Based on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2) who although they were cognitively impaired, were able to make themselves understood by staff, the Facility failed to ensure they were free from physical abuse, in the form of unwanted and inappropriate physical contact by a contracted employee (consulting Podiatrist). On 01/02/25, both residents reported that the Podiatrist had touched them in a sexually inappropriate manner and their recounting of the incidents to facility administrative staff and the police remained consistent. Both Resident #1 and Resident #2 reported being shocked after the incidents occurred. Based on the reasonable person concept, it would be more likely than not, that Resident #1 and Resident #2 would have experienced psychosocial harm, recurrent fear, anxiety or anger as a result of the sexual abuse since there is an expectation that they would not be touched inappropriately by a provider that had been entrusted to care for him/her. Findings include: Review of the Facility Policy titled Abuse Prohibition, dated revised 10/24/22, indicated the following: -Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. -Sexual abuse is nonconsensual sexual contact of any type with a patient. It includes but is not limited to sexual harassment, sexual coercion, or sexual assault. 1. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/02/25, indicated that Resident #2 reported to a Certified Nurse Aide (CNA) at 1:00 P.M., that when the Podiatrist had finished cutting his/her toenails, he grabbed his/her breasts. Resident #2 was admitted to the Facility in May 2023, diagnoses included dementia and anxiety disorder, and he/she resided on the Memory Care Unit. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 11/21/24, indicated that Resident #2 was severely cognitively impaired, with a score of 4 out of 15 on his/her Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Review of Resident #2's Podiatry Note, dated 01/02/25, indicated the Podiatrist trimmed his/her calluses. During an interview on 01/22/25 at 2:10 P.M., Certified Nurse Aide (CNA) #2 said that on 01/02/25 at approximately 10:30 A.M. she brought Resident #2 to the shower room, where the Podiatrist was seeing residents. CNA #2 said she left the Resident #2 alone with the Podiatrist, once he/she was seated. During an interview on 01/24/25 at 1:52 P.M., Certified Nurse Aide (CNA) #1, described the Podiatrist as average height and weight with salt and pepper hair (mixed dark and gray hair). CNA #1 said the Podiatrist often used the shower room when treating residents on the Memory Care Unit, and that the shower room door closed automatically. CNA #1 said that on 01/02/25 at approximately 1:00 P.M., Resident #2 was walking in the hallway with a strange expression on his/her face, and that she stopped him/her and asked, Are you ok? CNA #1 said that Resident #2 told her that the foot doctor touched his/her breasts and that he/she was surprised and shocked when he did that. CNA #1 said that Resident #2 told her I can't believe that happened! Review of Resident #2's Witness Statement, dated 01/02/25, as told to and documented by the Director of Social Services, indicated that Resident #2 said that the Podiatrist grabbed his/her breasts. The Statement indicated that Resident #2 said the incident occurred in the Podiatrist's room and that he/she described the Podiatrist as heavy, older, and with white hair. The Statement indicated that while the Podiatrist was touching Resident #2's breasts he/she asked the Podiatrist, What are you doing?, and that the Podiatrist responded, I am touching you. The Statement indicated that Resident #2 then told the Podiatrist Keep it to yourself buddy! Review of the Police Report, dated 01/02/25 and timed 3:28 P.M., indicated that when the Officer asked Resident #2 how his/her day had been, he/she began to talk about the Podiatrist without prompting. The Report indicated Resident #2 told the officer, He grabbed my breasts while he/she put his/her hands on his/her breasts to demonstrate. The Report indicated that Resident #2 told the Officer that the incident happened in the show room. The Report indicated that the Officer observed that Resident #2 was clearly upset about the incident. During an interview on 01/22/25 at 3:17 P.M., the Director of Social Services said that despite Resident #2's dementia, he/she was consistent with the details of his/her account of the incident on 01/02/25, when he/she was interviewed by several staff members and the police later that day. 2. Review of the Report submitted by the Facility via the HCFRS, dated 01/02/25, indicated that Resident #1 reported to staff, that when the Podiatrist had finished treating his/her feet, he put his hands down his/her shirt and felt his/her breasts. Resident #1 was admitted to the Facility in March 2021, diagnoses included dementia with mild behavioral disturbance, anxiety disorder and he/she resided on the Memory Care Unit. Review of Resident #1's Quarterly MDS Assessment, dated 11/08/24, indicated that Resident #1 was moderately cognitively impaired, with a score of 7 out of 15 on the BIMS. Review of Resident #1's Podiatry Note, dated 01/02/25, indicated the Podiatrist trimmed his/her calluses. During an interview on 01/22/25 at 1:52 P.M., the Director of Rehabilitation (DOR, which also included a review of her Written Witness Statement dated 01/02/25) said that during an Occupational Therapy session on 01/02/25 just before 1:30 P.M., Resident #1 told her that he/she was inappropriately touched earlier that morning. The DOR said that when she asked Resident #1 who had touched him/her, he/she responded, the man who came to cut my toenails, touched my breast area. Review of Resident #2's Witness Statement, dated 01/02/25, as told to and documented by the Director of Social Services, indicated that Resident #2 said I was feeling OK, until I got my toenails cut. The Statement indicated that Resident #1 reported that after the man (later identified as the Podiatrist) finished cutting his/her toenails, in his/her room, the Podiatrist put his hand down the top of his/her shirt and grabbed his/her breasts. The Statement indicated that Resident #1 described the Podiatrist as medium height with hair that was going gray. The Statement indicated that when Resident #1 told the Podiatrist What do you think you are doing? and stated You don't do this to me!, he answered I want to. The Statement indicated the Podiatrist left Resident #1's room after he/she told him to leave. The Statement indicated the incident occurred before lunch, and that Resident #1 couldn't recall the exact time. The Statement also indicated that Resident #1 was shocked by the Podiatrist's behavior and that he/she said, he was always nice to me before. During an interview on 01/22/25 at 11:20 A.M., Resident #1 told the Surveyor that some of the staff are not nice. When the Surveyor asked Resident #1 for an example, he/she responded, a doctor put his hand down my shirt. Resident #1 said The doctor for my toes put his hand down my shirt and grabbed my breasts. Resident #1 described the doctor as having dark hair that was going gray. Review of the Police Report, dated 01/02/25 and timed 3:28 P.M., indicated that Resident #1 told the Officer that the Podiatrist put his hands down the top of his/her shirt, moved them around, and touched his/her breasts. The Report indicated that Resident #1 had seen the Podiatrist before without incident. The Director of Social Services said that despite Resident #1's dementia, he/she generally had a good grasp on his/her circumstances, recognized staff and often remembered their names. The Director of Social Services said that Resident #1 tended to stay in his/her room and rarely socialized with other residents. The Director of Social Services said that despite the similarities between Resident #1 and Resident #2's allegations, she ruled out the possibility that they may have learned of each other's allegations, because both residents lived on opposite ends of the unit, were on different staffing assignments, did not generally socialize with each other, and did not seek each other out for conversation. During a telephone interview on 01/23/25 at 9:14 A.M., the Podiatrist said that he started covering podiatry services at the Facility last year and