**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at risk for nutritional decline, the Facility failed to ensure based on his/her comprehensive assessment, that he/she maintained acceptable parameters of nutritional status, when he/she experienced a severe undesired significant weight loss and required the addition of protein supplements due to malnutrition. Findings include: The Facility Policy titled Nutritional Assessment, undated, indicated the dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframe's) and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive assessment, the nutritional assessment will be systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. The multidisciplinary team shall identify, upon the resident's admission and upon his/her change of condition and co-existing risk factors that may place the resident at increased risk for impaired nutrition. Sources of information may include, standardized nutrition screening and assessment tools, Resident Assessment Instrument, assessments from other disciplines, observation, resident and family interviews and the resident's medical record. Once current conditions and risk factors are identified, assessed and analyzed, the individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Interventions will be developed within the context of the resident's prognosis and personal preferences. The individualized care plans shall address to the extend possible: identified causes of impaired nutrition, resident's personal preferences, goals and benchmarks for improvement, timeframe's and parameters for monitoring and reassessment. The Facility Policy titled Weight Assessment and Intervention, undated, indicated that resident's weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team and or physician orders. - Any weight change of 5% or more since the last weight assessment is retaken for confirmation, - If the weight is verified, nursing will immediately notify the dietician in writing. - The threshold for significant unplanned and undesired weight loss will be based on: - 1 month - 5% weight loss is significant; greater than 5% is severe. - 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. - 6 months - 10% weight loss is significant: greater than 10% is severe. - If the weight loss is desirable, this is documented. - Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change is met or not. - Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, dietician, pharmacist, and the resident or legal surrogate. - Individualized care plans will address the identified causes of weight loss, goals and benchmarks for improvement, timeframe's and parameters for monitoring and reassessment. - Interventions for undesirable weight loss are based on careful consideration of resident choice and preferences, nutrition hydration needs, functional factors that may inhibit independent eating, environmental factors that may inhibit appetite or desire to participate in meals, chewing and swallowing abnormalities and the need for diet modifications, medications that may interfere with appetite, chewing, swallowing or digestion, the use of supplementation and or feeding tubes, end of life decisions and advanced directives. Resident #1 was admitted to the Facility in December of 2022, diagnoses included dementia, hallucinations, delusions, paranoia, atrial fibrillation (irregular heart beat), high blood pressure and SIADH (Syndrome of Inappropriate Antidiuretic Hormone secretion), and a fall at home that resulted in a left fractured wrist and ulnar. Review of Resident #1's Care Plan titled Nutritional Problem,, initiated 12/2022 and reviewed and renewed with the completion of his/her MDS's in March and May of 2023, indicated Resident #1 was at risk for weight loss due to variable oral intake and cognitive decline with interventions that included the following: - he/she will consume at least 50% of meals. - encourage family to bring in culturally preferred meals. - maintain skin integrity. - obtain weights as ordered. - report a significant weight loss of 3 pounds (lbs) in 1 week, > (greater than 5% in 1 month, >7.5% in 3 months or > 10% in 6 months. - provide supplements as ordered to promote a gradual weight gain. Review of Resident #1's admission Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 required supervision of 1 staff member for eating, had swallowing difficulty, received speech therapy and weighed 140 lbs. Review of Resident #1's Quarterly MDS, dated [DATE], indicated Resident #1 required extensive physical assistance of 1 staff member for eating, had no difficulty with swallowing, no speech therapy, weight was 168 lbs. and he/she had no weight loss in the past 3 months. Review of Resident #1's Quarterly MDS, dated [DATE], indicated Resident #1 required extensive physical assistance of 1 staff member for eating, had coughing or choking during meals or when swallowing medications, was holding food in his/her mouth, received speech therapy, weight