**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R15's Face Sheet, dated 08/01/24, documents R15 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, chronic kidney disease stage 3, major depressive disorder, anxiety, hyperlipidemia, and constipation. R15's Care Plan, with a revised date of 05/15/24, documents a focus area of ADL (Activities of Daily Living) function rehab: dependent for ADL's- assists only minimally. Not a candidate for restorative programming. Further decline in ability/participation likely due to cognition and end of life care. Documented interventions include serve diet as ordered and tolerated, see POS (Physician Order Sheets) or tray card for current diet, set up tray per R15 preference, feed R15 meal, record intake for each meal offer subs for foods not eaten. R15's Care Plan also documents a Focus area of Nutrition: the resident has a potential nutritional problem r/t (related to) dementia. Documented interventions include provide and serve supplements as ordered, provide, serve diet as ordered, monitor intake and record every meal, RD (Registered Dietitian) to evaluate and make diet change recommendations PRN (as needed). R15's Order Summary Report, dated 8/1/24, documents active orders of regular diet, mechanical soft texture, nectar/mildly thick consistency, dated 9/14/23, may participate in meal of the month, special occasion and holiday meals, using diet consistency, Lip plate for all meals, Supercereal at breakfast, Magic cup (Nutritional Supplement) at lunch and supper dated 8/23/23, 2.0 calorie Supplement three times a day 90 cc (cubic centimeters) dated 4/2/24, and Hospice care/services, dated 7/18/23. R15's Minimum Data Set (MDS), dated [DATE], documents in Section C, a Brief Interview for Mental Status (BIMS) score of 03, indicating R15 has severe impaired cognition. Section GG documents R15 is dependent for eating. R15's weight summary documents the following weights: 02/16/24 125.6 lbs. (pounds), 03/05/24 123.2 lbs., 04/02/24 118.8, 05/09/24 116.0 lbs., 06/03/24 114.9 lbs., and 07/04/24 116.5 lbs. On 07/29/24 at 11:50AM, R15 was served mechanical soft pork fritter, mashed potatoes with gravy, green beans, peaches with nectar thickened juice and water. There was no magic cup (Nutritional supplement) observed on R15's tray. On 07/30/24 at 11:45AM, R15 was served mechanical soft turkey, mashed potatoes with gravy, mixed vegetables, cobbler, nectar thickened water and juice. There was no magic cup (Nutritional supplement) observed on R15's tray. On 08/01/24 at 9:34AM, V3 (Dietary Manager) stated no resident on 07/29/24 and 07/30/24 received a nutritional supplement at lunch. V3 stated V27 (Dietary Aide) told her she forgot to send out the nutritional supplements on 07/29/24 and 07/30/24 at lunch. V3 said V27 talked to her about it, and told her she forgot the nutritional supplement both days at lunch meal. V3 said she educated V27 about making sure they are served. V3 said all residents who are to receive the nutritional supplement should have received them. V3 said R15 should have received her nutritional supplement, but stated she doesn't eat the nutritional supplement a lot. V3 stated R15 receives nutritional cereal at breakfast, and if R15 doesn't eat well, they will make her the nutritional cereal at lunch and supper as well. V3 said she knows R15 has had a weight loss, but R15 is on hospice care, and it is expected for her to lose weight. On 08/01/24 at 9:40AM, V27, (Dietary Aide) stated she did not serve any resident a nutritional supplement on 07/29/24 and 07/30/24 at lunch meal. V27 said on 07/29/24 she was nervous with serving, and she forgot all about the nutritional supplements. V27 stated on 07/30/24, the day was very crazy, and she didn't think about the nutritional supplement at all. Based on observation, interview, and record review, the facility failed to provide nutritional supplementation as recommended for three (R3, R15, and R4) of six residents reviewed for nutrition in a sample of 27. This failure resulted in significant weight loss for R3. Findings include: 1. R3's face sheet documents an admission date of 02/19/2024, with diagnoses including: acute kidney failure, chronic atrial fibrillation, chronic venous hypertension with inflammation of bilateral lower extremity, anxiety disorder, hyperuricemia without signs of inflammatory arthritis and tophaceous disease, malignant neoplasm of colon, type 2 diabetes mellitus without complications, and osteoarthritis. R3's Care Plan documents a focus area titled Nutrition, dated 