that he had been to the Facility a few times. The Podiatrist said he was at the Facility on 01/02/25 for approximately 4 hours, between breakfast and lunch, and that he saw close to 40 residents during that time. The Podiatrist said that he used the shower room to see residents when he provided services on the Memory Care Unit, and that he sometimes treated residents in their rooms as well. The Podiatrist said that the CNAs on the unit helped to transport residents to the shower room, but only assisted him during treatment if a resident was being resistant to care and needed reassurance. The Podiatrist said he was aware of the allegations against him and that he only provided the residents with routine foot checkups. The Podiatrist said that he did not act inappropriately. During an interview on 01/22/25 at 5:15 P.M., the Director of Nurses (DON) said it was alarming that two residents (Residents #1 and #2) that didn't interact with each other had the same allegation on the same day, involving the Podiatrist. During an interview on 01/22/25 at 5:30 P.M., the Administrator said the Company that provided the Podiatrist had been contacted, and that the Podiatrist was no longer allowed at the Facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the Physician/Nurse Practitioner (NP) of changes in condition for two Residents (#65 and #85) out of a total sample of 19 residents. Specifically: 1. For Resident #65, facility staff failed to: -notify the Physician/NP timely of significant weight loss which resulted in delayed treatment and monitoring of the Resident, and continued significant weight loss. -notify the Resident's Legal Guardian of a change in treatment relative to significant weight loss prior to initiating medication treatment which required the Guardian's consent. 2. For Resident #85, facility staff failed to: -notify the Physician/NP of significant weight loss identified with weekly weights, resulting in inadequate treatment and monitoring of the Resident's nutritional status. Findings include: Review of the facility's policy titled Weights and Heights, dated 6/1/01 and revised 6/15/22, indicated the following: -Patients are weighed upon admission and re-admission, then weekly for four weeks, and monthly thereafter. -Additional weights may be obtained at the discretion of the interdisciplinary team (IDT). -The purpose was to obtain baseline weight, identify significant weight change, and to determine possible causes of significant weight change. -Refer to Weights and Heights procedure. Review of the facility's procedure titled Weights and Heights, dated 6/1/01 and revised 2/1/23, indicated but was not limited to the following: -A licensed nurse or designee will weigh the patient. -admission and re-admission weights will be obtained within 24 hours of admission. -If the body weight is not as expected, re-weigh the patient. -Significant weight change is defined as >5% in one month >10% in six months -The licensed nurse will: >Notify the physician/APP and Dietician of significant changes. >Document notification of physician/APP and Dietician in the PCC Weight Change Progress Note. Review of the facility's Notification of Change in Condition policy, dated 11/28/16 and revised 7/1/24, indicated the following: -The purpose is to provide appropriate and timely information about changes relevant to the patient's condition. -A center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: >a significant change in the patient's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). >a need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment). 1. Resident #65 was admitted to the facility in July 2022 with diagnoses including Dementia, Hypothyroidism, and Non-toxic Single Thyroid Nodule. Review of Resident #65's Advance Directive Care Plan, initiated 7/19/22 and revised 11/10/23, indicated: -The goal was for the Resident and Guardian to participate in decisions related to medical care and treatment. -The Resident was a full code and had a Legal Guardian. -Staff were to inform the Resident's Guardian of any changes in status or care needs. Review of Resident #65's Nutrition Care Plan, initiated 3/18/24 and revised 10/24/24, indicated: -The Resident was at nutritional risk related to gradual weight loss trend (3/18/24). -Weigh as ordered and alert Dietician and Physician to any significant loss or gain (3/18/24) -Monitor for changes in nutritional status and report to food and nutrition/Physician as indicated (3/18/24). -Monitor intake at all meals, offer alternate choices as needed, alert Dietician and Physician to any decline in intake (3/18/24). -The Resident's goal was to maintain stabilized weight of current body weight (CBW- 120 lbs ) +/- three lbs x 90 days (10/24/24 with a target goal date of 1/21/25). Review of Resident #65's Physician orders, dated 6/15/23 with a start date of 7/1/23 indicated: -weigh monthly. Review of Resident #65's Weights and Vitals Summary indicated the following weights: -7/1/24 -141.7 pounds (lbs) -8/1/24 - 136.4 lbs -9/3/24 -132.2 lbs -10/1/24 - 130.6 lbs (weight change of 7.8% over three months) -10/14/24 - 120 lbs -No weight was documented for November 2024 and December 2024 in the Weights and Vitals Summary -1/1/25 - 90.6 lbs Review of Resident #65's Nurse Practitioner (NP) Note, dated 8/9/24, indicated: -The Resident had experienced a 15 lb weight loss over the last year. -The Resident had unintended weight loss. -The Resident's body mass index (BMI) was still healthy at 23.4. -Consider caloric supplementation if needed. Review of Resident #65's Quarterly Nutrition Assessment, dated 9/16/24, indicated the following: -The Resident's usual body weight (UBW) was 145 lbs. and BMI was within normal limits (WNL) though low for age. -The Resident's diet was appropriate. -The Resident had a gradual weight loss over 180 days. -Continue to follow. Review of Resident #65's Minimum Data Set (MDS) Assessment, dated 9/16/24, indicated: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 total possible points. -The Resident was independent for eating. -The Resident weighed 132 lbs -Weight loss of greater than five percent in one month or greater than 10% in six months had not been identified. Review of Resident #65's clinical record indicated: -The Resident was discharged to the hospital on [DATE] related to fall with injury and re-admitted to the facility on [DATE] with diagnosis of left hip fracture. -The Resident's re-admission weight obtained 10/14/24, was 120 lbs (15% weight loss over a 90-day period). Review of Resident #65's Physician orders dated 10/24/24, indicated: -House supplements with meals. Review of Resident #65's General Progress Note, dated 10/24/24, and written by the Certified Dementia Practitioner (CDP) indicated: -The Resident's Guardian had been contacted via email that same day with consent forms for medications . -An update was provided on the Resident's medical status. Further review of the General Progress Note did not include information relative to what medications required consent and what update was provided pertinent to the Resident's medical status. Review of Resident #65's November 2024 Medication Administration Record (MAR) indicated: -The Resident's weight was 120 lbs on 11/1/24. -Mirtazapine (Remeron: antidepressant medication that can be used to stimulate one's appetite and requires consent for administration) Tablet 7.5 milligrams (mg), one tablet at bedtime for Dementia was ordered for the Resident on 11/15/24. -Mirtazapine Tablet 7.5 milligrams (mg) was administered to the Resident: >11/15/24 through 11/18/24 >11/21/24 through 11/30/24 -Mirtazapine Tablet 7.5 mg was held on 11/19/24 and 11/20/24, due to no consent to administer the medication. Review of an email communication, dated 11/18/24 (three days after Mirtazapine medication was ordered and administered), from the CDP to Resident #65's Guardian indicated: -A consent for Mirtazapine was attached to the email. -The Resident was not eating well and had experienced a 10% weight loss over the last 180 days. -The Resident was often refusing to eat and often refusing to drink health shakes. -The Resident reports he/she is not hungry. -Consent to administer Mirtazapine was requested in attempt to stimulate the Resident's appetite so that he/she would begin to eat more. Review of Resident #65's clinical