**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to comprehensively assess and monitor high blood pressure and rectal bleeding for 1 of 3 residents (R2) reviewed for change in condition. Findings include The American Heart Association (AHA) defines hypertensive crisis as a systolic blood pressure higher than 180 and/or diastolic pressure higher than 120. Blood pressure in this range can result in but not limited to stroke, heart attack, loss of kidney function, and aortic dissection. AHA directs for blood pressures that meet this criteria to wait at least 1-2 minutes and take the blood pressure again and consult your doctor immediately. R2's face sheet dated 2/12/25, identified diagnoses of malignant neoplasm (cancerous tumor) of left lower lobe, neoplasm of bone, type 2 diabetes (condition that affects how the body uses sugar as fuel), hypertension (high blood pressure), anemia (low red blood cells), thrombocytopenia (low platelets), irritable bowel syndrome (chronic stomach and intestinal disorder that causes diarrhea, abdomen pain, cramps, bloating, and gas), gastroenteritis and colitis (inflammation of the digestive tract), and diverticular disease of intestines (inflammation or infection of the pouches formed in the colon). R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 did not have cognitive impairment, R2 needed maximum assistance with toilet hygiene, and staff assistance on and off the toilet. R2 was continent of bowel and had occasional incontinence of bladder. R2's progress note dated 12/31/24 at 3:43 a.m., identified at 12:45 a.m. R2 fell while self transferring from toilet to wheelchair. A medium amount of blood was noted in the toilet. Blood pressure reading was 200/72 (normal blood pressure range for adults is 120/80). The note did not identify where the blood originated from. In review of R2's record dated 12/31/24, there was no indication R2 vital signs were rechecked or monitored nor a comprehensive assessment and monitoring of the bleeding until approximately 3:00 a.m. when R2 had large amounts of bleeding from the rectum. R2's progress note dated 12/31/24 at 3:51 a.m., identified at 3:30 a.m., R2 was sent to the hospital via ambulance for large amount of rectal bleeding/clotting. R2's ambulance run report dated 2/12/25, identified ambulance dispatched to facility at 3:04 a.m., and arrived at emergency department at 4:21 a.m. for hemorrhage with primary impression blood in vomit or stood (GI bleed). Blood pressure readings from ambulance were as follows: -3:34 a.m. 138/64 -3:39 a.m. 111/62 -4:00 a.m. 119/63 -4:14 a.m. 97/62 R2's hospital Discharge summary dated [DATE], identified R2 had an intensive care unit (ICU) hospital stay from 12/31/24-1/6/25 with a diagnosis of hemorrhagic shock (life threatening condition that occurs when a person loses a lot of blood and the body cannot get enough oxygen to the organs), gastrointestinal hemorrhage, secondary to a colonic arterial bleed as per imaging of the abdomen, and underwent inferior mesenteric artery embolization and given a blood transfusion. discharged back to facility 1/6/25. During a phone interview on 2/13/25 at 9:41 a.m., nursing assistant (NA)-A stated R2 had been in bed at the beginning of the shift on 12/31/24. R2 required assistance of one person to transfer and was surprised when R2's bathroom call light was on. NA-A went to R2's room and found her on the floor in the bathroom. NA-A noted blood in the toilet but R2 did not complain of pain or tenderness and did not appear hurt from the fall. NA-A assisted R2 back to bed after licensed practical nurse (LPN)-A assessed R2. NA-A stated not long after the fall, R2 again put her call light on and when she entered her room R2 said I think I made a mess in my pants. NA-A noted R2's brief was full of bright red blood and completely full. NA-A left room to get supplies and notified the nurse of blood overflowing from R2's brief. NA-A called LPN-A to the room when she realized that the blood was not stopping and they could not get ahead of it. NA-A told LPN-A that she thought R2 should be sent in and LPN-A agreed and called an ambulance. NA-A stated R2 required three complete bed changes before the ambulance got there from all the blood. NA-A was not sure if LPN-A had taken R2's vital signs again after she had fallen. During a phone interview on 2/13/25 at 9:27 a.m., LPN-A stated R2 fell while transferring from the toilet to the wheelchair on 12/31/24. LPN-A was surprised R2 did not call for help to transfer from the toilet as she required assistance of one staff for help. LPN-A noted a small amount of blood in the toilet and examined R2's rectal area and saw a small amount of blood but thought it was from hemorrhoids. R2's blood pressure was elevated at 200/72 at the time of the fall. A short time after the fall, R2 put her call light on again and said she had an incontinent episode, the incontinent garment contained a significant amount of blood. LPN-A stated she missed documentation of the