from the facility asked about a bedside swallow eval to be done at the facility. V21 said he was aware the facility had Speech Therapy but did not know what their hours were. A letter dated 6/19/23 provided by V22 (Director of Operations) from V21's office and signed by V21, documents In my medical opinion, the risk of aspiration posed by conducting a bedside swallowing evaluation was greater than the risk of remaining NPO pending the swallowing study that was originally ordered. R1 was monitored while NPO for dehydration and glucose readings remained within parameters. Given her history of aspiration with resultant pneumonia maintaining her NPO status and IV therapy pending definitive evaluation and treatment of her dysphagia was deemed the safest course of action. On 6/15/23 at 9:00 AM, V22 said that they did what the physician ordered. V22 said the physician (V21) ordered R1 to be NPO. V22 said they scheduled R1 for a barium swallow on 5/30/23 but R1 did not swallow the barium. V22 said they then had an appointment for 6/8/23 and that is the soonest they could get an appointment then sent R1 out on 6/6/23. V22 said he does not know what else they could have done. R1's Care Plan documents a Care Plan Description of Nutritional Risk difficulty swallowing with a Goal of Maintain or improve weight and health status with a start date of 5/22/23. Documented interventions include: diet as ordered (start date 5/22/23), provide adaptive equipment as needed (start date of 5/22/23), weight as ordered (start date of 5/22/23), swallow eval as ordered by physician (start date of 5/22/23), NPO until swallow eval completed (start date 5/22/23), IV fluids per orders (start date of 5/23/23), transfer to (local hospital) for PEG tube placement (start date 6/6/23), and fortified pudding per orders once clearance after swallow study (start date 5/24/23). There were no orders, interventions, nor documentation in R1's medical record for a referral to the dietician, speech therapy, or orders for blood work to monitor R1's electrolytes during the 16 days that R1 was on NPO status. There is no documentation in R1's medical record that R1 received any nutrition, orally or parentally, from 5/20/23 until R1's hospitalization on 6/6/23. The facility policy titled Abuse Prevention Policy and Procedures (dated 8/16/19) documents the facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. Under the section titled Definitions, neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. b). R2's face sheet documents R2 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance, hallucinations, unspecified, Essential (primary) hypertension, bilateral transient visual loss, bradycardia, unspecified. R2's MDS (Minimum Data Set) assessment dated [DATE] documents in section C, Cognitive Patterns, a (Brief Interview for Mental Status) score of 99, indicating that an interview could not be conducted due to resident is rarely/never understood. The IDPH (Illinois Department of Public Health) Incident report labeled Final report dated 5/31/23 documents that on 5/26/23 at 11pm, V2 (Administrator) received a call from a CNA (Certified Nurse Assistant) reporting an allegation of abuse that took place between the nurse in charge and R2. V19 (LPN/Licensed Practical Nurse) was removed from the floor by V2 and asked to write a statement. Immediate assessment of residents was given by V3 (DON/Director of Nurses) with no injuries noted. Police were called and two officers arrived and interviewed V19, then viewed video footage along with the owner (V1) and interviewed R2. The nurse (V19) was suspended pending outcome of investigation. Physician, POA (Power of Attorney), Ombudsman, and police were notified. Head to toe assessment completed on R2 with no injuries noted. R2 did not recall anything happening tonight. V19 was interviewed by V1 (Owner) Administrator and police. V19 stated she was trying to keep R2 from getting all the snacks. V19 said she was following training that she had been given at a psychiatric hospital. It was explained to