**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a newly admitted resident on tube feeding was weighed weekly. This failure resulted in R125 losing 16.8 pounds (11.4% weight loss) in 18 days. The facility failed to monitor weights, assess residents who have had a significant weight loss and implement interventions to prevent further weight loss. This failure resulted in R20 losing 12.6 pounds (7.67% weight loss) in 1 month and R231 losing 10.2 pounds (6.6% weight loss) in 13 days. This applies to 3 of 5 residents (R20, R125 and R231) reviewed for nutrition in the sample of 26. The findings include: 1. R125's Face Sheet shows that he admitted to the facility on [DATE] with diagnoses of: severe protein-calorie malnutrition, gastrostomy, dysphagia and parkinsonism. R125's Physician's Order Sheet (POS) printed on 11/20/24 shows an order dated 10/24/24 for, Weekly weights x 8 weeks . The POS shows orders for NPO (nothing by mouth) and an order for enteral feeding. R125's Nutritional Risk assessment dated [DATE] shows, admitted with diagnosis of metabolic encephalopathy, osteomyelitis of left ankle and foot He is NPO d/t [due to] dysarthria and on new peg tub for enteral feeding .Wife denies any notable significant changes to weight in past month .at risk for unintended weight loss .dehydration pressure injury weight goal-weight will be maintained +/- 5% or gain by review Interventions: Monitor weight weekly for 8 weeks and then monthly or as indicated .Additional Comments: Will continue to monitor weight, TF (tube feeding) tolerance and intervene as needed. RD (Registered Dietitian) available for consult PRN (as needed). R125's Weights and Vitals Summary printed 11/20/24 shows a weight of 147.8 pounds on 10/24/24 and a weight of 131 lbs on 11/11/24 (11.4% weight loss in less than a month). There are no other documented weights between 10/24/24 and 11/11/24. On 11/20/24 at 9:22 AM, V4 (Registered Dietitian) said that all new admissions are weighed upon admission and then weekly to monitor for weight loss or gain. V4 said that any one who is triggered to be at high risk for weight loss have weights done weekly. V4 said that if a resident is on tube feeding, they are at high risk for weight loss and their weights should be closely monitored. V4 said that she saw R125 when he first arrived at the facility. V4 said that he was admitted with continuous tube feeding orders so she changed the rate and time frame so he did not have to be on continuous feedings but would still get the same amount of calories and nutrition. V4 said that R125 did not have any documented weights for some time and she is not sure why. V4 said that once R125 got a weight done, it showed a weight loss so she increased his tube feeding rate. V4 said that weekly weights would have helped identify a weight loss sooner so interventions could have been implemented to prevent further weight loss. The facility's Nutrition-Hydration-Weight-Assessment and Intervention Policy revised on 1/27/22 shows, The facility shall measure resident weights on admission, for the next two days, and weekly for 4 weeks thereafter .Weights are recorded in the resident's medical record .Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, the dietitian shall be notified, and the notification documented in the resident's medical record. The dietitian will respond within 24 hours of notification .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month-5% weight loss is significant; greater than 5% is severe . 3. R231's face sheet shows she is an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with diagnoses including fracture of left pubis, type 2 diabetes, unspecified dementia, muscle weakness, hypertension, osteoporosis, and history of failing. R231's Weight Report for November documents: 11/6/24 -154.5 lbs, 11/7/24 - 147.5 lbs and on 11/19/24 - 144.3 lbs. R231's weights show that she had a significant weight loss of 10.2 pounds (6.6%) in 13 days. R231's Mini Nutritional assessment dated [DATE] shows a score of 6 indicating she is malnourished. R231's Diet card shows a regular diet, all meals milk only; no juice or coffee. R231's Nutrition Risk assessment dated [DATE] documents she is on a regular diet, requires set assistance, partial moderate assistance with feeding, fair appetite, (R231) reports not eating very much, (V8 R231's spouse) reported her intake of about 30%, she reported not being able to choose foods. (R231) is at risk for unintended weight loss due to malnourished score of 6, poor appetite, bed bound, and assistance with feeding. On 11/18/24 at 1:12 PM, R231 was lying in her bed, she said I'm hungry. V8 was in the room and said lunch usually comes between 1:00 PM to 1:30 PM. At 1:30 PM, the noon meal was not delivered. At 1:48 PM, V8 was upset R231's noon meal was not delivered yet. He said my wife is hungry. On 11/19/24 at 9:51 AM, R231 was in her room eating her breakfast meal. Her meal ticket said milk with all meals. There was no milk on her tray, she had a cup of orange juice and coffee. V13 (Unit Manager) entered the room and said to R231, where is V7 (Certified Nursing Assistant) she was in here helping you. On 11/19/24 at 12:56 PM, V7 (CNA) said R231 is alert and forgetful, she is two person transfer with a mechanical lift. She needs to be set up for meals, this morning she encouraged her to feed herself and she was able to do it so she left the room. R231 told her she was hungry and wanted her lunch before therapy. At 1:00 PM, therapy arrived to R231's room she had not been served lunch yet. On 11/20/24 at 12:35 PM, V4 (Dietitian) said R231 came in with pelvic fracture and was sent out to the hospital and re-admitted . Staff should weigh residents on admit and re-admission. V8 reported to her R231's normal weight is about 150 pounds. R231 was not weighed when she was re-admitted on [DATE], her initial weight on admission was 154 pounds we re-weighed her a day later and she was 147 pounds. On 11/19/24 her weight was 144 lbs. She has lost weight and she recommended nutritional shakes and protein in between meals. If a resident is voicing they are hungry staff should notify us so we can accommodate an earlier meal. She did not know R231 was requesting her meal to be delivered before therapy. 2. On 11/19/2 at 10:41 AM, R20 was being served breakfast. Both V9 and V10 (Certified Nursing Assistants-CNA) said R20 is a total feed so she was served at a later time during meals. Review of R20's weights shows: 9/3/2024-169.0 pounds (lbs.), 10/1/2024-170.1 lbs and on 11/14/2024-157.5 lbs. R20's weights show that she had a significant weight loss of 12.6 pounds (7.67%) in 1 month. R20 had no nutritional assessments or nutritional intervention related to this significant weight loss. On 11/20/24 at 9:13 AM, V4 (Dietitian) said R20 was weighed last on 11/6/24 and her weight was totally different from her usual weight. V4 said on 11/7/24 she requested a reweigh. On 11/14/24, R20's reweigh was 157.5 lbs. V4 said she did not know why the reweigh was not done until after a week. V4 said she was also not made aware of R20's reweight results sooner. V4 said when she entered R20's latest weight of 157.5 lbs, it did not trigger a significant weight loss until it was brought to her attention by this surveyor. V14 said she will do nutritional assessments and recommendations today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to report adverse side effects immediately, failed to monitor the use of psychotropic medications, and failed to carry out the orders to hold medication for a resident showing signs of adverse effects of excessive drowsiness. This failure resulted in R1 being sent out to the hospital for evaluation for stroke like symptoms. This applies to 1 of 3 residents (R1) reviewed or unnecessary medications in the sample of 5. The findings include: R1's face sheet shows she is [AGE] year-old female with diagnosis including somnolence (excessive drowsiness 8/15/24), altered mental status (8/15/24), unspecified dementia with other behavioral disturbance, heart disease, delusional disorder, anxiety disorder, unspecified hearing loss, vascular dementia with psychotic disturbance, mood (affective) disorder, and glaucoma. R1's hospital Records dated 8/15/24 documents [AGE] year-old female with a history of vascular dementia and behavioral disturbances presents with acute encephalopathy and lethargy likely suspect due to polypharmacy. R1's hospital discharge medication list dated 8/16/24 shows a decrease dose in her psychotropic medications including Depakote 125 mg (milligrams) two capsules three times a day and Seroquel 50 mg twice a day. On 8/22/24 at 9:19 AM, R1 was observed in her lying in bed. R1 was yelling and calling out from her room. V7 (Registered Nurse/RN) entered the room to assist R1, using the communication board to ask R1 what she needed. R1 was not able to verbally express her needs to V7. R1 was on the call light frequently and yelling when staff left the room. At 9:54 AM, V9 and V10 (Certified Nursing Assistant's-CNA's) provided care to R1 including incontinence care and transferring her from the bed to the wheelchair using a mechanical lift. R1 did not display behaviors of aggression, combativeness, and was compliant with all cares. On 8/22/24 at 9:38 AM, V7 (RN) said R1 has behaviors of combativeness and agitation. She was hospitalized in June and sent to behavioral health. She had a change in her psychotropic medications due to lethargy. She has been okay since her dose was decreased. She still has some behaviors of yelling out and screaming, but is more awake. If a resident is showing adverse effects from the medication, nursing should hold the medication and notify the physician. On 8/26/24 at 8:57 AM, V5 (Unit Manager) said R1 is alert, confused, and has behaviors of crying, screaming, restlessness, agitation, and combative during cares. Lately she has periods of sleepiness in the late morning towards noon, after lunch she is more awake. She has difficulty expressing her needs. On 8/15/2, V16 (R1'sdaughter) came to visit and was upset how R1 was sleepy, difficult to arouse, and drooling. V16 was concerned her mom had a stroke. She explained to R1's daughter, V15 (Psych Nurse Practitioner) assessed R1 yesterday and there were new orders to hold the psychotropic medications (Seroquel 100 mg and Clonazepam 0.5 mg) if R1 was lethargic. She