**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement interventions to prevent weight loss and failed to notify the physician of weight loss for one resident (Resident #15) in a selected sample of 13 residents. The facility's census was 33. Review of the facility's weight monitoring policy, revised 05/07/24, showed the following information: -Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. -Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. -The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: Identifying and assessing each resident's nutritional status and risk factors; Evaluating/analyzing the assessment information; Developing and consistently implementing pertinent approaches; Monitoring the effectiveness of interventions and revising them as necessary. -Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following, to the extent possible: Identified causes of impaired nutritional status; Reflect the resident's personal goals and preferences; Identify resident-specific interventions; Time frame and parameters for monitoring; Updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or a new causes of nutrition-related problems are identified. If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate. The resident and/or resident representative will be involved in the development of the care plan to ensure it is individualized and meets personal goals and preferences. -Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. -The physician should be informed of a significant change in weight and may order nutritional interventions. -The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss. -Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed. -The Registered Dietitian (RD) or Dietary Manager (DM) should be consulted to assist with interventions; -Actions are recorded in the nutrition progress notes. -Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. 1. Review of Resident #15's face sheet (a document that provides a quick snapshot of an individual's medical and personal information) showed the following information: -admission date of 05/04/22. -Diagnoses included Parkinson's disease without dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs or trunk), without mention of fluctuations, stroke, dementia, and cognitive communication deficit. Review of the resident's care plan, revised 04/22/24, showed the following information: -At risk for impaired nutritional status. -Offer alternatives if meal intake is less than 75%. -Monitor the resident's weight at least monthly and more often as ordered/indicated. -RD to consult monthly and make recommendations as needed. -Prepare and serve the resident a regular diet as ordered. -Encourage the resident and/or family to participate in meal planning regarding likes/dislikes and attempt to honor his/her preferences. -The resident preferred a scoop plate at meals to promote independence. -On 07/26/24, the resident was diagnosed with a terminal condition related to senile degeneration of the brain; -Family chose for the resident to receive hospice services. -The resident was confused at times related to dementia; -Remind the resident to chew well and eat slowly (due to at risk for gastric reflux). Record review of the resident's hospice chart showed the resident admitted to hospice on 08/01/24. Review of the resident's weight record showed the following: -On 12/16/24, a nurse documented the resident weighed 183.2 pounds (lbs). -On 01/13/25, a nurse documented the resident weighed 177.2 lbs (a 3.2% loss in 1 month). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 01/16/25, showed the following information: -The resident had unclear speech (slurred or mumbled words); -Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Usually understands - misses some part/intent of message but comprehends most conversation; -Short and long term memory problem; -Functional limitation in range of motion: No impairment; -Moderately impaired cognitive skills for daily decision making; -Inattentive fluctuates (comes and goes, changes in severity); -Required supervision with eating; -Required substantial/moderate assistance with upper body dressing, personal hygiene and transfers; -Used a manual wheelchair for transfers; -Weighed 177.0 lbs; -The resident had a 5% or more weight loss in the last month and not on a physician prescribed weight-loss regimen; -Received Hospice services. Review of the resident's electronic medical record showed staff did not updated the resident's care plan to reflect the newly identified weight loss or interventions implemented related to weight loss. Review of the resident's weight record showed on 02/03/25, a nurse documented the resident weighed 177.0 lbs. Review of the resident's nurses' notes showed the following information: -On 02/26/25, at 2:04 P.M., a nurse documented the resident continued on hospice for end-of-life care. The resident ate meals in the dining room and fed self without difficulty while supervised by care staff for safety. The resident had