record included no evidence the Resident's Guardian was notified of the change in medication to administer Mirtazapine on 11/15/24 and the medication was discontinued on 12/3/24. Review of a Physician order, dated 11/20/24, indicated: -liquid protein daily, 30 cc (unit of measure) one time a day. Review of Resident #65's clinical record included no evidence the Resident was weighed in December 2024. Review of Resident #65's Weights and Vitals Summary indicated the Resident weighed 90.6 lbs on 1/1/25 (24.5% loss in three months: significant weight loss). Review of Resident #65's Quarterly Nutrition Consult, dated 1/13/25, indicated: -The Resident weighed 90.6 lbs and the Resident's BMI was 15.5 (underweight), low. -Current weight shows significant loss, 24.5% x 90 days. -Add nourishment BID (two times daily[the type of nourishment or the amount of nourishment to be provided was not indicated]). -Order weekly weights for four weeks to monitor. -No further assessment needed. Review of Resident #65's clinical record did not include any evidence that the Physician/NP was notified of: -The Resident's significant weight loss on 10/1/24 (130.6 lbs). -The Resident's continued significant weight loss on 10/14/24 (120 lbs) and 1/1/25 (90.6 lbs). -The Dietician's recommendations to add nourishment BID and order weekly weights for four weeks on 1/13/25. On 1/15/25 at 1:10 P.M., the surveyor observed Resident #65 sitting in a wheelchair in the Unit Dining Room wearing a hospital gown that was tied loosely around his/her neck, and forearms and lower legs were exposed. The surveyor observed that the Resident was very thin, both sides of the Resident's neck were sunken in behind his/her collar bone, and the Resident's exposed lower legs and forearms were thin and bony. During an interview on 1/15/25 at 1:23 P.M., CNA #1 said that staff weighed residents monthly, weekly, or daily, and that the Nurse alerted the CNAs relative to when to obtain weights. CNA #1 also said that the Nurses entered the residents' weights into the computer. During an interview on 1/15/25 at 2:04 P.M., the NP said she started providing routine coverage at the facility in October 2024 and saw Resident #65 for the first time on 10/16/24, after the Resident returned from the hospital on [DATE]. The NP said she did not have access to any of the residents' electronic health records for about one month after she began providing routine coverage at the facility and was dependent on staff reports and a written communication log for any changes in residents' conditions during that time. The NP said she had not been alerted that Resident #65 had experienced weight loss and the facility staff did not notify her of Resident #65 having had severe weight loss. The NP said if the facility identified significant weight changes for a resident, the staff would notify her so that she could evaluate the weight loss and implement appropriate treatment interventions. The NP said if the facility had notified her of the Resident's severe weight loss, she would have ordered a chest x-ray and blood work to evaluate for malignancy. The NP said she was not notified that Resident #65's weight was 90.6 lbs on 1/1/25. The NP also said she had not yet been notified of the Dietician's recommendations from 1/13/25 to implement nourishment BID and to order weekly weights. The NP said she wished the facility had notified her of the Resident's weight loss a couple of months ago. During an interview on 1/15/25 at 3:37 P.M., the Dietician said she worked part time at the facility and she did have opportunities where she observed residents eating, but that she was only in the facility approximately one to two times per week, so she depended on staff reports and documentation for monitoring residents for nutrition. The Dietician said the facility held a Risk Meeting weekly and that Resident #65 was discussed weekly at that meeting. The Dietician also said Resident #65 was on her radar for weight loss. The Dietician said that the facility identified Resident #65 as having had a significant weight loss on 10/1/24 and the Resident's weight loss was discussed at the Risk Meeting on 10/3/24. The Dietician said that she assessed Resident #65 on 10/18/24, following the Resident's return to the facility from the hospital on [DATE]. The Dietician said that the re-assessment she completed on 10/18/24 was due to the Resident having had a change in condition relative to a hip fracture. The Dietician said when she re-assessed the Resident on 10/18/24, she recommended house supplements. The Dietician said when she recommends house supplements for residents, either a Nurse or she will enter the order into the computer for the Physician to review within one day of the recommendation. The Dietician further said that she did not enter the order into the computer until 10/24/24 for Resident #65 to be provided with house supplements and that she was unsure why obtaining the order for the house supplements was delayed. During an interview on 1/15/25 at 4:04 P.M., with Unit Manager (UM) #1 and UM #2, UM #1 said that Resident #65 was not eating well and was losing weight when he/she returned from the hospital. UM #2 said that the Resident's Guardian had been contacted regarding initiating Remeron as an appetite stimulant, and the Guardian did not consent to Remeron being administered. UM #1 said that the facility held weekly Risk Meetings where residents with weight loss were discussed. UM #1 said that the Dietician was not always present at the meetings and would send the Risk Team an email with her recommendations for residents with weight loss if she could not be at the meeting. UM #1 said that the Dietician sent an update to the Risk Team for the meeting that was scheduled for 1/9/25 and the Dietician's recommendations included adding nourishment BID and weekly weight monitoring for Resident #65. UM #1 further said that the meeting scheduled for 1/9/25 did not occur and the recommendations made by the Dietician for Resident #65 had not yet been implemented. UM #1 said that the Risk Meeting did not have to occur in order for recommendations to be implemented. During an interview on 1/15/25 5:00 P.M., the Physician said that he had no recall of having been notified of Resident #65's significant weight loss. During an interview on 1/17/25 at 8:05 A.M., Resident #65's Guardian said the facility contacted her via email regarding the Resident's weight loss and requested consent to administer Remeron to the Resident to stimulate his/her appetite. The Guardian said that she read the email on 11/20/24 and spoke with facility staff on 11/20/24 and that staff reported wanting to initiate the use of Remeron in order to try and stimulate the Resident's appetite. The Guardian said that no other interventions had been discussed with her other than use of Remeron on 11/20/24. The Guardian said that she did not provide consent for the Remeron to be administered and she did not understand why the facility staff were recommending Remeron when other non-pharmacological interventions had not been implemented. During a follow-up interview on 1/17/25 at 10:15 A.M., the NP said she ordered 30 cc of liquid protein for Resident #65 on 11/20/24. The NP said she ordered the liquid protein specifically for bone healing due to the Resident having had a hip fracture. The NP said that the liquid protein could have some nutrition supplementation benefit, but she did not order it specific for the Resident's nutrition because she did not know the Resident had significant weight loss. 2. Resident # 85 was admitted to the facility in October 2024, with diagnoses including Alzheimer's Disease, Malignant Neoplasm of Unspecified site of right breast, Major Depressive Disorder, Urinary Tract Infection, Abnormalities of gait and mobility, Generalized muscle weakness. Review of the Minimum Data Set (MDS) Assessment, dated 10/30/24, indicated Resident #85: -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of 15. -required setup assistance from staff for eating and required moderate assistance from staff for Activities of daily living (ADL) areas (dressing, bathing, positioning, transfers, ambulation). -had a weight of 150 lbs and height of 60 inches. -had no therapeutic weight approaches. -had no known weight loss or gain in the past 6 months. Review