V19 that we do not put our arms around residents and escort them down hallways. V19 was suspended pending the investigation. The investigation determined R2 was seeking snacks from the snack cart and V19 told her to stop because she was taking all the snacks. V19 moved R2 away from the snack cart and then started to argue with R2. V19 then escorted R2 to a chair, had her sit down. R2 then attempted to obtain snacks from the nurse's cart. V19 then took R2 by the arms with her (V19) around her and led her (R2) to hallway leading to resident's room. Resident interviews were conducted with no resident reporting knowledge of incident or that they witnessed incident. Staff interviews indicate witnessing V19 arguing and escorting R2 to her hallway leading to R2's room with her arms around her. Based on employee statements, V19 interacted with R2 in an inappropriate manner, along with a direct violation of training provided to her as an employee, and facility protocols. Due to the outcome of this investigation, her (V19) employment will be terminated. On 6/14/23 at 5:45 AM, V1 (Owner) said that V19 (LPN) was holding R2 from behind with her arms around her. V1 said that V19 took R2 away from the area the snacks were in and then shoved R2 on her shoulders and walked away. V1 said that they have video footage of the incident, but cannot go back that far to view it now. V1 said that V19 was immediately fired. On 6/14/23 at 5:50 AM, V26 (CNA) said she witnessed V19 put arms around R2 and push her up the hall and was yelling at her. V26 said another staff had reported it to the Administrator. On 6/14/23 at 6:05 AM, V27 (CNA) said she was there for the incident between V19 and R2. V27 said she saw V19 put her arms around R2 and take her up the hall and was yelling at her. V27 said she felt this was wrong and she called the Administrator and reported it. The facility policy titled Abuse Prevention Policy and Procedures (dated 8/16/19) documents under the section titled Definitions, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to consistently and accurately weigh residents and ensure residents with a history of weight loss received ordered supplements with meals for 4 of 13 residents (R70, R90, R94, and R96) reviewed for nutrition status in a sample of 49. This failure resulted in R70 who had a history of severe weight loss continuing to have an 10 % (significant weight loss) in the past six months. Findings include: 1. R70's face sheet documented an admission date of 11/12/21 and diagnoses including: Alzheimer's disease, schizophrenia, generalized anxiety disorder. R70's 12/9/22 MDS (Minimum Data Set) documented a BIMS (Brief Interview for Mental Status) score of 2, indicating severe cognitive impairment. R70's Physician Orders documented: 8/23/22 order for whole milk at all meals, 8/23/22 order for add 2 butters to hot vegetables at lunch and supper, 12/31/22 order for give ice cream or sherbet at lunch and supper. R70's nutritional risk care plan start date 11/12/21 documented interventions: 8/23/22 whole milk served at all meals, 6/1/22 give ice cream or sherbet at lunch and supper, 8/23/22 add butters to hot vegetables at lunch and supper. R70's unnamed weight log printed 1/31/23 documented weights as: 2/21/22 165.0 pounds, 3/9/22 165.4 pounds, 4/10/22 154.4 pounds, 5/9/22 154.2 pounds, 6/10/22 149.8 pounds, 7/7/22 151.2 pounds, 8/15/22 148.7 pounds, 8/29/22 149.2 pounds, 9/5/22 150.6 pounds, 10/3/22 146.5 pounds, 10/10/22 144.4 pounds, 10/17/22 143.9 pounds, 10/25/22 144.9 pounds, 10/31/22 142.6 pounds, 12/10/22 140 pounds, 1/11/23 139.4 pounds, 1/29/23 136 pounds. This represents an approximate 8.54% (Significant weight loss) in the previous six months. R70's 6/29/22 progress note made by V4 Registered Dietitian (RD) documented in part .RD Wt (Weight) Note: Wt: 6/10 149.8# . resident is showing a wt loss of 9.4% in 3 months (3/9 165.4#), loss of 13.7% in 6 months (121/5 sic. (12/5) 173.6#) . remains on regular diet with ice cream/ sherbet at lunch and supper . suggest to change milk served to