incident. LPN-A stated she did recheck R2's blood pressure in-between the times R2 put in her call light on, but did not document it and did not recall what the vital signs were or if they were abnormal. During an interview on 2/15/25 at 9:13 a.m., LPN-B was unsure what signs or symptoms to monitor for high blood pressure aside from providing ordered medications and giving water to drink. LPN- B reviewed R2's chart for vital signs and fall follow-up from 12/31/24 and verified no vital signs were completed after the initial set after R2's fall and no additional documentation was completed on rectal bleeding. During an interview on 2/12/25 at 10:02 a.m., registered nurse (RN)-A stated after a fall vital signs are done immediately and then residents are assessed for the next three shifts for fall follow-up but that did not necessarily include completing vital signs. High blood pressure is typically above 140-150 systolic (top number). Right after a fall a fall you would expect the blood pressure to be a little bit higher, however, LPN-A should have re-checked R2's blood pressure to verify it did not remain that high. R2 did not have rectal bleeding prior to the fall. During an interview on 2/12/25 at 12:50 p.m., director of nursing (DON) stated anything greater than 140 systolic medical doctor (MD)-A was to be notified. 200/72 is a high blood pressure. DON would expect the licensed nurses to complete an assessment and take a manual blood pressure to verify the blood pressure results. DON felt the assessments and vital signs were taken but just not documented after the fall. DON stated every person is different and it being emergent would depend on the individual situation. MD-A was always available and requested phone calls if staff were on the fence about a situation. During a phone interview on 2/13/25 at 10:21 a.m., MD-A stated he would want to be notified of a blood pressure that was 180 or above systolically and would want the blood pressure monitored every few minutes to see if it comes down. The facilities blood pressure monitoring guidelines, undated, identified to provide trained medication aides and licensed nurses with direction regarding blood pressure and pulse monitoring when a resident is prescribed an ace inhibitor/angiotensin receptor blocker, or beta blocker. The policy does not address when high or low blood pressure is obtained when not taking these medications. The facilities procedure for falls dated 8/22, identified the nurse call MD-A's cell phone directly (with the phone number provided) as needed. MD-A must be notified by phone if a resident is on a blood thinner with active bleeding/bruising/head injury, or internal injury is suspected related to unstable vital signs, neuro exam or if the resident sustains other significant injury resulting in new or worsening pain.

Based on observation, interview, and document review, the facility failed to assess resident for safety and the ability to self-administer medications (SAM) for 1 of 1 resdient (R99) with nebulizer treatment. Findings include: R99's medical diagnoses indicate R99 with hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of right dominant side due to a stroke), dysphagia (inability to swallow food or liquid), aphasia (damage to the speaking or language areas of the the brain), depression, diabetes, and chronic obstructive pulmonary disease. R99's physician orders indicate R99 admitted to facility on 1/5/24, start date of 1/5/24 for, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG[milligram]/3 ML[milligram] 3 ml inhale orally four times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE. During an observation on 1/22/24 at 3:19 p.m., R99 was in bed with nebulizer treatment mask being held in her left hand away from her face as nebulizer machine was running. At 3:20 p.m., the nebulizer mask was on her bedside table while the machine was running with liquid observed in the nebulizer cup attached to the mask and tubing. During observation and interview with the licensed practical nurse (LPN)-B on 1/22/24 at 3:35 p.m., LPN-B walked with surveyor to R99's room and assessed the nebulizer. The nebulizer machine was running with the mask on the bedside table. LPN-B stated the medication was finished and turned off the machine. LPN-B stated, I did leave the room while I administered it. She did remove the mask also this morning, so I do not know how much of the medication she [R99] received. LPN-B stated she did not know if R99 had a SAM assessment to determine if R99 was safe or competent to administer her nebulizer treatment. During interview with LPN-C on 1/22/24 at 3:45 p.m., LPN-C stated, someone is not with her [R99] the whole time to watch her take that med. She is not getting all of her medications if she takes it off and we don't know how much of the med she has taken. During interview with the unit case manager and registered nurse (RN)-A on 1/22/24 at 3:45 p.m., RN-A stated R99, is not appropriate for self-administration of meds. If