went in the room and called out R1's name. R1 opened her eyes but could not keep them open. R1 usually feeds herself; that day she needed assisting with meals. R1 was receiving three psychotropic medications scheduled three times a day including Depakote 375 mg, Seroquel 100 mg, and Clonazepam 0.5 mg. R1 was hospitalized for behaviors in mid-June and returned to the facility on July 3rd with increased doses of her psychotropic medications. R1 was sent out to the hospital for evaluation for stroke symptoms and CT's showed negative for a stroke. Psychotropics can cause sleepiness and R1 was not tolerating the doses of the psychotropic medications. If a resident is showing signs of adverse effects, nursing should hold the dose and notify the physician on onset of the changes. On 8/26/24 at 9:32 AM, V4 (RN Agency) said she was R1's nurse on 8/15/24. She is an agency nurse, and it was her first time caring for R1. Around lunch, a lady V16 (R1'sdaughter) came up to me and asked if she was R1's nurse and to come to the room. When she went to R1's room. R1's daughter was upset and crying, she said look at her, this is not my mother. R1 was sedated and drooling on herself, she was not able to eat because she was knocked out. The night nurse reported if R1 is too sedated to hold the antipsychotic medication. When she looked at the medications R1 was scheduled to receive, Depakote 375 mg, clonazepam 0.5 mg and Seroquel 100 mg three times a day. She was thinking why is R1 on so much medication. She gave what was scheduled, I have nothing to base it off, I felt terrible I gave the medications too. She questioned it, but she did not know the resident. R1's daughter requested to have her sent out to the hospital. She gave the morning dose and said she could not recall if she gave the afternoon dose, If it was scheduled I must have given the medications to her, I could have given the medications. On 8/26/24 at 1:15 PM, V2 (Director of Nursing) said staff should be monitoring the resident for side effects of psychotropic medications. Increased sleepiness is the first side effect of these medications. Nursing should hold the medication and notify the physician immediately. She confirmed the order to hold the medication did not reflect on R1's Medication Administration Record (MAR) on 8/15/24 for the morning and afternoon dose. R1 was sent out to the hospital and returned to the facility with a decreased dose in her psychotropic medications. R1's nurses note dated 8/6/24 documents medication at lunch held, R1 lethargic not able to feed herself. (There was no documentation the physician was notified). R1's nurses note dated 8/12/24 documents, R1 very sleepy refusing to eat lunch, afternoon medication held, not able to take medication. (There was no documentation the physician was notified). R1's nurses note dated 8/14/24 documents, R1 refused to eat breakfast, took morning medications. She refused to eat lunch, lethargic, noon medications held. R1 seen by V14 (Psych NP) new orders in place. R1's nurses note dated 8/14/24 documents, R1 refused to eat dinner, Seroquel 100 mg held this evening due to lethargy. R1's Psych NP note dated 8/14/24 documents asked to R1 for increased sleepiness for the past two days. R1 encountered in the wheelchair moaning to tactile, did not open eyes. Discussed with NOD (nurse on duty) will hold clonazepam and Seroquel when drowsy/sleepy. R1's nurses note dated 8/15/24 by V4 documents R1's daughter visibly upset about mother's mental status. R1 sitting up in wheelchair increased lethargy, right sided mouth drooling and upper extremity weakness. R1 drowsy and unable to respond to verbal stimuli. R1's daughter expressed this is not her normal behavior. R1 observed increased sedation post am scheduled medications. R1 sent out to the local hospital. R1's V16 (Nurse Practitioner) note dated 8/15/24 documents R1 seen for lethargy, R1 agitated this morning, poor appetite, more sedated now. Somnolent (excessive drowsiness), opens eyes briefly, nonverbal, acute somnolent worsening; ER for evaluation, R1's Medication Administration Record dated August 2024 shows orders for clonazepam 0.5 mg give one tablet three times a day for anxiety; Seroquel 100 mg one tablet three times a day for unspecified mood affective disorder (the orders do not show to hold if sleepy/drowsy on 8/15/24 for the am and pm dose). R1's MAR shows on 8/15/24; Seroquel 100 mg and Clonazepam 0.5 mg was documented given for the am and afternoon dose. R1's MAR shows orders for antipsychotic medication monitor for dry mouth, constipation, blurred vision, disorientation, confusion, lethargy, drooling, difficulty urinating .start date of 8/17/24 (after hospitalization). The facility's Psychotropic Medication Policy states, Psychotropic medications include any drug that affects brain activities associated with mental processes and behavior physicians and physician extenders (Physician Extender and Nurse Practitioner) will use psychotropic medications appropriately, working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring .monitoring psychotropic drug use daily, noting any adverse effects such as increased somnolence or functional decline .