whole and add 2 butters to hot vegetables at lunch and supper for added calories . R70's 8/21/22 progress note made by V4 (RD) documented in part .RD Wt Note: . WT: 8/15 148.7# . resident showing loss of 10% in 6 months (2/21 165#) . remains on diet plan of regular with ice cream or sherbet at lunch and supper . at this time will suggest to please add weekly wts to monitor weight fluctuations and change milk served to whole and add 2 butters to hot vegetables at lunch and supper for added calories R70's 1/26/23 progress note made by V5 (RD) documented in part . RD Weight Review . WT- 139.4# . Resident is showing a gradual weight loss over the past 6 months (148.7# on 8/15/) . (R70) does have pertinent dx (diagnosis) of Alzheimer's and Schizophrenia, on Clonazepam and Risperidone which can affect intakes and weights . She is confused at all times, often wandering all around facility which can also contribute to weight decline (increase energy expenditure) .supplements/ supplemental foods in place to add extra calories. Current order: whole milk at all meals, 2 butters to hot vegetables at lunch and supper . ice cream or sherbet at lunch and supper . On 1/24/23 at 1:07 PM, R70 was sitting in the dining room and was served a noon time meal tray with chicken, rice, broccoli and cheese, tea, coffee, and pureed fruit. No butter or ice cream was served to R70. R70's ice cream was observed to be in a bag at the serving station with R70's name on it. On 1/26/23 at 1:16 PM, R70 was sitting in the dining room and was served the noon time meal consisting of Meat loaf, hashbrowns, green beans, dinner roll, apple sauce, lemonade, tea, ice cream, and one pat of butter open by her plate but not used. No milk was served to R70 and no butter was put on her hot vegetables. R70's 1/26/23 meal ticket documented in part ice cream or sherbet; 2 pats butter to hot vegetables . whole milk . On 1/26/23 10:58 AM, V5 (RD) said if R70 did not receive the two pats of butter to hot vegetables, ice cream, and whole milk R70 would not have received approximately 300 calories. V5 said if staff are not serving all the ordered items to residents it could contribute to weight loss. V5 said R70 has had a gradual weight loss over a period of several months. V5 said she expected all staff to follow the resident's diet orders. 2. R94's face sheet documented an admission date of 7/27/22 and diagnoses including: memory deficit following unspecify cerebrovascular disease, secondary hypertension, hyperlipidemia muscle weakness, vitamin B12 deficiency anemia. R94's 10/28/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. R94's Physician Orders documented a 1/25/23 order for 2 pats of butter to vegetables at noon and supper meals. R94's Nutritional Risk care plan with a start date of 7/27/22 documented interventions: 7/27/22 diet as ordered. R94's unnamed weight log printed 1/31/23 documented: 7/27/22 185 pounds, 8/1/22 188.4 pounds, 9/5/22 191.2 pounds, 10/10/22 184.1 pounds, 11/7/22 184.9 pounds, 12/10/22 182 pounds, 1/12/23 165.8 pounds, 1/25/23 164 pounds. R94's 1/26/23 meal ticket documented in part . 1ea (each)/ 1 tsp (teaspoon) - Dinner Roll/ Margarine . 2 pats of butter on hot vegetable . On 1/26/23 at 1:23 PM, R94's noon time meal of meat loaf, hash browns, green beans, a dinner roll, and applesauce was delivered to his room with only one pat of butter on his tray. On 1/26/23 at 1:53 PM, V7 Certified Nurse's Assistant (CNA) reviewed R94's 1/26/23 noon meal ticket with the surveyor and said R94 should have received two butters on his noon time meal tray. On 1/26/23 at 3:40 PM, V5 (RD) said on the 1/26/23 noon time meal R94 should have received three pats of butter (1 for the dinner roll and 2 on the hot vegetables.) On 1/27/23 at 2:12 PM, V4 (RD) said the intervention of adding 2 pats of butter is ensured by watching meal service. V4 said the staff member delivering the resident's tray is responsible for ensuring residents with an order for 2 pats of butter on hot vegetables has the butter delivered. On 1/31/23 at 12:06 PM, V5 (RD) was asked why there was no RD review note when R94 had a 7.1 pound weight loss (3.7%) from 9/5/22 at 191.2 pounds to 10/10/22 at 184.1 pounds V5 responded she did not know why there was no RD review. V5 said the RD will run a weight report to review all monthly and weekly weights in the facility and any changes will be captured in that report. V5 said she was not familiar with R94 and if weight fluctuations were normal and if a 3.7% loss in a month would require a RD review. R94's 1/25/23 progress note from V5 (RD) documented in part .RD Weight & Quarterly Review . Wt (weight) 165.8# (pounds) (1/12) . Resident is showing significant weight loss of 10.4% x 6 months (185# on 7/27) and 9.9% x3 months (184.1# on 10/10). Staff shared with RD an updated wt from today (1/25)- 159.6# which represents some further weight loss . Due to weight loss, would recommend starting . adding 2 pats of butter to hot vegetable sides at lunch and supper for extra calories. Monitor weights and intakes: Refer to RD as needed. R94's Progress noted dated 1/26/23 at 7:02 AM documented in part .RD reviewed weights for (R94) and suggested added 2 pats of butter to hot vegetables and health shake at Breakfast. Dr. (Doctor) notified and approved new orders. Tray card and snack list has been updated . The facility's October 2017 Therapeutic Diet policy documented in part . 2. A therapeutic diet must be prescribed by the resident's attending physician (or non- physician provider). The attending physician may delegate this task to a registered or licensed dietitian . 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet . 3. R76's face sheet documents a date of admission to the facility on 5/5/21. This same face sheet documents R76 has diagnoses including vascular dementia with behavioral disturbance, other schizophrenia, and anxiety disorder. R76's MDS (Minimum Data Set) dated 1/13/23 documents a BIMS (Brief Interview of Mental Status) score of 99, indicating R76 has severe cognitive impairment. Section G of the same MDS notes that R76's self-performance for eating is extensive assistance and support given is one- person physical assist. The same MDS notes that for transfers, walk in room, walk in corridor, locomotion on and off unit, R76's support provided is extensive assistance and one-person physical assist. R76's MDS also notes that she uses a wheelchair as a mobility device and her balance during transitions and walking is not steady, only able to stabilize with staff assistance. On 1/31/23, V1 (Administrator) said that R76 uses a wheelchair and requires staff assistance but R76 is also impulsive and will get up without asking for assistance. V1 said that R76 has an unsteady gait. R76's care plan with a start date of 5/5/21 documents a focus area of Nutritional Risk, with history of refusing some meals, diabetic, low Vitamin D. The goal listed on the same care plan is to maintain or improve weight and health status. Some of the interventions listed on R76's care plan include diet as ordered, encourage oral intake, provide non-distracting eating environment as needed, weights as ordered. R76's Physician Orders List documents an order dated 5/6/21 for LCS (low concentrated sweets), NAS (No added salt), mechanical soft diet. This document also notes an order dated 6/19/21 for weekly weights. On 1/32/23 at 9:35am, V1 said that the 6/19/21 order for weekly weights should have been discontinued and the original order should have said weekly weights times 4, then monthly, and then only back to weekly when the RD (Registered Dietician) recommends them. V1 said this is how they do all admissions. The same physician order list documents an order on 12/16/22 for whole milk with meals, add ice cream to supper and on 1/26/23 to add 2 pats of butter with hot vegetables, health shakes BID (twice daily) between meals. R76's Vital Sign Grid documents that on 1/29/22, R76 weighed 129.6 pounds (lbs) and approximately one year later on 1/25/23, R76 weighed 118 lbs. R76 was sometimes being weighed weekly and sometimes monthly during