was 105 lbs, and he/she had a significant weight loss of 10% or more, in 6 months. The MDS indicated Resident #1 was not on a prescribed weight loss regime. Review of Resident #1's monthly weights, as documented by nursing indicated the following: 12/01/22 - 140.0 lbs. on admission, standing scale 12/18/22 - 140.0 lbs. hospital weight 01/07/23 - 166.2 lbs. via wheelchair scale 02/04/23 - 168.0 lbs. via wheelchair scale 03/10/23 - 118.8 lbs. standing scale 04/01/23 -114.0 lbs. via wheelchair scale 05/04/23 - 110.4 lbs. via wheelchair scale 06/01/23 - 104.8 lbs. via wheelchair scale 07/06/23 - 92.0 lbs. via wheelchair scale Resident #1 had a documented weight gain of greater than 10%, (in less than 30 days) with a weight of 140 lbs. on 12/01/22 and a weight of 169.9 lbs. on 12/24/22, however Resident #1 was not re-weighed per facility policy. Based on his/her documented weights, Resident #1 had a weight loss greater than 7.5 % 3 months, with a weight of 140.0 lbs. on 12/18/22 and a weight of 118.8 lbs. on 3/10/23, however Resident #1 was not re-weighed per facility policy. Further review of Resident #1's Dietician Progress Note, dated 3/13/23, indicated the admission weight of 140 lbs., (obtained back in December 2022) was likely inaccurate and the recorded weight on 3/10/23 of 118 lbs., was due to decreased oral intake and poor appetite. The Note indicated Glucerna supplements 3 times daily were implemented, continue weekly weights and trend weights from the new baseline of 118 lbs. obtained on 3/10/23. During an interview on 7/13/23 at 3:19 P.M., the Dietician said Resident #1 did have a weight loss, but the weight documentation in the 168 pound area were disputed due to inaccurate scales. The Dietician said the Facility re-calculated all the weight scales and re-weighed all the residents in March 2023. The Dietician said at that time, the Interdisciplinary Team decided the baseline weight for Resident #1 was 118 lbs. The Dietician said there was a period of time when Resident #1 was not eating anything. The dietician and the Food Service Director initiated serving rice and cooked vegetables for lunch and dinner to Resident #1 when no food was available from family members. The dietician said Resident #1 had been eating better but, she had not observed Resident #1 eating recently. The dietician said Resident #1 continued to suffer severe weight loss from March 2023 to through July 2023. However, although the facility determined in March 2023 that Resident #1's actual baseline weight was 118.0 lbs, he/she continued to experience an undesired weight loss, and based on his/her documented weight of 92.0 lbs., on 7/06/23, he/she had a severe significant weight loss of greater than 7.5 % in a 90 day period (with of loss of greater than 20% in that period). Further review of Resident #1's clinical record indicated on 5/31/23, Resident #1 developed a stage 2 pressure (break in skin, presents as an abrasion, blister or shallow crater) wound to his/her right buttock, a wound consult was completed and blood tests were ordered. Review of Resident #1's blood laboratory test results indicated his/her pre-albumin (blood test to measure malnutrition) level was critically low and he/she required the addition of a supplement for protein malnutrition (lack of proper nutrition). During an interview on 7/13/23 at 2:29 P.M., Certified Nursing Aide (CNA) #2 said Resident #1 was on her assignment almost everyday. CNA #2 said she feeds Resident #1 each morning while he/she is in bed. CNA #2 said breakfast is his/her best meal and likes 2 bowls of hot cereal, bananas and sometimes will drink orange juice. CNA #2 said Resident #1 does not eat well for lunch unless food brought in by the family is available. During an interview on 7/13/23 at 2:50 P.M., CNA #3 said she has cared for Resident #1 and that he/she eats breakfast in bed and usually is confused. CNA #3 said Resident #1 needs to be fed all meals, that he/she likes bananas. CNA #3 said Resident #1 but does not eat much at all for lunch. CNA #3 said an Ensure supplement is always available on his/her bedside table and Resident #1 will take a sip sometimes when offered by staff, but that she was not sure how much he/she drinks if staff does not and physically go in help him/her. During an interview on 7/13/23 at 4:30 P.M., Nurse #1 said she cares for Resident #1 daily, providing medications and treatments as ordered. Nurse #1 said Resident #1 eats breakfast in bed daily and needs to be fed by staff for all meals. Nurse #1 said Resident #1 eats fairly well for breakfast, but not much for lunch and dinner. Nurse #1 said Resident #1 will eat food brought in by family when available, and that Family brings in food approximately every other day. Review of Resident #1's Progress Note, dated 7/13/23, written by the Assistant Director of Nursing, indicated Resident #1 had triggered for weight loss on 7/12/23 and a re-weight was completed on 7/13/23, and he/she weighed 100.6 lbs.