of the Medication Administration Record (MAR) for November 2024, indicated a Physician order initiated on 10/28/24, for weights to be obtained every Monday for 4 weeks. Review of Physician orders from October 2024 through January 2025, did not include any orders for ongoing weights, after the initial 4 weeks of weights were completed. Review of the Electronic Record Weights & Vital Signs Module, and MARs for October 2024 and November 2024 indicated: -No record of a weight for the 4th week after admission [DATE] through 11/30/24). Review of the Electronic Record Weights & Vitals indicated the following weights: -10/28/24: 150.4 lbs. -11/4/24: 139.4 lbs. (7.3% loss) -11/11/24: 139.5 lbs. -11/18/24: 144.4 lbs. -12/11/24: 140.8 lbs. -1/16/25: 130.4 lbs. (13% loss) Review of Resident #85's Nutrition Care Plan, initiated 11/14/24, indicated: -Resident was at nutritional risk related to hypercholesterolemia, Hypertension, Alzheimer's Disease, Breast Cancer, UTI, Depression, and poor intake. -Interventions included: >Weigh, as ordered. >alert Dietician and Physician of any significant weight loss or gain. During an interview on 1/15/25 at 9:11 A.M., Certified Nurses Aide (CNA) #5 said that if a resident needs to be weighed, the Nurses let the CNAs know. During an interview on 1/15/25 at 4:05 P.M., Nurse #5 said that residents are weighed upon admission, weekly for 4 weeks, then monthly or per order and the weights are documented on the MAR. Nurse #5 said if a weight loss occurs, the MD[Physician]/NP/Dietician and family are updated right away. Nurse #5 said if staff notice there is a change from the previous weight, then the Resident should be re-weighed to verify the weight is accurate. The surveyor and Nurse #5 reviewed Resident #85's medical record and Nurse #5 said there was no active Physician orders for weights and weights have not been completed since 12/12/24. During an interview on 1/16/25 at 8:14 A.M., UM #2 said Resident #85 had no active weight order and the Physician, NP, Dietician, and family had not been notified of the weight change that occurred between 10/28/24 and 11/4/24, or any other weight loss since admission, but those individuals should have been notified. UM #2 said Nurses ask the CNAs to obtain a weight, when the MAR indicates a weight is due. UM #2 said if there is a discrepancy from the previous weight, then the resident is reweighed. If the resident has a weight loss or gain, the Nurse needs to notify the MD/Family/ Dietician right away. During an interview on 1/16/25 at 12:55 PM, Dietician #1 said that every resident is weighed upon admission, weekly for four weeks then monthly. Dietician #1 said a Physician order should be in the medical record indicating how often a weight is needed. Dietician #1 said that a Nurse should have notified her and the Physician/NP of Resident #85's significant weight loss (-7.3%) on 11/4/24, but they were not notified until 1/16/25. Dietician #1 said the last time she had seen Resident #85 was for his/her admission review on 10/30/24. On 1/16/25 at 1:45 P.M., the surveyor observed staff weighing Resident #85 for a weight of 130.4 lbs. via Hoyer lift scale (lifting device used to assist caregivers). During an interview at the time, UM #1 said that this weight further indicates significant weight loss which would be reported to the Dietician and MD/NP. During an interview on 1/17/25 at 10:49 A.M., the NP said that she was not updated about Resident #85's weight loss prior to 1/16/25, and had she been updated on 11/4/24 that a weight loss had occurred, she would have put interventions into place right away to prevent further weight loss. The NP said she expected that the facility follows their weight policy, and that weights are standard orders upon admission. During an interview on 1/17/25 at 11:37 A.M., Dietician #1 said that the facility should be following their weight policy and said that had she been notified of the weight loss on 11/4/24, she would have completed another Nutrition Consult and potentially initiated nutritional interventions at that time. During an interview on 1/17/25 at 2:16 P.M., CNA #1 said that Nurses alert the CNA's when a weight needs to be obtained, either verbally or write the weight request on the assignment sheets. CNA #1 said some residents receive daily, weekly, or monthly weights depending on what the need is. CNA #1 said that if a weight discrepancy is noticed, the CNA should reweigh the resident right away or the Nurse will tell them to reweigh. CNA #1 said if the resident loses or gains over 5 lbs, they should reweigh and then the Nurse will call the Physician. CNA #1 said staff has a sitting scale, a wheelchair scale, and a Hoyer scale, and all the scales are in good working condition. Please Refer to F657, F692, and F712.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for two Residents (#65 and #85) out of a total sample of 19 total residents. Specifically, the facility failed to: 1. For Resident #65, A.-address significant weight loss and implement effective interventions when the Resident was identified to have greater than 7.5 percent (%) weight loss prior to a hospitalization. -adhere to Physician orders for monthly weight monitoring. B.-implement and monitor weekly weights as required after the Resident was hospitalized and re-admitted to the facility. -implement and monitor dietary interventions timely when dietary supplements, additional nourishment, and weekly weights were recommended. -adequately monitor meal and dietary supplement intakes after significant weight loss was identified by facility staff. 2. For Resident #85, -adequately monitor the Resident's weights after admission to the facility, resulting in failure to assess the Resident's significant weight loss in a timely manner. Findings include: Review of the facility's policy titled Weights and Heights, dated 6/1/01 and revised 6/15/22, indicated the following: -Patients are weighed upon admission and re-admission, then weekly for four weeks, and monthly thereafter. -Additional weights may be obtained at the discretion of the interdisciplinary team (IDT). -Hospital weight will not serve as admission or re-admission weight. -The purpose was to obtain baseline weight, identify significant weight change, and to determine possible causes of significant weight change. -Refer to Weights and Heights Procedure. Review of the facility's Weights and Heights Procedure, dated 6/1/01 and revised 2/1/23, indicated the following: -A licensed nurse or designee will weigh the patient. -admission and re-admission weights will be obtained within 24 hours of admission. -If the body weight is not as expected, re-weigh the patient. -The weight will be entered into the Point Click Care (PCC: electronic health record) Weights/Vitals Signs module on that shift. -The Weights Exception Report will be reviewed by a licensed nurse with follow-up as indicated. -Significant weight change is defined as >5% in one month >10% in six months -The licensed nurse will: >Notify the Physician/APP and Dietician of significant changes. >Document notification of Physician/APP and Dietician in the PCC Weight Change Progress Note. Review of the facility's policy titled Food and Nutrition Goals and Objectives, dated 5/1/23, indicated: -The purpose was to provide food and nutrition services to meet the physiological and psychosocial needs of patients/residents. -Resident's nutritional status is assessed, and individualized plan of care is implemented, and outcomes are monitored and evaluated to promote optimal nutritional status. Review of the Centers for Disease Control and Prevention (CDC) guidelines titled Adult BMI (Body Mass Index: calculation used as a potential health indicator) Categories dated 3/19/24, indicated the following relative to BMI for adults [AGE] years of age and older: -BMI of less than 18.5 = underweight -BMI of 18.5 to less than 25 = healthy weight -BMI of 25 to less than 30 = overweight -BMI of 30 or greater = obesity 1A. Resident #65 was admitted to the facility in July 2022 with diagnoses including Dementia, Hypothyroidism, and Non-toxic Single Thyroid Nodule. Review of Resident #65's Dietary Activity Log indicated the Resident had been receiving large portions of food for meals and fortified oatmeal for breakfast since 3/18/24. Review of Resident #65's Physician