this time frame. R76's vital sign grid documents the following additional weights: 01/08/22: 129.2 lbs 01/11/22: 140.2 lbs 01/15/22: 126.4 lbs 01/29/22: 129.6 lbs 05/09/22: 131 lbs 06/10/22: 119 lbs 06/23/22: 138 lbs 07/07/22: 134.8 lbs 08/15/22: 149.1 lbs 10/29/22: 147.8 lbs 11/07/22: 123.8 lbs 11/19/22: 126.9 lbs 12/10/22: 128.3 lbs 12/26/22: 120.1 lbs 12/31/22: 116.8 lbs 01/11/23: 116 lbs 01/25/23: 118 lbs 01/29/23: 127 lbs R76's progress note written by V4 (Registered Dietician/RD) documents on 10/29/22, RD Quarterly Nutritional Review: HT (height) 63, WT (weight) 10/10 147.8#, BMI (Body mass index) 26.3 noted that HTN (hypertension), anxiety disorder, T2DM (type 2 diabetes mellitus) schizophrenia, h/o (history of) UTI (urinary tract infection) noted with medication of: Aricept, HCTZ (hydrochlorothiazide), quetiapine, ativan, levothyroxine, escitalopram, melatonin, pravastatin, metformin and others, is tolerating a diet plan of NAS (no added salt), LCS (low concentrated sweets) mechanical soft with intakes reported around 50-100%. Resident is reported to eat in the main dining area and feeds herself. Wts (weights) are showing gradual increase in the last 6 months and currently stabilizing round 147-149#, Present wt range is within desirable per BMI . at this time diet plan remains appropriate and no changes requested. Refer to RD as needed. R76's Vital Sign Grid documents the next weights after the 10/29/22 RD Quarterly Nutritional Review were on 11/7/22 (123.8 lbs) and 11/19/22 (126.9 lbs). This shows a 24 pound weight loss in 9 days, from 147.8 lbs on 10/29/22 to 123.8 lbs on 11/07/22. R76's progress note documents on 11/25/22 RD wound/wt Review: HT: 63, WT/CBW (weight/current body weight): 126.9#, BMI: 22.5 resident is reviewed related to showing significant wt loss 14.1% in last month (10/10 147.8#) and loss of 14.9% in the last 3 months (8/15 149.1), .noted wts had been fluctuating 130-150# range and at this time noted in upper 120# area diet plan remains on LCS, NAS, mechanical soft and intakes are reported around 100% of meals and fluids around 480ml (milliliters) at this time will request to please recheck wt and place resident on weekly weights. No change in diet plan at this time with intakes noted .monitor weekly wts and refer to RD as needed. There is no evidence to show that R76's weight was rechecked at this time. R76's weight grid documents that the next weight after the 11/25/22 recommendation to re-weigh her was 126.2 lbs on 11/30/22. There are no weights documented again until 12/10/22. R76's progress note by V4 dated 12/15/22 titled RD WT note documents HT: 63, WT: 12/10 128.32#, BMI: 22.8 noted that resident is showing wt loss in the last 3 months of 13.9% (8/15 149.1#) .noted diet plan of mechanical soft LCS, NAS and intakes are around 100% of meals .at this time will request to please add to weekly wts to monitor and please change milk served to whole and add ice cream to supper for added calories, continue to monitor intakes and wts and refer to RD as needed. R76's weight grid documents the next weights are as follows: 12/26/22 - 120.1 lbs, 12/31/22 - 116.8 lbs, 1/11/23 - 116 lbs and on 1/25/23 - 118 lbs. R76's progress note by V4 documents on 1/25/23 RD weight/Wound & Quarterly Review: HT: 63, Wt: 116.0#, BMI: 20.55 Resident showing significant weight loss of 13.9% x(times) 6 months (134.8# on 7/7) and 21.5% x3 months (147.8# on 1010/22) .resident remains on LCS, Mech soft diet with thin liquids. She feeds herself with meal intakes averaging 75-100% per record. For extra calories, resident receives whole milk at meals and ice cream at supper. Per discussion with staff, resident is very active. Self propels in wheelchair all around facility. Amount of activity is likely contributing to weight decline and increasing R76's needs .would recommend adding extra 2 pats butter to hot vegetable sides at lunch and supper and start health shake as snack between meals at 10am & 2pm. Continue rest of nutrition plan monitoring weights and intakes. RD will follow routinely but