mumbled speech and was able to verbalize some wants and needs with care staff anticipating and meeting any additional needs. -On 03/01/25, at 11:44 A.M., a nurse documented the resident continued on hospice for end-of-life care and was currently up in the wheelchair via maximum assistance of one staff. The resident was in the dining room awaiting the noon meal. Fed self breakfast in the dining room while supervised by care staff for safety. -On 03/02/25, at 11:21 A.M., a nurse documented the resident continued on hospice for end-of-life care. Ate breakfast in the dining room and slowly fed self. -On 03/03/25, at 12:15 P.M., a nurse documented the resident continued on hospice for end-of-life care. The resident was in the dining room awaiting the noon meal. The resident fed self breakfast in the dining room without difficulty with good intake while supervised by care staff for safety. Review of the resident's weight record showed on 03/03/25, a nurse documented the resident weighed 172.0 lbs (a 2.2% loss/1 month; 6.1% loss/2 month). Review of the resident's electronic medical record showed staff did not updated the resident's care plan to reflect the newly identified weight loss or interventions implemented related to weight loss. Review of the resident's nurses' notes showed the following information: -On 03/06/25, at 4:23 P.M., a nurse documented the resident continued on hospice for end-of-life care and was currently up to his/her wheelchair with maximum assistance of one staff, and in dining room awaiting the evening meal with meals in dining room while supervised by care staff for safety. -On 03/11/25, at 9:59 A.M., a nurse documented the resident continued on hospice for end-of-life care. The resident was up in his/her wheelchair via maximum assistance of one staff. Care staff propelled the resident to and from the dining room for the morning meal where he/she fed himself/herself. The resident remained stiff with a flat affect. He/she had mumbled speech and continued to speak in a low tone but able to verbalize some wants and needs with care staff anticipating and meeting any additional needs. Review of the resident's weight record showed on 03/13/25, a nurse documented the resident weighed 162.0 lbs (5.8% loss in 10 days; 11.5% loss/3 months). Review of the resident's electronic medical record showed staff did not updated the resident's care plan to reflect the newly identified weight loss or interventions implemented related to weight loss. Review of the resident's nurses' notes showed the following information: -On 03/14/25, at 7:37 A.M., the Director of Nursing (DON) entered the resident's weight of 162.0 which triggered a weight warning notification in the note. -On 03/15/25 at 12:36 P.M., a nurse documented the resident continued on hospice for end-of-life care, and was currently up in his/her wheelchair in the dining room completing the noon meal while supervised by care staff for safety. -On 03/16/25, at 10:50 A.M., a nurse documented the resident continued on hospice for end-of-life care. The resident utilized a wheelchair for mobility with care staff propelling the majority of the time as he/she was unable due to weakness. The resident ate meals in the dining room and fed self slowly. Review of the resident's weight record showed on 03/17/25, a nurse documented the resident weighed 159.0 lbs (1.8% loss 1 month/10.2% loss in 3 months). Review of the resident's electronic medical record showed staff did not updated the resident's care plan to reflect the newly identified weight loss or interventions implemented related to weight loss. Review of the resident's nurses' notes showed the following information: -On 03/17/25 at 12:23 P.M., the DON entered the resident's weight of 159.0 which triggered a weight warning notification in the note. -On 03/17/25 at 2:05 P.M., a nurse documented the resident continued on hospice for end-of-life care. The resident ate meals in the dining room and slowly fed self while supervised by care staff with care staff assisting with feeding as needed. -On 03/20/25 at 1:01 P.M., a nurse documented the resident continued on hospice for end-of-life care. The resident was in the dining room with staff assisting him/her with feeding of the noon meal. The resident spoke in a low tone and speech remained mumbled. Review of the resident's meal intake record showed the following: -On 03/21/25, staff documented: Breakfast: ate 50%, supplement column was blank indicating a supplement was not offered; Lunch: ate 50%, supplement column was blank indicating a supplement was not offered; Supper: 25%, supplement column was blank indicating a supplement was not offered. -On 03/22/25 staff documented: Breakfast: ate 100%, supplement column was blank indicating a supplement was not offered; Lunch: ate 50%, supplement column was blank indicating a supplement was not offered; Supper: Staff did not document meal intake for any residents. -On 03/23/25, staff documented: Breakfast: column left blank for the resident, supplement column was