orders, dated 6/15/23 with a start date of 7/1/23, indicated: -weigh monthly. Review of Resident #65's Weights and Vitals Summary indicated the Resident weights as follows: -7/1/24: 141.7 pounds (lbs) -8/1/24: 136.4 lbs -9/3/24: 132.2 lbs -10/1/24: 130.6 lbs (weight change of 7.8% over three months) -10/14/24: 120 lbs -No weight was documented for November 2024 and December 2024 in the Weights and Vitals Summary -1/1/25: 90.6 lbs Review of Resident #65's Nurse Practitioner (NP) Note, dated 8/9/24, indicated the Resident: -was seen for an annual exam. -experienced a 15 lb weight loss over the last year. -had unintended weight loss. -body mass index (BMI) was still healthy at 23.4. -appeared well-nourished. -had no edema. -should be considered for caloric supplementation if needed. -Nursing reported good PO (per os: by mouth) intake. Review of Resident #65's Quarterly Nutrition Assessment, dated 9/16/24, indicated: -The Resident's usual body weight (UBW) was 145 lbs. -The Resident's BMI was within normal limits (WNL) though low for age. -The Resident's diet was appropriate. -The Resident had a gradual weight loss over 180 days. -Continue to follow. Further Review of the Quarterly Nutrition assessment dated [DATE], did not indicate that the Resident's weight loss from the 7/1/24 weight was addressed. Review of Resident #65's Minimum Data Set (MDS) Assessment, dated 9/16/24, indicated: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 total possible points. -The Resident was independent for eating. -The Resident weighed 132 lbs. -Weight loss of greater than five percent in one month or greater than 10% in six months had not been identified. Review of Resident #65's Weights and Vitals Summary indicated: -the Resident weighed 130.6 lbs on 10/1/24 -decreased weight from 141.7 lbs on 7/1/24 -with significant loss of 7.8% over three months (7/1/24 - 10/1/24). Further Review of the medical record did not indicate that Resident #65 has been assessed for the 7.8% weight loss identified on 10/1/24. 1B. Review of Resident #65's clinical record indicated: -The Resident was discharged to the hospital on [DATE], related to a fall with injury. -The Resident was re-admitted to the facility on [DATE], with a diagnosis of left hip fracture. -no evidence the Resident was re-assessed by the Dietician between 10/1/24 (when the significant weight loss was identified) and 10/10/24 (when the Resident was discharged to the hospital). -no evidence the facility had implemented any new interventions to address the Resident's significant weight loss between 10/1/24 and 10/10/24, prior to the Resident being hospitalized . -The Resident's re-admission weight obtained 10/14/24, was 120 lbs. Further Review of the clinical record did not indicate that weekly weight monitoring had been implemented as required after Resident #65 was re-admitted to the facility. Review of Resident #65's Nutrition Care Plan, initiated 3/18/24 and revised 10/24/24, indicated: -The Resident was at nutritional risk related to gradual weight loss trend (3/18/24). -Weigh as ordered and alert Dietician and Physician to any significant loss or gain (3/18/24). -Monitor for changes in nutritional status and report to food and nutrition/Physician as indicated (3/18/24). -Monitor intake at all meals, offer alternate choices as needed, alert Dietician and Physician to any decline in intake (3/18/24). -Offer alternate food choices if less than 50% consumed at mealtime (3/18/24). -Provide large entree portions and fortified oatmeal with breakfast (3/18/24). -The Resident's goal was to maintain stabilized weight of current body weight (CBW: 120 lbs ) +/- three lbs x 90 days (10/24/24 with a target goal date of 1/21/25). Review of Resident #65's October 2024 Physician orders indicated: -An order, initiated on 7/21/22 and discontinued on 10/31/24, for regular diet texture. -An active order, initiated 10/31/24 with no stop date, for regular liberalized diet, regular texture, standard thin liquids consistency. -An active order, initiated 10/24/24 with no stop date, for House Supplement with meals. Review of Resident #65's Nurse Practitioner (NP) Note, dated 10/16/24, indicated: -The Resident was seen for a routine visit following hospitalization. -The Resident had Dementia and decline was expected. -Continue supportive care. Further review of the NP Note did not include any evidence the Resident had been evaluated for significant weight loss. Review of Resident #65's Activities of Daily Living Care Plan, initiated 7/19/22 and last revised 10/14/24, indicated: -May require assistance for eating due to Dementia and new hip fracture 10/10/24, which is not being surgically repaired. -Provide assist of one for eating. Review of Resident #65's clinical record indicated the Dietician did not assess the Resident after re-admission to the facility on [DATE] until 10/18/24. Review of the Resident's Nutrition Consult, dated 10/18/24, indicated: -The Consult was being completed due to the Resident having had a significant change in status due to a fall and subsequent injury. -The Resident's current weight was 120 lbs, and was significant for weight loss of 13% over 180 days. -The Resident's BMI was 20.6, within normal limits, low for age. -Will add House Supplement BID (twice daily) with lunch and dinner. -Will continue to follow with changes. Review of Resident #65's Nutrition Progress Note, dated 10/18/24, indicated: -A Nutrition Assessment was completed that same day. -The Resident's Nutrition Concern(s) Category: No concern(s) identified. Review of Resident #65's Significant Change in Status MDS, dated [DATE], indicated: -The Resident was severely cognitively impaired as evidenced by a BIMS score of one out of 15 total possible points. -The Resident had no episodes of rejection of care. -The Resident required substantial/maximal assistance (helper does more than half the effort) for eating. -The Resident weighed 120 lbs. -The Resident had experienced significant weight loss and was not on a Physician prescribed weight loss regimen. Review of Resident #65's NP Notes, dated 10/19/24 and 10/21/24, indicated the Resident was seen for acute rounding visits. Neither NP Note indicated that the Resident was evaluated for significant weight loss. Review of Resident #65's Physician orders dated 10/24/24, indicated that House Supplements were not ordered for the Resident until 10/24/24 (six days after the Dietician's recommendation on 10/18/24). Further review of the Physician's orders failed to indicate: -ordered amounts for the supplement that was to be provided. -instructions for monitoring the amount of the supplements consumed by the Resident. Review of Resident #65's NP Note, dated 10/25/24, indicated: -The Resident was seen for acute rounding relative to persistent pain. -The Resident had been progressively declining since his/her hip fracture and was expected to decline. -The Resident's Guardian was in agreement to expand guardianship to change code status. -Continue supportive care. Further review of the NP Note did not include any evidence the Resident was evaluated for significant weight loss. Review of Resident #65's NP Notes, dated 10/31/24, 11/5/24, 11/8/24, and 11/13/24 indicated: -The Resident was progressively declining since his/her hip fracture and was expected to decline. Review of the 11/13/24 NP Note indicated that the Resident's current Advanced Directive was for full code (all medical measures will be taken to maintain life) status. Further review of each NP Note included no evidence that the Resident's significant weight loss had been evaluated by the NP. Further Review of the medical record did not indicate that weekly weights for Resident #65 had been obtained since re-admission to the facility. Review of Resident #65's October 2024 Medication Administration Record (MAR) indicated the following: -No house supplements were administered to the Resident on 10/24/24 and 10/25/24 (ordered by the Physician on 10/24/24). -House supplements were administered to the Resident with meals from 10/26/24 through 10/31/24. Further Review of the October 2024 MAR did not indicate the quantity of the House Supplements consumed by the Resident. Review of Resident #65's Certified Nurses Aide Documentation Survey Report (flow sheet) for eating indicated: -Meal percentages consumed for 30 of 56 meals