please consult as needed. R76's diet card dated 1/26/23 documents LCS (low concentrated sweets), dental soft (mechanical soft), thin liquids. The same diet card also notes milk - 4 fluid ounces (oz), #8 dip - Ground Meatloaf w/ (with) gravy. #8 dip/2oz gvy (gravy) - Mashed potatoes and gravy, 4oz spdl (spoodle) - soft country cooked country chpd (chopped) [NAME] Beans - No bacon, 1 ea (each)/1 tsp (teaspoon) - Dinner Roll/margarine, 4oz spdl - cinnamon peaches, 1 cup diet beverage. Additional notes on R76's diet card list to add ice cream, 2 pats butter to hot vegetable, whole milk. On 1/26/23 at 12:15pm, R76 was noted to propel herself to the dining table and remained at the table until her meal was served at 12:30pm. At 12:30pm, R76's meal tray was noted to have cut up meatloaf with no gravy, mashed potatoes with no gravy, green beans without 2 pats of butter, and no dinner roll with margarine. R76 was observed at this time to consume 100% of her meal. On 1/26/23 at 12:30pm, when questioned about R76's diet card, V7 (CNA/Certified Nurse Assistant) stated that they were out of gravy and then went to get 2 pats of butter and put this on R76's vegetables. No dinner roll with margarine was ever brought back to R76. On 1/26/23 at 12:35pm, V6 (CNA) said they frequently do not go by the menu. She stated if they are out of something, they substitute it. V6 also said that R76 almost always consumes 100% of her meals and they document her intakes with every meal. On 1/26/23 at 11:17am, V1 (Administrator) stated that the process for weighing residents is that the weekly weights have to be done by Sunday. V1 said that the weights are then sent to the nursing director, and they are reviewed. V1 said if there are any weights that are really off, they have staff go re-weigh them. V1 said the problem with the weights being off is that V4 (Registered Dietician) thought she would be helpful and enter them without sending them to the nursing director, and that lead to missing weight loss and residents not getting re-weighed. On 1/27/23 at 2:12pm, V4 said she can't explain (R76's) 24-pound weight loss in 1 week. V4 said if there is a weight really off, she would ask for them (residents) to be re-weighed. V4 said she would not know if weekly weights were not being done usually until the next month when she comes back. V4 said in her notes she says refer to RD if needed and therefore would expect the facility to let her know of the weight. V4 said there are a lot of variances with being weighed .type of scale, location, whether they have had a bowel movement, the time of day. V4 said she looks at a trend with weights and if she notices a weight off, she would ask for a re-weigh and if not she would make a recommendation. On 1/31/23 at 8:35am, V1 stated that R76 is eating all the time and gets a lot of snacks. V1 said there is no way R76 lost that much weight in a week (in reference to the 24- pound loss from 10/29/22 to 11/7/22) and should have been re-weighed. V1 stated that they use a wheelchair scale on side 2. It can also be used as a standing scale. V1 said she believes the problem with (R76's) big weight loss in 1 week is due to staff not subtracting the wheelchair when they weigh residents. 4. R96's facility Face Sheet with a print date of 1/27/23 documents R96 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, anxiety disorder, and nutritional deficiency. R96's MDS (Minimum Data Set) dated 8/19/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R96 is cognitively intact. R96's current Care Plan dated 8/19/22 documents a focus area of At risk for fluid imbalance/weight loss. This same care plan includes the following interventions, weights as ordered (8/19/22), two butters to hot vegetables at lunch and supper (8/23/22), whole milk with meals (11/9/22), house shakes with ice cream at 10am, 2pm, and 6pm (11/9/22), add ice cream to lunch and supper (11/9/22), double portions at meals (11/9/22), Boost drink (11/9/22), mirtazapine as ordered for appetite (1/4/23). R96's progress notes documents on 