she pulls off the mask then there is no way to make sure she is taking the complete dose of the medication. During interview with RN-B on 1/23/24 at 12:27 p.m., RN-B stated she was assigned to care for R99 on 1/21/24 during the evening shift. RN-B stated R99, sometimes pulls it off [nebulizer mask] and I will re-put it back on. I have left the room before and come back and it is still running so I have to put back on her. I try to stay in her room. If she pulls off the mask she is not getting the full dose. RN-B stated R99 did not have a SAM order to safely administer her own medications. During interview with LPN-D on 1/23/24 at 1:58 p.m., LPN-D stated she was familiar with R99 and stated R99 will take off the nebulizer mask several times during the administration of it. LPN-D stated she reminded R99 to keep the mask on and, when I walk past her room the face mask is on the floor [while still running]. LPN-D stated, if you are busy with 5 other patients then she [R99] won't get it put back on. LPN-D stated, My thought is that staff should be in there during the full administration [of the nebulizer]. LPN-D also stated R99 was not competent to SAM the nebulizer. During an interview on 1/24/24 at 1:00 p.m., director of nursing (DON) stated R99 was not competent to administer the scheduled nebulizer treatment because she takes it off. DON stated the SAM assessment is to be completed by the nurse manager at every admission, quarterly, or significant change Minimum Data Set (MDS) timing. DON stated R99 admitted to facility on 1/5/24 and had not had the SAM completed. Facility policy titled Self-Administration of Medications and Bedside Medications Policy and Procedure revised 11/22 state: Residents may choose to administer their own medication. Residents will be asked on admission if the do/do not wish to self-administer their own medications. Residents who wish to do so will be assessed by a minimum of three members of the health care plan team and the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than 5 percent (%). Six medication administration errors occurred out of 26 opportunities resulting in a 23.08 % medication error rate for 1 of 4 residents (R99) observed during medication pass. Findings include: R99's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R99 had severely impaired cognition and was diagnosed with kidney disease, diabetes, depression, chronic obstructive pulmonary disease (COPD- incurable lung disease causing breathlessness, frequent coughing, and chest tightness), hypertension, a heart dysrhythmia, and a stroke. R99's Order Summary Report dated 1/24/24, indicated R99's medications should have be crushed separately, dissolved in 15 milliliters (mL) of water each, and administered separately. The report indicated the following medications were to be administered via the gastric tube: 81 milligrams (mg) of aspirin daily, 25 mg of chlorthalidone (treat high blood pressure) daily, 25 mg of carvedilol (treat high blood pressure and heart failure) two times a day, 2.5 mg of apixaban (used to prevent serious blood clots from forming due to a certain irregular heartbeat) two times a day, 10 mg of escitalopram (used to treat depression and anxiety) daily, and 20 mg of lisinopril (used to treat high blood pressure) daily. During an observation and interview on 1/23/24 at 10:12 a.m., licensed practical nurse (LPN)-E was observed removing the aspirin, chlorthalidone, carvedilol, apixaban, escitalopram, and lisinopril from its packaging and placing them in the same medication cup. The medications were then transferred to a clear medication bag and crushed together using a manual levered machine. LPN-E then transferred the crushed medications to a small cup and entered R99's room. LPN-E diluted the medications in the cup with water set them on the side table and left the resident room to gather more supplies. LPN-E stated that she had not seen an order in the medical record indicating she could safely crush, dilute, and administer the medications together. LPN-E stated she expected the pharmacist to review the medications on admission and add a note to the resident orders if she could not crush, dilute, and administer them together and had not noted this in R99's chart. LPN-E then called the director of nursing (DON) per her report, to confirm she could administer the medications together. LPN-E stated the DON said as long as an order was not in the chart to administer the medications separately, she could combine and give them together through R99's gastric tube. LPN-E re-entered R99's room, flushed the gastric tube with water, and administered the combined medication solution through the gastric tube, and then again, flushed the tube with water. During an interview on 1/23/24 at 2:52 p.m., the consulting pharmacist (CP) stated when a resident was admitted to the facility, he completed a medication reconciliation but he did not assess whether nursing staff could safely dilute and administer medications together