provided on the day (7:00 A.M. through 3:00 P.M.) shift to the Resident were not recorded in October 2024. -Meal percentages consumed for 17 of 27 meals provided on the evening (3:00 P.M. through 11:00 P.M.) shift to the Resident were not recorded in October 2024. Review of Resident #65's November 2024 Medication Administration Record (MAR) indicated: -The Resident's weight was 120 lbs on 11/1/24. -The house supplement was administered to the Resident with meals between 11/1/24 and 11/30/24. -The Resident refused the house supplement five times. Further review of the November 2024 MARs did not include any information relative to the amounts of the house supplements the Resident consumed. Review of Resident #65's Certified Nurses Aide Documentation Survey Report (flow sheet) for November 2024 for eating indicated: -Meal percentages consumed for 16 of 58 meals provided on the day shift to the Resident were not recorded in November 2024. -Meal percentages consumed for four of 26 meals provided on the evening shift to the Resident were not recorded in November 2024. Review of a Physician order dated 11/20/24, indicated: -liquid protein daily, 30 cc (unit of measure) one time a day. Review of Resident #65's clinical record included no evidence that the Resident was weighed in December 2024. Review of Resident #65's NP Note, dated 12/16/24, indicated: -The Resident had trace (minimal) edema in both lower extremities. -The Resident remained a full code status. Further review of the NP Note included no evidence the Resident's significant weight loss had been evaluated by the NP. Review of Resident #65's Weights and Vitals Summary indicated the Resident weighed 90.6 lbs on 1/1/25 (24.5% loss in three months: significant weight loss). Further review of the Resident's Weights and Vitals Summary included no evidence that the Resident was re-weighed when the weight of 90.6 lbs was obtained (which indicated a loss of 29.4 lbs since the previously obtained weight in November 2024). Review of Resident #65's December 2024 Medication Administration Record (MAR) indicated: -The house supplement was administered to the Resident with meals between 12/1/24 and 12/31/24. Review of Resident #65's Certified Nurses Aide Documentation Survey Report (flow sheet) for December 2024 for eating indicated: -Meal percentages consumed for 16 of 56 meals provided on the day shift to the Resident were not recorded in December 2024. -Meal percentages consumed for 10 of 29 meals provided on the evening shift to the Resident were not recorded in December 2024. Review of Resident #65's January 2025 Medication Administration Record (MAR) indicated: -The house supplement was administered to the Resident with meals between 1/1/25 and 1/15/25. Further review of Resident #65's January 2025 MAR included no information to indicate the percentage of the house supplements the Resident consumed. Review of Resident #65's Certified Nurses Aide Documentation Survey Report (flow sheet) for January 2025 for eating indicated: -Meal percentages consumed for eight of 32 meals provided on the day shift to the Resident were not recorded between 1/1/25 and 1/15/25. -Meal percentages consumed for six of 14 meals provided on the evening shift to the Resident were not recorded between 1/1/25 and 1/15/25. On 1/10/25 at 9:21 A.M., the surveyor observed Resident #65 lying in his/her bed, wearing a hospital gown. The Resident was observed to have a small amount of oatmeal on the front of his/her hospital gown and was pulling the front of the hospital gown away from his/her body. Review of Resident #65's Quarterly Nutrition Consult, dated 1/13/25, indicated: -The Resident weighed 90.6 lbs and the Resident's BMI was 15.5 (underweight), low. -The Resident ate independently, supervision as needed. -Regular liberalized diet remained appropriate for promoting adequate intake to meet the Resident's estimated needs. -Meal intakes are 75-100% most meals. -Intake observation for meals was obtained via meal intake records. -Excellent appetite. -Current weight shows significant loss: 24.5% x 90 days. -Add nourishment BID (the type of nourishment or the amount of nourishment to be provided was not indicated). -Order weekly weights for four weeks to monitor. -No further assessment needed. On 1/15/25 at 1:10 P.M., the surveyor observed Resident #65 sitting in a wheelchair in the Unit Dining Room. The Resident was wearing a hospital gown that was tied loosely around his/her neck and his/her forearms and lower legs from the calf down to his/her ankles were exposed. The surveyor observed that the Resident was very thin and both sides of the Resident's neck were sunken in behind his/her collar bone, and the Resident's exposed lower legs and forearms were thin and boney. During an interview on 1/15/25 at 1:23 P.M., CNA #1 said that house supplements were delivered to the Unit by the kitchen staff and that House supplements were not stocked on the Unit. CNA #1 said that the kitchen staff sent one House supplement for each meal on Resident #65's meal trays. CNA #1 said that Resident #65 often consumed the house shakes and that the Resident enjoyed food items that were sweet tasting. CNA #1 also said that meal percentages consumed for every meal provided were to be recorded in the computer for all residents. CNA #1 said that not all meals got recorded at times when there was too much going on the Unit and if there were staff call-outs. CNA #1 said that residents are weighed monthly, weekly, or daily, depending on what the residents need and that the Nurse alerts the CNAs to weights needing to be obtained. CNA #1 said that the Nurse was responsible to enter the residents' weights into the computer as the CNAs were not allowed to enter the weights. During an interview on 1/15/25 at 2:04 P.M., the NP said she had started providing routine coverage at the facility in October 2024 and that she had seen Resident #65 for the first time on 10/16/24, after the Resident returned from the hospital on [DATE]. The NP said she did not have access to any of the residents' electronic health records for about one month after she began providing routine coverage at the facility and that she was dependent upon staff reports and a written communication log for any changes residents may have experienced during that time. The NP said she had not been alerted that Resident #65 had experienced weight loss. The NP said if the facility identified a significant weight change, she should have been notified in order to implement effective dietary interventions, and if necessary, testing to rule out any medical causes for the significant weight change. The NP said if she had been alerted to Resident #65 having a significant weight change, she would have ordered dietary supplementation, such as health shakes, and if weight loss continued, she would have ordered a chest x-ray and additional blood work to evaluate for malignancy. The NP said that she was not notified that the Resident experienced significant weight loss in October 2024 and that the Resident's weight was down to 90.6 lbs as of 1/1/25. The NP also said she had not yet been informed of the Dietician's recommendations to implement weekly weights and nourishment BID following the Dietician's assessment on 1/13/25. The NP said she wished the facility had notified her a couple of months ago that the Resident's weight was trending down and that the Resident had significant weight loss. During an interview on 1/15/25 at 3:37 P.M., the Dietician said she worked part time at the facility. The Dietician said that she did have opportunities where she observed residents eating, but that she was only in the facility approximately one time per week, so she depended on staff reports and documentation for monitoring residents for nutrition. The Dietician said the facility held a Risk Meeting weekly and that Resident #65 was discussed weekly at that meeting. The Dietician also said Resident #65 was on her radar for weight loss. The Dietician said the facility identified Resident #65 as having had a significant weight loss on 10/1/24 and that the Resident's weight loss was discussed at the Risk Meeting on 10/3/24. The Dietician said although the Resident had a gradual weight loss over the previous year that was identified in August 2024, and a significant weight loss identified on 