11/26/22, RD (Registered Dietitian) QUARTERLY REVIEW: HT (height): 68, WT (weight)/CBW (calculated body weight): 121.5# (pounds), BMI (Body Mass Index): 18.5 noted resident for quarterly nutritional review and at this time with dx (diagnosis) of pancreatic cancer w/ s/p (with status post) wipple procedure, COPD (chronic obstructive pulmonary disease), anxiety disorder, depression, HTN (hypertension). medications include: selenium, venlafaxine, bupropion, and others. currently on po (oral) diet plan of regular with thin liquids, whole milk at meals, ice cream at lunch and supper, 2 pats butter to hot vegetables at lunch and supper, double portions at meals along with house shakes with ice cream at 10a/2p/8p. intakes of meals currently 50-75% with fluids around 480 ml (milliliter). noted as of 11/9 tube for feeding was removed. resident wt is to be monitored weekly. at this time wts are showing progressive gain since removal of tube from 116.2# on 11/9 to present wt of 121.5#. no skin or lab concerns reported. also informed that daughter provides resident boost shakes and other snacks for her to keep in her room . at this time no change in diet plan. continue with weekly wts and refer to RD as needed. R96's Progress Notes dated 12/08/22 documents, Wound and weight meeting held today. Current weight is 120.9 which is a 1 lb gain from last weight. Current diet is regular with whole milk at meals, ice cream with lunch and supper and health shakes at snack time three times daily. She eats meals in her room independently. Family has provided snacks to keep in her room. She has recently started PT (Physical Therapy) and is more physically active. She will remain on weekly weight monitoring at this time. (Name of physician and family member) are aware of current weight, diet, and treatment plan. R96's progress notes document on 1/25/23 RD WEIGHT REVIEW: Ht (height)-68, Wt (weight)-112.0#, BMI- 17.03. Resident is showing significant weight loss of 7.9% x3 months (121.6# on 10/10) and 7.4% x1 month (120.9# on 12/5). Resident's PMH (past medical history) includes pancreatic cancer s/p wipple procedure, COPD, anxiety disorder, depression, HTN. Hx (history) of J-tube for supplemental tube feedings- removed 11/9 due to consistent tolerance of PO (oral) diet . No wounds/skin issues. (R96) continues on regular diet as tolerated with thin liquids. She (R96) feeds herself, typically eats in her room and meal intakes vary with average 25-75%- best at supper. She (R96) has reported a poor appetite. She is receiving a variety of supplements and supplemental foods to support her weight. Current orders: whole milk at meals, ice cream at lunch and supper, 2 pats butter to hot vegetables at lunch and supper, double portions at meals, and house shakes with ice cream at 10a/2p/8p. In addition, her daughter brings in snacks and Boost shakes for resident to keep in her room. Due to resident's weight loss and report of poor appetite, she was started on Mirtazapine on 1/4. She feels it is starting to help her feel more hungry and her intakes are showing some improvement. Feel that current nutrition plan is appropriate to support resident's weight, especially with initiation of appetite stimulant. Continue to monitor weights and intakes; RD will follow routinely but please consult as needed. R96's untitled weight report printed 1/27/23 includes the following weights, 8/21/22- 119.4 lbs. (pounds), 9/5/22- 118.0 lbs., 10/04/22 - 120.6 lbs., 11/07/22- 120.2 lbs., 12/27/22 - 113.2 lbs., 1/11/23 - 112.0 lbs., and 1/25/23 - 114.0 lbs. R96's Vital Signs Grid with a print date of 1/31/23 include the following weights, 11/14/22 - 118.9 lbs., 11/26/22 - 121.5 lbs., 11/28/22- 119.9 lbs., 12/05/22 - 120.9 lbs., 12/10/22 - 120.8 lbs., 12/17/22 - 115.3 lbs., 1/2/23 - 112 lbs., 1/11/23 - 112 lbs., 1/29/23 117 lbs. This indicates R96 had a weight loss of 7 pounds (5.8%) from 11/07/22 to 12/27/22 and weight gain of 5 pounds (4.09%) from 1/11/23 to 1/29/23. On 01/24/23 at 9:30 AM, R96 was observed sitting on the side of her bed with a meal tray