blank indicating a supplement was not offered; Lunch: ate 75%, supplement column was blank indicating a supplement was not offered; Supper: 25%, supplement column was blank indicating a supplement was not offered. -On 03/24/25, staff documented: Breakfast: ate 50%, supplement column was blank indicating a supplement was not offered; Lunch: ate 100%, supplement column was blank indicating a supplement was not offered; Supper: 50%, supplement column was blank indicating a supplement was not offered. Observation and interview on 03/24/25 showed the following: -At 10:18 A.M., a social worker from hospice entered the resident's room for a visit. She said the resident has had a recent general decline. He/she thought the resident had poor vision, but it was difficult for him/her to know for sure due to the resident's difficulty communicating. The social worker handed the resident his/her handled cup with a straw before leaving the room. -At 10:25 A.M., the resident still held the water cup and appeared to be trying to take a drink. He/she would look at straw/cup, but did not raise his/her arm high enough for the straw to reach his/her mouth. The resident lowered his/her arm slightly then back up slightly towards his/her never reaching the straw. The resident attempted this two times then lowered the cup to rest on his/her leg. During an interview on 03/24/25, at 12:20 P.M., the resident's family member said the resident had a weight loss of at least 22 lbs or more since November 2024. The resident now weighed 159 lbs. The family member wondered if the resident's weight loss had to do with him/her needing more assistance with meals. The family member also noticed the resident was not eating the snacks he/she brought which was a change for him/her. A few months ago perhaps, the resident told the family member he/she thought he/she had a problem because he/she could not urinate. The family member thought perhaps the resident was not drinking enough. Review of the resident's nurses' notes on 03/24/25, at 3:34 P.M., showed the DON entered the resident's weight of 159.0 which triggered a weight warning notification in the note. Review of the resident's progress notes on 03/24/25, at 11:15 P.M., showed the dietitian documented the following: -Weight Note: The resident was on a regular diet with thin liquids. -No meal intake documentation was available, -The resident's Braden assessment (a tool for determining pressure ulcer risk) indicated his/her nutrition was very poor. -The resident's weight on 03/24/25 was 159 lbs; this was down 6 lbs in 1 mo, and down 18 lbs since admit 02/03/25 (10.2% loss; the resident admitted in 2022, the facility changed EMRs 02/2025). -Offer the resident preferred foods and supplements as desired, monitor intake on current diet, and weight for significant changes. -Registered Dietician would follow and be available as needed. Review of the resident's meal intake record on 03/25/25, showed staff documented: Breakfast: Staff did not document meal intake for any resident; Lunch: ate 25%, refused the supplement; Supper: ate 50%, drank 100% of supplement. Review of the resident's nurses' notes, dated 03/25/25, showed the following: At 8:48 A.M., a nurse documented the resident continued on hospice for end-of-life care. Alert and oriented to self and family. Mumbled speech remained and spoke in a low tone and was able to voice some wants and needs with care staff anticipating and meeting additional needs. The resident ate meals in the dining room and fed self while supervised by care staff for safety. -At 8:59 A.M. (monthly summary), the resident on hospice services for end-of-life cares. The resident goes to the dining room for all meals and was assisted to eat by staff. The resident experienced a weight loss of 5% or more and was not participating in a physician-prescribed weight change program. The resident at a regular diet. Observation and interview on 03/25/25 at 10:00 A.M., showed Certified Nurse's Aide (CNA) B wheeled the resident to his/her room to transfer him/her to bed. The CNA said the resident was falling asleep in his/her wheelchair. After the CNA assisted the resident to sit on his/her bed, the resident mumbled softly that he/she wanted a drink of water, the CNA said he/she had some water on his/her table. After assisting the resident into a lying position, the CNA asked the resident if he/she wanted a drink or if he/she wanted to go to sleep. The resident did not answer. The CNA then pulled up the resident's blankets. The resident closed his/her eyes, and the CNA left room. The CNA did not give the resident a drink. Observations on 03/26/25, 12:03 P.M., 12:30 P.M., and 12:42 P.M., showed the resident laid in bed with his/her eyes closed, as dietary staff served residents in the dining room. During an interview on 3/26/25, at 12:50 P.M., Licensed Practical Nurse (LPN) C said the resident became over stimulated easily so staff got him/her up later in the meal and assisted him/her to eat. Review of the resident's nurse's note on 