through a gastric tube. CP stated if the nursing staff had questions regarding the safe administration of medications through a gastric tube, he would have been able to assist them with this but did not recall anyone asking for assistance with this recently. CP stated if medications were crushed, diluted, and administered together, he would worry about a possible compatibility issue between the medications and the adverse effects this could have on a resident. During an interview on 1/24/24 at 8:25 a.m., the DON stated she expected the pharmacist and physician to review the medications on admission to ensure they could have been safely crushed, diluted, and administered together through a gastric tube. The DON stated she had received a message from the pharmacist yesterday indicating he did not review the medications to ensure they could be crushed, diluted, and given together through a g-tube and she was surprised by this. The DON stated she would be concerned the medications should not have been mixed and could adversely affect the resident. During an interview on 1/24/24 at 12:48 p.m., the medical director (MD) stated he was not aware of an order or a policy indicating nursing staff could combine and administer medications together through a g-tube. The MD stated if this was the current policy, it should have been updated to indicate nursing staff should not mix medications together like this and instead administer the medications separately. The Institute for Safe Medication Practices article titled Preventing Errors When Preparing and Administering Medications Via Enteral Feeding Tubes dated 11/17/22, indicated that multiple medications should not be mixed and given at once through an enteral tube because of possible medication incompatibility issues. The facility Administration of Medication Via Feeding Tube dated 12/22, indicated that medications administered via a feeding tube could be mixed and administered together unless specific instructions not to were received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to reassess resident's ability to safely and independently take medications and ensure appropriate storage of medications for 1 of 1 residents (R)9 reviewed for self-administration of medications who was found to keep her medications at bed-side. Findings include: According to R9's annual Minimum Data Set(MDS) assessment dated [DATE], R9 was cognitively intact. R9 suffers several medical disorders, most significantly a chronic pain syndrome for which R9 complains of nearly constant pain and requires oral medication for relief. A physician order for R9 indicated, may be independent with medications after set-up. Nurse to check back in 1/2 hour to make sure medications have been taken. May have certain medications at the bedside: TUMS, diclofenac gel [non-steroidal arthritis rub]. Tums tablet chewable (calcium carbonate antacid), give 1 tablet by mouth as needed for supplement. May self-administer and keep at the bedside. Follow label directions and Diclofenac Sodium Gel 1% apply to affected areas topically as needed for pain management related to other hypertropic osteoarthropathy multiple sites, may keep tube at the bedside for self-administration use two times daily and PRN (as needed). A review of R9's medication administration record (MAR) for September and October of 2022 included no documentation of PRN use of Diclofenac gel or Tums tablets. R9's care plan did not include a specific area for self-administration of medications; however, a focus problem area last revised 12/2/21 indicated R9 had pain related to reverse total shoulder arthroplasty and inflammation in left wrist. Also bilateral osteoarthritis of knees. Another focus problem area last revised 7/28/20 indicated R9 has forgetfulness, a decline in strength and mobility, wears bilateral hearing aids and had very independent personality. A psychosocial focus problem area last updated 10/13/21 indicated R9 had some memory impairments. On 10/11/22, at 12:03 p.m. R9 was observed to have a 30 ml plastic medication cup sitting on a table in her room full to the top with large [NAME] medication tablets of various sizes. R9 stated these were Tums and she preferred to keep them out in the medication cup as it was easier for her to get to them. R9 stated she took several Tums each evening. R9 stated the nurses would usually bring her medications to her and stand there while she took them. R9 stated she was not able to clearly see the medications as they were small, and she was not sure what medications she was taking. R9 stated she would not be able to identify what her pain pill looked like, and would not be able to differentiate between a tablet of Tylenol and her opioid pain medication. R9 said she might take 3 or 4 pills at a time, but was not able to say what they were for or describe the frequency with which she took them. R9 stated some nurses would leave her medications for her to take rather than stand to watch her take them, and sometimes she