on her bedside table. R96's tray had partially eaten scrambled eggs and a whole piece of sausage. R96's meal tray also had a bowl of mostly eaten dry cereal. There was a small cup of thick milk shake type drink on R96's tray. There were no other glasses located on R96's meal tray or bedside table. R96 stated she had weight loss, but they had started her on an appetite stimulant. When asked if she preferred to eat her cereal dry without milk, R96 stated she doesn't always get served milk and sometimes she has to ask for it. R96 stated if she asks for it the staff will say they will get it and then never come back. R96 stated she was not served any liquids with this meal other than the shake type drink. On 01/24/23 at 12:59 PM, R96 was served chicken, rice, broccoli with cheese, oranges, and tea. There was no milk on R96's tray. R96 asked for milk and unknown staff returned with a glass of milk. There was no ice cream observed on R96's meal tray. On 01/27/23 at 08:30 AM, R96 was observed sitting on the edge of her bed with a partially eaten breakfast tray in front of her. R96 was eating dry cereal with no milk. There was an empty glass observed on R96's meal tray that appeared to have had milk in it. When asked if she was served milk R96 stated she was but she had drunk it, since she was thirsty. R96 stated they had forgotten to bring her milk at supper on 1/26/23. When asked if she would like milk for her cereal R96 stated she would. This surveyor reported to the nursing staff passing meal trays R96 would like some milk for her cereal. R96's undated meal ticket documents R96 is to be served a regular diet with 2 pats butter to vegetable (lunch and supper), double portions to meals. Under Notes the same meal ticket documents, Send ice cream with empty glass, whole milk, 2 pats of butter on hot vegetables, double portions, whole milk all meals. R96's Physician Orders dated 01/2023 includes the following dietary orders, 8/20/22- regular diet as tolerated, 8/23/22- whole milk with meals, 11/09/22- add ice cream to lunch and supper, and mirtazapine 15 milligrams once daily. On 01/26/23 at 3:42 PM, when asked why R96 was not served milk and/or ice cream, V1 (Administrator) stated, I don't know. I didn't serve her meals. When asked if she would expect R96 to be served ice cream and milk as recommended by the dietitian V1 stated, It should have been served. On 01/26/23 at 3:08 PM, V4 (Dietitian) stated R96 is to have whole milk served at all meals. V4 stated R96 is to have ice cream served at lunch and supper and then a health shake with ice cream at 10 AM, 2:00 PM, and 6:00 PM. This surveyor reviewed with V4 observations of breakfast on 1/24/23 with no milk served to R96 and lunch on 1/24/23 when R96 had to ask for milk and was not served ice cream. When asked if not getting her supplements as recommended would have an impact on R96's weight, V4 stated the supplements would provide extra calories but it could be a combination of factors causing the weight loss. V4 stated they would have to investigate further to determine if that was causing the weight loss. On this same date at this same time, V5 (Dietitian) stated she was aware of R96's weight loss and that an appetite stimulant had been started. V5 stated R96's weights were trending up since starting the stimulant. 01/31/23 at 9:28 AM, V1 (Administrator) stated when she spoke with R96 in December 2022, related to her weight loss, R96 reported she didn't have an appetite. V1 stated they contacted R96's physician and he gave them an order for an appetite stimulant that wasn't covered by R96's insurance. V1 stated then they contacted the physician a second time for a different appetite stimulant. V1 stated that is when mirtazapine was ordered. On 1/26/23 at 12:40pm, V6 (CNA) said that when they weigh a resident, they use the wheelchair scale. If a resident is able to walk they stand on it, if not they push the resident in the wheelchair on the scale. V6 said they have to subtract the weight of the wheelchair after weighing a resident in a wheelchair.