04/24/24, documents: the resident has potential nutritional problem r/t (related to) diet restrictions with an intervention dated 02/27/24 stating: RD (Registered Dietician) to evaluate and make diet change recommendations PRN (as needed). R3's Dietician Review, dated 03/22/24 at 10:05 AM, documents: risk factors for weight loss may include advanced age and restrictive diet order, BMI (Body Mass Index) is calculated as 22.8. BMI evaluation is > 65 y/o (years old), underweight (<23.0) factors affecting nutritional needs include: intake is fair-good, stage 3 wound left buttocks, left hip surgical wound, stage 2 wound coccyx, own teeth, ambulatory/wheelchair, normal weight, independent, alert, advanced age. (V14) (Regsitered Dietician/RD) reviewed evaluation of current condition includes: nutrition/weight does not require additional diagnosis at this time. Additional recommendations may be necessary. 2020 calories, 88 grams protein - 1.2 g/kg, 2020 ml fluids - 1 ml/calorie. V14 (RD) initial assessment. R3's Nutrition/Dietary Note, dated 05/24/24 at 10:44 AM, documents, Note text: weight loss note: Ht (height): 66 in (inches), wt (weight): 112 lbs (pounds) (mechanical lift) BMI (body mass index): 18.1 indicates underweight. admission weight was 141.2 lbs (wheelchair). This indicates a weight loss of 21.1% (30 lbs) x 2 months. Spoke with (V3, Dietary Manager) regarding inconsistent weight methods. States that current weight seems accurate. Will monitor next month weight to assess weight trends. Current diet: CCD (consistent carbohydrate diet)/NAS (no added salt), regular texture and regular liquids, intakes are mostly 76-100% per documentation, feeds self, no reports of chewing/swallowing difficulties. Meds (medications), labs, and skin reviewed above. Pt (patient) has multiple wounds - stage 3 to left buttock, stage 2 coccyx and surgical wound. Per (V3) pt refuses supplements. Supplements recommended due to skin breakdown and weight loss. Goals: 1. Maintain adequate nutrition/hydration, 2. stable wt/<5% change within 1 mos (month) period, 3. Labs acceptable to MD (medical doctor) 4. Improved wound healing. Plans: 1 continue CCD-NAS/Reg (regular)/thin liquids. 2. Provide extra oz (ounce) protein with meals to aid with wound healing. 3. Monitor wt intake, labs, and skin 4. Refer to RD (Registered Dietician) PRN (as needed). R3's Nutrition/Dietary Note, dated 06/21/24 at 10:37 AM, documents, Note text: weight loss follow up/wound Note: Ht: 66 in, Wt: 110.4 lbs (mechanical lift) BMI: 17.8 indicates underweight. admission weight was 141.2 lbs (wheelchair). This indicates a weight loss of 21.8% (30 lbs) x 4 months. Current diet: CCD/NAS, ground meat and regular liquids, intakes are mostly 76-100% per documentation, feeds self, no reports of chewing/swallowing difficulties. Meds, labs, and skin reviewed above. Pt has multiple wounds - stage 3 to left buttock, stage 2 coccyx and surgical wound. Per (V3) pt refuses supplement. Supplements recommended due to skin breakdown and weight loss. Goals: 1. Maintain adequate nutrition/hydration, 2 stable wt/<5% change within 1 mos period, 3. Labs acceptable to MD 4. Improved wound healing. Plans: 1 continue CCD-NAS/Reg /thin liquids. 2. Provide extra oz protein with meals to aid with wound healing. 3. Monitor wt intake, labs, and skin 4. Refer to RD PRN. R3's Nutrition/Dietary note, dated 07/19/24 at 11:51 AM, documents, Note text: weight loss follow up/wound note: Ht:66 in, Wt: 110.4 lbs (mechanical lift) BMI: 17.8 indicates underweight. No weight for July. Current diet: CCD/NAS, ground meat and regular liquids, intakes are mostly 76-100% per documentation, feeds self, no reports of chewing/swallowing difficulties. Meds, labs, and skin reviewed above. Pt has multiple wounds - stage 3 to left buttock, stage 2 coccyx and surgical wound. Per (V3) pt refuses supplement. Supplements recommended due to skin breakdown and weight loss. Goals: 1. Maintain adequate nutrition/hydration, 2. stable wt/<5% change within 1 mos period, 3. Labs acceptable to MD 4. Improved wound healing. Plans: 1 continue CCD-NAS/Reg /thin liquids. 2. Provide extra oz protein with meals to aid with wound healing. 