found medications had been left in her room for her when she had been out. R9 stated sometimes she would leave the room herself without taking the medications nurses had brought her, but would return later and take them. R9 said the medications simply sat at her bedside until she was ready to take them. During an interview and observation on 10/11/22, at 12:09 p.m. a licensed practical nurse (LPN)-A stated residents can self-administer medications, but first a nurse case manager must do an assessment to determine if they are able to do so safely. LPN-A stated it was important for the resident to be alert and oriented, and thought a nurse should determine if the resident was able to correctly and safely take medications before they were able to allow resident self-administration. LPN-A stated medications could not be left in a resident room unless the resident was there and had an order to self-administer. LPN-A also stated medications could not be stored in a resident's room unless there was a physician's order. In addition, LPN-A stated medications kept in a resident's room should remain in the original container with a label indicating the medication and dosing instruction. LPN-A went to R9's room and observed the Tums in the plastic medication cup, and after R9 allowed it, located a plastic storage container in her drawer that held loose [NAME] colored medication tablets of various sizes. This container held approximately 1.5 to 2 cups of tablets and had a hand written note on the top indicating they were Tums, but no dosage, directions or expiration date was included. R9 stated the medications were her Tums and had been supplied by a family member. LPN-A stated she would notify the case manager. During an interview on 10/11/22, at 12:57 p.m. a registered nurse (RN)-A stated residents had the right to self-administer medications if they had a physician's order and had been assessed to be able to take medications appropriately. RN-A stated the facility's current assessment for self-administration of medications addresses whether a resident is oriented and has the visual and physical capacity to take medications independently. RN-A stated a resident should be able to identify their medications and have a basic understanding of what they are taking and when. RN-A stated medications must be stored in their proper containers with a printed label with medication name and directions. RN-A stated R9 needed to be re-evaluated for safety with self-administration of medications. During an interview on 10/11/22, at 1:17 p.m. the director of nursing (DON) stated self-administration of medications was allowed, but expected the nurse case manager and the interdisciplinary team to review a completed assessment and discuss the resident's ability to safely and independently take medications as ordered. DON stated residents with difficulty identifying medications should only self-administer medications that had been set up by a nurse, and even then it may not be appropriate. DON stated it would depend on the resident and how determined they were to take their medications independently. During an interview on 10/11/22, 1:56 p.m. the administrator stated she had been made aware of an incident that had occurred on 10/4/22 when a nurse, LPN-B found a cup with R9's medications in her room, pre-set, awaiting for R9 to take them. LPN-B identified an error in the medications, and removed them from the room, but R9 had not identified that there was an error. During an interview on 10/11/22, 3:30 p.m. R9 stated she did not understand a reason why non-prescription medications could not be kept in residents' rooms, saying they are safe if they are sold over the counter. R9 denied keeping any medications in her room aside from Tums; however, at that time, a tube of Diclofenac gel was observed sitting on her overbed table. A facility policy titled Self-Administration of Medication, not dated or signed, indicated residents may choose to administer their own medications. The guidelines in the policy indicated that to prove competency, the resident must verbalize an understanding of the medications that are ordered and the potential side effects and the nurse shall set up and bring medications to the resident during the time period prescribed. The licensed nurse shall record the medication on the MAR as self-administered by the resident. The nurse shall return during the shift to ensure the medications were taken and sign MAR verifying the medications were taken. Residents who are doing self-administration of medication may also arrange with the care plan team to take their medication from a locked container in their room and record their own administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to reassess and monitor the effectiveness of interventions and coordinate care among the interdisciplinary team for 1 of 1 residents (R10) who had a significant weight loss and poor nutritional status. Findings include: According to