10/1/24, no new interventions were implemented for the Resident following the Risk Meeting held on 10/3/24. The Dietician said that she was continuing to monitor the Resident for dietary supplementation need. The Dietician said that Resident #65's meal intake percentages were not bad and that she monitored meal intake percentages based off of the meal percentage intakes that were entered into the computer. The Dietician also said the facility was good about entering meal percentage intakes. When the surveyor asked about the meal percentage monitoring when several meals were not entered into Resident #65's record, the Dietician said she did not think meal intake percentage recording had been a problem and she would have to look into it. The Dietician said that she did not see Resident #65 between 10/1/24 and 10/10/24, when the Resident was discharged to the hospital, and that she did not re-assess the Resident until 10/18/24, following the Resident's return to the facility on [DATE]. The Dietician said that the re-assessment she completed on 10/18/24 was due to the Resident having had a change in condition relative to a hip fracture and that the change in condition assessment was not triggered due to weight loss. The Dietician said that when she re-assessed the Resident on 10/18/24, she recommended house supplements. The Dietician further said she did not enter the order into the computer until 10/24/24 for the Resident to be provided with house supplements and that she was unsure why obtaining the order for the house supplements was delayed. During an interview on 1/15/25 at 4:04 P.M., with Unit Manager (UM) #1 and UM #2, UM #1 said that Resident #65 was not eating well and was losing weight when he/she returned from the hospital. UM #2 said no interventions were implemented relative to the Resident's weight loss. UM #1 said that Resident #65's weight was down to 90.6 lbs on 1/1/25, the weight was discussed at the facility's weekly Risk Meeting and no re-weight was requested by the Dietician. UM #2 said she did not think the Resident's weight of 90.6 lbs was accurate and that she had requested CNAs re-weigh the Resident. UM #2 asked the surveyor if the re-weight was in the Resident's clinical record. UM #1 was observed to review the Resident's clinical record and said that the record included no information relative to a re-weigh after the weight that was obtained on 1/1/25. UM #1 also said the Dietician did not always attend the weekly Risk Meeting and that the Dietician would provide an email to the facility with recommendations for residents. UM #1 said that the Dietician sent an update to the Risk Team for the meeting that was scheduled for 1/9/25 and the Dietician's recommendations included adding nourishment BID and weekly weight monitoring for Resident #65. UM #1 further said that the meeting scheduled for 1/9/25 did not occur and the recommendations made by the Dietician for Resident #65 had not yet been implemented. UM #1 said that the Risk Meeting did not have to occur in order for recommendations to be implemented. UM #1 also said that Resident #65 received house supplements and the amount consumed by the Resident should be monitored in the Resident's clinical record. UM #2 said she did not know why Resident #65's re-weight from 1/1/25 was not in the Resident's record and that she was going to re-weigh the Resident. On 1/15/25 at 5:15 P.M., the surveyor observed UM #2 request that CNA #6 assist her to weigh Resident #65. CNA #6 assisted the Resident to his/her room and UM #2 transported the chair scale to the Resident's room for weighing. UM #2 said the Resident's weight was 101.2 lbs. UM #2 said that the Resident's current weight still indicated a significant weight loss over the last three months. UM #2 further said, the process is broken. Let's just say that. On 1/16/25 at 8:40 A.M., during an observation and interview, the surveyor observed Resident #65 lying in bed. There were two meal carts observed on the Unit at the time and the surveyor observed CNA #2 passing meal trays from the meal carts to residents in their rooms. CNA #2 said that she was passing meal trays to residents who ate in their rooms and that she would be assisting Resident #65 to eat. The surveyor observed UM #2 in the hallway and asked UM #2 if the surveyor could observe Resident #65's breakfast meal tray. UM #2 removed the tray from the meal cart and picked up the meal ticket which indicated special request for House supplement. The surveyor observed the Resident's breakfast tray contained a covered plate and a covered bowl that UM #2 said was fortified oatmeal. The breakfast tray did not contain a house supplement. UM #2 said that the house supplement was a health shake that was to be sent to the Unit on the Resident's meal tray from the kitchen. UM #2 said that House supplements were not stocked on the Units and it was the kitchen staffs' responsibility to send the house supplements on the meal trays. UM #2 said she needed to go to the kitchen to obtain a house supplement to give to Resident #65. On 1/16/25 at 8:47 A.M., the surveyor observed Resident #65 holding a house supplement while sitting up in bed. The Resident took two sips of the house supplement through a straw, then held the supplement in front of him/herself. During an interview on 1/16/25 at 8:50 A.M., CNA #2 said that she normally assisted Resident #65 to eat breakfast. CNA #2 said that it was hit or miss relative to the Resident accepting the house supplement. CNA #2 said that she found that the Resident more frequently did not accept the house supplement than accept the house supplement at breakfast. CNA #2 also said that Resident #65 required physical assistance from staff to eat. On 1/16/25 at 9:10 A.M., the surveyor observed Resident #65 positioned upright in bed. CNA #2 was seated next to the Resident's bed assisting the Resident to eat. The Resident was eating slowly and accepting small bites of french toast. The surveyor observed the bowl of fortified oatmeal was uncovered, and the bowl was still full. During an interview on 1/17/25 at 7:55 A.M., the Regional Nurse said Nurses are triggered to obtain residents' weights when they view the administration records in the electronic health records. The Regional Nurse said that when the Nurse records the weights into the administration record, that record of weight does not automatically transfer into the Weights and Vitals module in PCC and the Nurse would then have to also enter the weight into the Weights and Vitals module. The Regional Nurse said that he would not expect the Nurses to have to record the weight twice because the weight was already recorded in the clinical record. The Regional Nurse also said that the Weights Exception Report was generated by the weights entered into the Weights and Vitals module in PCC, so if only the Weights Exception Report was being reviewed, staff would miss identifying significant weight changes if not reviewing all of the weight information in the clinical record. The Regional Nurse said that the Nurses were responsible to determine whether a weight obtained was accurate, whether a re-weigh was required, and obtain a re-weight. During a follow-up interview on 1/17/25 at 10:15 A.M., the NP said she ordered 30 cc of liquid protein for Resident #65 on 11/20/24. The NP said she ordered the liquid protein specifically for bone healing due to the Resident having had a hip fracture. The NP said that the liquid protein could have some nutrition supplementation benefit, but that she did not order it specific for the Resident's nutrition because she did not know the Resident had significant weight loss. 2. Resident #85 was admitted to the facility in October 2024, with diagnoses including Alzheimer's Disease, Malignant Neoplasm of Unspecified site of right breast, Major Depressive Disorder, and Urinary Tract Infection. Review of the Minimum Data Set (MDS) Assessment, dated 10/30/24, indicated Resident #85: -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of 15. -required setup assistance from staff for eating and required moderate assistance from staff for Activities of Daily Living (ADL) areas (dressing, bathing, positioning, transfers, ambulation). -had a weight of 150 lbs and height of 60 inches. -had no therapeutic weight approaches. -had no known weight loss or gain