3. Monitor wt intake, labs, and skin 4. Refer to RD PRN. R3's Order Summary Report, dated 8/1/24, under Dietary orders document active orders of regular diet, ground meat texture, regular/thin consistency, dated 04/24/24 and carb controlled diet/ no added salt, dated 3/14/24. There was no order for added protein noted on R3's Order Summary Report. The facility document titled, week 3 Monday documents: mechanical soft diet: 1 each ground pork fritter with gravy, sauce, 4 ounce scalloped potatoes, 4 ounces green beans, and 4 ounces peaches. On 07/29/24 at 12:10 PM, R3 received a #10 scoop (3.25 ounces) of ground pork fritter, R3 did not receive the extra ounce of protein with his meal. R3's dietary card did not document extra protein for R3. On 07/29/24 at 12:21 PM, V6 (Cook) stated they substituted mashed potatoes for the scalloped potatoes and the #10 scoop is what is listed for the mechanical soft residents to receive for the pork fritter. The facility document titled, week 3 Tuesday documents: mechanical soft diet: 3 ounces ground roast turkey with gravy, 2 ounces poultry gravy, #8 scoop mashed potatoes, 4 ounces Brussel sprouts, 1 each moistened roll/margarine, # 12 scoop warm blueberry cobbler. On 07/30/24 at 12:05 PM, R3 received 3 ounces of ground turkey. R3 did not receive extra protein with his lunch. The facility document titled, week 3 Wednesday documents: mechanical soft diet: 6 fluid ounces choice of juice, 1 serving moistened choice of cereal, 2 each eggs, 1 each soft cinnamon rolls with icing, 8 fluid ounces milk. On 07/31/24 at 8:12 AM, R3 received cereal and a cinnamon roll for breakfast. There were no eggs observed on R3's tray. R3's food intake record documents on 07/31/24 a 3 for breakfast indicating R3 consumed 75 - 100% of R3's breakfast. The facility document titled, week 3 Thursday documents: mechanical soft diet: 6 fluid ounces choice of juice, 1 serving moistened choice of cereal, 1 slice sausage breakfast pie with gravy, 1 slice softened toast, 1 teaspoon margarine/jelly, and 3 fluid ounces milk. On 08/01/24 at 8:04 AM, R3 received 2 sausage links and toast for breakfast. There were no eggs observed on R3's tray. On 07/29/24 at 1:17 PM, R3 stated, The food is horrible here. I will leave a note to tell staff to put my food on the table and wake me up if I'm sleeping and they will not do it. I will wake up and my food is sitting there and is cold, and it is already bad enough. The scrambled eggs are horrible, they are watery and make with that liquid egg stuff. The fried eggs are ok sometimes, sometimes they are brown, who knows what kind of oil they are using back there to cook with. Sometimes the omelets are ok, and sometimes not, it is not hard to make an omelet or fry an egg. R3 said he does not know where the cook learned to cook, but it's not right. He stated some of the food here is tough and he cannot chew it, he has no teeth, what do they expect? He eats what he can deal with. He feels like they are trying to starve him here, he is used to eating more. R3 was alert to person, place, and time. On 08/01/24 at 8:07 AM, V15 (Certified Nurse Aide/CNA) stated R3 did not get the eggs that were served because he does not like the scrambled eggs, she stated they do not bring anything else in place of the eggs if the resident does not want the eggs. R3 received two sausage links, the same as everyone else. On 08/01/24 at 9:39 AM, V27 (Dietary) stated she is not aware of any supplements for R3 or any extra protein; they do not offer him a different protein if he does not like the one they are serving. R3 does eat eggs, just not scrambled, he is ok with fried and omelets. On 08/01/24 at 11:07 AM, V3 (Dietary Manager) stated she is not aware R3 is supposed to receive extra protein with any meals. The extra protein is not on his dietary card because she was not aware of it, and no recommendation has been given to nursing by her to be given to the physician because she was not aware. She would have to look through his dietary notes and talk to V14 (Registered Dietician/RD) to find out about that. If the resident does not like scrambled eggs, they will send the plate out without the scrambled eggs, they do not put anything else in the place of them. They tried a few supplements with R3 once, super cereal, gelato and the health shake she believes, and he didn't like them. They tried all three on the same day and did not try them again. There was no order for them, or probably documentation because they just tried them once. V3 stated they substituted the eggs and sausage links breakfast for the sausage pie breakfast today, which was 2 eggs and 2 sausage links. On 08/01/24 at 2:20 PM, R3 stated he tried something similar to ice cream once, but it got melty while he was eating his food. It could have been better if it was frozen. On 08/01/24 at 11:40 AM, V22 (Registered Nurse) stated she believes any recommendation from V14 (Registered Dietician) goes to