R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], R10's primary diagnosis was dementia and she was not able to complete a basic cognitive assessment. The MDS indicated R10 required supervision, set up and cues for eating, and did cough during meals. R10 weight was 125 pounds, had intact skin, and at risk for pressure ulcers. According to a quarterly MDS dated [DATE], R10 was not able to complete the basic cognitive assessment and had memory problems; required set up and cues for eating and weighed 130 pounds. According to both of these MDS, R10 suffered malnutrition. According to R10's care plan focus problem area dated as last revised 10/27/21, R10 had a nutritional problem, moderate protein/calorie malnutrition and unplanned weight loss. The care plan indicated R10 had previously been on a supplement of prosource for additional protein but this was discontinued on 1/27/21 because R10 did not have any skin breakdown. A 4 ounce dietary supplement was added to be given three times daily starting 4/21/22, but this also indicated R10 would often push it away and therefore the supplement should be offered with meals. According to physician orders for R10 facility was to provide: general diet, mechanical soft texture, extra moisture such as gravy, sauce, broth. Bacon ok per patient/family desire. Cut to bite-size pieces. Verbal cues for 1 bite at a time. Additionally, the orders included: dietary supplement 120 cc between meals three times a day for weight loss. According to R10's recorded weights, on 10/6/22, R10 weighed 115 pounds and on 9/8/22, the resident weighed 118 lbs, a weight loss of 2.5% in one month. On 6/9/22, the resident weighed 124.9 lbs. The weight loss from 6/9/22 to 10/6/22 equaled a loss of 7.9%. On 4/7/22, R10 weighed 132 lbs. The weight loss between 4/7/22 and 10/6/22 equaled a 10.6% weight loss. According to R10's medication administration record (MAR), the physician ordered supplements were offered 33 times between 10/1/22 and 10/11/22. R10 refused the supplement or took only sips of the supplement in 17 out of 33 offerings. A review of R10's meal intake showed the facility was offering five meals per day. In a 14 day look back from 10/12/22 R10 was offered 70 meals of which she consumed 75-100% of only eight. R10 had 40 instances where she consumed 25% or less of the meal offered and twice refused all foods offered. According to the last nutritional progress note in R10's chart 7/27/22 ,12:37 p.m. Data: Per Speech Therapy: Continue with the mechanical soft diet and thin liquids. Bacon okay per patient request (patient/family desire) Bacon cut to bite sized pieces. Moderate verbal cues for 1 bite at a time. Continued close supervision during meals, assistance with meal set up. Cues for slow rate, small bites/sips, alternate solids/liquids, upright positioning during and 30 minutes after meals, chin tuck. Thorough oral cares 3-5X/day, check for any pocketing following meals and clear residue. Action: Dietary plan of care updated. Response:[left blank]. During an interview on 10/12/22, 9:03 a.m. a family member (FM)-A stated she had talked with the facility nurse case manager for R10 regarding on-going weight loss. FM-A stated the family was concerned about R10's weight loss as they have noted it seems like she is down a few pounds every week. The family is taking turns coming to the facility to assist R10, and they generally bring in something that they know R10 will eat, but FM-A said it takes R10 a long time to finish anything. FM-A stated R10 would usually eat macaroni and cheese if she brought it, as well as soft fruits such as peaches, but she had noticed some things R10 used to eat on a regular basis she no longer seems interested in. FM-A stated she was not sure if R10 was taking the offered supplements, and did not know if anything different had been tried. FM-A stated staff took R10 to the dining room, but because of Covid limiting activities in the nursing home, FM-A did not believe she could go to the dining room to see how well R10 was doing on her own, or with staff assistance. FM-A said R10 liked soup but she did not know how often it was offered or how much R10 was eating overall. During an interview on 10/12/22, 10:12 a.m. R10 was observed to have a visitor, FM-B who provided R10 with a dish of macaroni and cheese. R10 was feeding herself with on-going cues from FM-B. FM-B stated family was aware R10 was losing weight and thought it must be a normal consequence at the end of life. FM-B was unsure what the facility could be doing to encourage R10's nutritional intake, but stated R10's food preferences seemed to have changed. FM-B stated R10 did not like the supplement that was offered, and did not seem to enjoy sweets anymore. FM-B said R10 would probably eat macaroni and cheese every day, might eat mashed potatoes if they did not put gravy on them and loved soup, but seemed to dislike textures and might spit out lumps and vegetable. On 10/12/22, 10:14 a.m. a resident assistant (RA)-A stated R10 required assistance