in the past 6 months. -was at risk for developing pressure ulcers. Review of the Electronic Record Weights & Vital Signs Module, and Medication Administration Records for October 2024, November 2024, and December 2024, indicated the following weights were obtained: -10/28/24: 150.4 lbs (three individual weight entries of 150.4 lbs were documented on this date) -11/4/24: 139.4 lbs (decrease of 7.3 % in less than 30 days) -11/11/24: 139.5 lbs. -11/18/24: 144.4 lbs. -No evidence of weight obtained on the fourth week after admission. (11/24/24 through 11/30/24) -12/11/24: 140.8 lbs. -No evidence of the Resident having been weighed between 1/1/25 and 1/15/25 (prior to the surveyor's inquiry on 1/16/25). -1/16/25: 130.4 lbs (20 lbs. weight decline since admission and 13% weight decline over three months/ 90 days). Further review of the Weights & Vitals Record indicated the Resident experienced a 7.3 % weight loss (significant) from 10/28/24 to 11/4/24. There was no evidence that a re-weigh was obtained after the weight obtained on 11/4/24, that validated the accuracy of the Resident's weight. Review of Resident #85's clinical record did not include evidence that the facility assessed the Resident to determine if interventions should be implemented to address the weight loss. Review of the Nutrition Care Plan initiated 11/18/24, for Nutritional Risk, indicated Resident #85: -was at nutritional risk related to Alzheimer's disease, breast cancer, Depression and poor intake. -Weigh as ordered, and alert Dietician and Physician of any significant weight loss or gain. -Honor food preferences within meal plan. -Monitor for changes in Nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. -Monitor intake at all meals, offer alternative choices as needed, alert Dietician and Physician to any decline in intake. During an interview on 1/15/25 at 9:11 A.M., CNA #5 said that if a resident needed to be weighed, the Nurses let the CNAs know. During an interview on 1/15/25 at 4:05 P.M., Nurse #5 said that residents are weighed upon admission, weekly for 4 weeks, then monthly or per order and the weights are documented on the MAR. Nurse #5 said if a weight loss occurs, the MD[Physician]/NP/Dietician and family are updated right away. Nurse #5 said if staff notice there is a change from the previous weight, then the resident should be re-weighed to ensure the weight was accurate. The surveyor and Nurse #5 reviewed Res

**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 falls, with interventions for safety that included the assistance of one staff member with toileting, transfers and mobility, the Facility failed to ensure he/she was provided with an adequate level of staff supervision to maintain his/her safety, when on 06/26/24, Certified Nurse Aide (CNA) #1 left Resident #1 unsupervised and unattended standing with his/her walker in the bathroom, Resident #1 fell backwards to the floor, complained of pain, and was transferred to the Hospital Emergency Department where he/she was diagnosed with a fractured left scapula (shoulder blade), and was also noted to have a right elbow skin tear. Findings include: The Facility's Policy, titled Falls Management, dated 03/15/24, indicated residents would be assessed for risk for falls and interventions would be implemented as appropriate, including staff providing strategies to minimize risk for falls. Review of the Report submitted by the facility via the Health Care Facility Reporting System (HCFRS), dated 06/27/24, indicated Resident#1 fell backwards in his/her bathroom while standing with his/her walker. The Report indicated, Resident #1 was left unattended while CNA #1 went to get his/her recliner chair that was out in the hallway. The Report indicated Resident #1 sustained a fractured left scapula and right elbow skin tear and a small cut on his/her right eyebrow. Resident #1 was admitted to the Facility in December 2023, diagnoses included history of falls, abnormalities of gait and mobility, muscle weakness and dementia. Review of Resident #1's Minimum Data Set (MDS) Quarterly Assessment, dated 05/24/24, indicated he/she required maximum assistance with care and required partial to moderate assistance from one staff member for ambulation. Review of Resident #1's Falls Care Plan, reviewed and renewed with his/her May MDS, indicated intervention (dated as initiated on 12/11/23) included for staff to provide extensive assistance of one for transfers and minimum to moderate assistance of one for toileting. Review of Resident #1's Care [NAME] Report (utilized by Certified Nurse Aides, provides direct care staff with a brief overview of each resident's needs), indicated he/she required limited assistance of one staff member to stand and transfer with his/her walker. Review of Resident #1's Lift Transfer Evaluation, dated 06/01/24, indicated he/she was assessed by the Rehabilitation Department as requiring limited to minimal assist to stand, pivot, and transfer. Review of Resident #1's Occupational Therapy Discharge summary, dated [DATE] indicated he/she was unable to stand without upper extremity support and an assistive device for 10 seconds. Review of Resident #1's Nurse Progress Note, dated 06/27/24, indicated that CNA #1 left Resident #1 standing alone with his/her walker in the bathroom doorway, then a few seconds later Nurse #1 heard a bang and found Resident #1 on the floor in his/her bathroom after he/she had fallen backwards. The Note indicated Resident #1 sustained injuries on his/her left humerus (upper arm bone), right elbow and right forehead and was transferred to the Hospital Emergency Department. Review of Resident #1's Hospital X-ray Report of his/her left shoulder, dated 06/27/24, indicated he/she had a fracture of the left scapula. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she was admitted to the Hospital 06/27/24, diagnosed with a left scapular fracture requiring an orthotic sling and found to have a chronic pulmonary embolism. During an interview on 08/22/24 at 3:23 P.M., Nurse #1 said on 6/26/24 at approximately 9:05 P.M., she had administered medication to Resident #1's roommate, and as she was exiting the room to return to her medication cart (located just outside the room) she saw Resident #1 and CNA #1 on their way out of the bathroom. Nurse #1 said she heard CNA #1 trying to talk Resident #1 into going into bed instead of sleeping in his/her recliner chair that was in the hallway (and needed to be brought into the room) and he/she declined. Nurse #1 said she heard CNA #1 pulling the recliner chair into the room. Nurse #1 said while she was outside the door to Resident #1's room, at her medication cart, she heard a bang, went back into Resident #1's room and found Resident #1 lying on the floor in the bathroom after falling backwards. Nurse #1 said CNA #1 had left Resident #1 standing in the bathroom doorway, unattended, to bring the recliner chair into the room. Nurse #1 said Resident #1 complained of pain and said my shoulder is broken. Nurse #1 said after assessing Resident #1 for injuries, she and CNA #1 lifted him/her up off the floor, placed him/her in the recliner, and she obtained an order to transfer Resident #1 to the Hospital Emergency Department. During an interview on 08/23/24 at 9:46 A.M., CNA #1 said she knew Resident #1 had a history of falls and that he/she should not have been left standing in the bathroom unsupervised. CNA #1 said she left Resident #1 standing with his/her walker in front of the toilet and left the bathroom to bring a linen bag and a trash bag out in the hall to clear the clutter and said she had asked Nurse #1 to watch Resident #1 and then heard him/her fall. During an interview on 08/22/24 at 2:08 P.M., CNA #2 said Resident #1 required assistance with all Activities of Daily Living (ADL's) and that she would not leave him/her unattended or alone standing in the bathroom. During an interview on 08/22/24 at 2:15 P.M., The Administrator said that when she completed the facility's investigation that there were inconsistencies with CNA #1's statement, related to the details of where she was at the time of the fall and what she was doing. The Administrator said Resident #1 was left unattended by staff standing with his/her walker, but should not have, fell in the bathroom and sustained injuries requiring a hospital stay.