V3 (Dietary Manager) first, then to the nurse on duty who would then notify the doctor. On 08/01/24 at 12:20 PM, V3 stated any recommendations from the RD should come to her first then go to the nurse and then to the doctor. On 08/02/24 at 3:50 PM, V14 (Registered Dietician) stated she did put a recommendation in for an extra ounce for protein for R3 in May, she has the report where she sent it to V3 (Dietary Manager), when she generates her recommendations, the program automatically generates a report that can be sent to the physician by the facility. V14 stated with his weight loss and wounds, she would expect him to receive the extra protein, and she was not aware he was not. V14 stated she was unaware the supplements were only offered to R3 one time at the same time, she would have expected them to be offered more than once. V14 stated she would expect if there was a protein item being served that R3 did not like, she would expect something different offered in its place, especially since she recommended extra protein. V14 stated if a resident is not served the full meal and only receives a couple items of the meal, she would not consider that to be a 75 - 100% intake. She stated she uses all that information that is documented on a resident to make her recommendations. The facility policy, dated 10/13, titled, Nutrition Supplements and Nourishments documents; It is the policy of (this health care facility) to provide additional calories and/or protein to residents who cannot and/or are not capable of consuming adequate nutrients through their regular meals. It is also the policy of (this health care facility) to provide guidelines for the selection, ordering, use, and monitoring of nutrition supplements and nourishments. Procedure: 1. The need for a nutrition supplement and/or nourishment should be determined by the physician, nursing staff, dietitian, and/or interdisciplinary team (IDT). 5. Nutrition supplements and/or nourishments must be ordered by the physician and are part of the resident's diet order. Nutrition supplements are medical nutrition products and are to be served only with a physician's order. 8. The volume and frequency of supplement is based on the resident's needs. The policy titled, Resident Weight Monitoring, dated 03/19, documents: Procedure step 7. If there is an actual significant weight change (i.e. (in example) +/-5% x 1 month, +/-1 7.5% x 3 months, +/- 10% x 6 months), the resident, POAHC (Power of Attorney for Health Care)/family/guardian, physician and dietitian are notified. The physician shall be notified using the MD (physician) notification of weight change form. 8. The Food Service Manager and interdisciplinary team review the resident's weights and nutritional status, and make recommendations for intervention. 9. The Dietitian shall review and document all significant weight changes along with any recommended nutritional interventions in the dietary progress notes in the medical record monthly. 10. Nursing contacts the physician to convey recommendations from the interdisciplinary team and/or dietitian, and obtains any new orders. 11. Significant weight changes are reviewed in the weekly weight committee meeting. The weight committee will also identify and trends of gradual weight loss or gain. Significant changes in weights are documented in the care plan with goals and approaches/interventions listed. 3. R4's July 2024 Physician Orders document a diet order for a regular diet, pureed texture, pudding thick liquids, and high calorie/high protein supplement BID (twice a day) served with lunch and supper. On 7/29/24 at 12:08 PM, R4 was sitting up in a reclining wheeled chair being fed by V8 (CNA). R4's meal consisted of pureed pork fritter, mashed potatoes with gravy, green beans, peaches, pudding thick cranberry juice and water. R4 did not have a high calorie/high protein supplement, which V8 confirmed. On 7/30/24 at 12:30 PM, R4 was being fed by V16, CNA. R4's meal consisted of pureed turkey, mashed potatoes with gravy, peas, cake, dinner role, pudding thick tea and water. V16 stated R4 gets a high calorie/high protein supplement at times, and had one last night for supper. V16 confirmed R4 did not receive a supplement at lunch today. On 7/30/24 at 12:35 PM, V6 (Cook) stated R4 gets the high calorie/high protein supplement at supper, but V6 was not aware R4 was supposed to get it at lunch too. On 7/31/24 at 8:44 AM, V14 (Registered Dietician) confirmed R4 is to be receiving the ordered nutritional supplements BID due to a history of weight loss.