from staff to eat. RA-A said sometimes R10 was able to eat with supervision, but usually required extensive assistance. RA-A has not noticed any special favorite foods being served to R10 at meal time but said she will start spitting it out if she does not like it and they would stop feeding her then. During an interview on 10/12/22, 11:19 a.m. the facility dietary manager (DM) stated she did not meet with the interdisciplinary team or the nursing department on a routine basis, but she expected nursing staff to notify her if a resident had on-going weight loss. DM stated she had a list of residents with weight loss that she would review on a weekly basis. DM stated R10's last nutritional review had been done by her in July when her MDS was due, but unfortunately, DM stated she fell off my radar. She is supposed to be a weekly review. DM stated she was not aware of R10's continued weight loss, and said it was the responsibility of the unit nurses to notify the dietary department. DM also stated she was not aware that R10 was not taking significant amounts of her dietary supplement or that her meal intake was low. DM stated staff could notify her in person, via a phone call or send her an email so she could review the current care plan, look again at the favorite foods list, talk with family and revise the nutritional plan for R10. During an interview on 10/12/22, 12:16 p.m. R10's physician (MD)-A stated he was concerned about R10's weight loss as it is always challenging for elderly patient's to get enough protein and overall calories to prevent cachexia (weakness and weight loss). Given R10's weight loss, MD-A stated an expectation for a nutritionist or dietician to remain involved on a regular basis in adjusting R10's plan in order to prevent continued weight loss and to be sure she was maintaining her muscle mass. MD-A stated R10 might require more frequent meals, increased assistance with feeding or a change in supplements depending on what nutritional needs were assessed by the nutritionist. MD-A stated R10 should have received more regular assessments since July for possible interventions given her on-going weight loss. During an interview on 10/12/22, 12:36 p.m. the facility's registered dietician (RD)-A stated an expectation to be notified of residents who have on-going and or significant weight loss. RD-A stated she had not been notified of R10's continued weight loss, but had she received notification she would have done a careful assessment including a review her physical condition and diagnosis, review medical notes and progress notes, watch how R10 is eating and look at her medication regime to see if she could determine what might be contributing to the weight loss. RD-A stated family may not want to take an aggressive route, but it was important to review the resident and family wishes again to ensure there is no wish to start tube feedings, to utilize appetite stimulating medications or conversely, to choose hospice care at end of life. RD-A stated that after an assessment was done, she would be able to work the DM-A and facility case manager on a change in her plan of care and suggest alternative supplements since R10 was not taking what was offered at this time. During an interview on 10/12/22, 12:52 p.m. the facility director of nursing (DON) stated weights were measured by nursing staff at least weekly. If a weight changed by 5 lbs or more, or if the electronic health record indicated a significant change in weight, the unit nurse was expected to notify the unit case manager who would then notify the DM-A. DON stated weight loss was monitored by the DM-A, but DON was unable to state when regular communication occurred between the nursing department and the dietary department. DON stated DM-A did not attend the morning meeting, and stated weight loss was not usually discussed at their morning meetings or interdisciplinary meetings. Facility provided a policy titled Weight Policy, last updated 7/15/13 that indicated a staff nurse would immediately notify the RN case manager and dietary manager of a weight loss of 5 lbs or more. The dietary manager was to notify the dietician who would evaluate a weight change of 5% in 30 days, 10% in 180 days or others as appropriate, and nursing would notify the physician. The policy indicated nursing, the dietary manager and dietician would work together to determine interventions including one or all of the following: 8 oz of whole milk at all meals, high calorie deserts for dinner and supper, health shakes or supplements between meals, supplements with medication pass, alternative food consistency, meet with residents and family to determine favorite foods and beverages and get their input on why they think there is weight loss, rule out conditions and medications that may cause a poor appetite, get recommendations from physician, family or resident, other interventions as indicated. The policy did not provide a procedure for systemic communications among team members.