03/26/25, at 1:47 P.M., showed a nurse documented the resident continued hospice for end-of-life care and currently rested in bed with his/her eyes closed. The resident continued with mumbled speech and spoke in a low tone and was unable to voice wants and needs with care staff anticipating and meeting any needs. The resident ate his/her meals in the dining room and slowly fed himself/herself while supervised by care staff for safety. Observation on 03/26/25, at 2:33 P.M., showed the resident laid in bed moving around with his/her eyes closed. During an interview on 03/26/25, at 4:20 P.M., LPN C said he/she thought the aides got the resident up for lunch today but was not sure. The CNAs did not tell the nurse they did not get him/her up, or that he/she wanted to sleep. During an interview on 03/26/25, at 4:25 P.M., the Director of Nursing (DON) said the following: -The resident must have not wanted to get up for lunch. -Staff did not tell the DON he/she did not want up, but at times the resident did not want to get up. -The resident needed assistance to eat and did not eat in his/her room. The resident received hospice services. Review of the resident's nurses note dated 03/26/25, at 4:44 P.M., showed a nurse documented the resident reported to a CNA that he/she would like his/her lunch held and to eat it for dinner as he/she wanted to sleep through lunch. The resident was currently in the dining room feeding self without difficulty while supervised by care staff for safety. Review of the resident's meal intake record, dated 3/26/25, showed staff documented: Breakfast: ate 100%, supplement column was blank indicating a supplement was not offered; Lunch: refused, supplement column was blank indicating a supplement was not offered; Supper: refused, drank 100% of supplement. Review of the resident's significant change MDS, dated [DATE], showed the following changes from the previous MDS: -Severely impaired cognition; -Functional limitation in range of motion: Impairment on both sides -Required substantial/moderate assistance with eating; -Dependent on staff for upper body dressing, personal hygiene and transfers; -Weighed 159.0 pounds; -The resident had a 5% or more weight loss in the last month and not on a physician prescribed weight-loss regimen. During an interview on 03/26/25, at 4:20 P.M., LPN C said the following: -Staff reviewed residents' care plans in the electronic medical record (EMR). Recently the facility changed EMRs. If staff could not find a resident's care plan in the current EMR, they could look in the old system. Recently, staff still had access to residents' records. The LPN thought all residents' care plans were now in the new EMR. The facility's MDS Coordinator's position was eliminated and he/she thought corporate would complete the MDSs and care plans. The LPN did not know the new process for care plans. -The resident had Parkinson's disease with episodes of stiffness. Those episodes had increased and now staff typically supervised him/her during meals. -The CNAs or nurses obtained residents' weights, and the nurses entered the weights under the vital signs tab in the resident's EMR. The EMR created an alert if a resident had a weight change. -The dietician monitored residents' weights. -If a resident frequently refused meals or had a questionable appetite, staff monitored the resident's meal intake. -Dietary staff recorded the percentage of the meal the resident ate, and the Dietary Manager entered the percentages into the EMR for the dietician to review. -The dietician recommended interventions such as house shakes. -The DM reviewed the dietician's recommendations, and if the dietician recommended house shakes for a resident, the dietary manager added that resident's name to the house shake list, and dietary staff placed the shake on the resident's meal tray. Observation on 03/26/25, at 4:35 P.M., showed the resident sat in a wheelchair, at a dining room table. On the table in front of the resident was a small plastic cup of tea and a house shake poured into a small plastic cup. Both cups had straws and as the resident sat at the table, he/she moved the straws around the cups with his/her fingers and occasionally took a drink using the straw. Observations on 03/27/25 showed the following: -At 8:20 A.M., the resident sat in his/her wheelchair at a dining room table. Rolled silverware sat in front of the resident on the table. -At 8:27 A.M., LPN F spoke briefly with the resident and brought him/her a small plastic cup of water, no straw. -At 8:44 A.M., CNA B stood next to the resident and gave him/her a bite of cereal. -At 8:47 A.M., CNA B walked away from the resident then returned, gave him/her a bite of cereal, then left again. Dietary then served the resident eggs, bacon, and toast in scoop plate and a small plastic cup of tea, with no straw. Staff did not serve the resident a house shake. -At 8:51 A.M., CNA B stood next to the resident and gave him/her a drink of his/her water. CNA B left the resident again. Each time the CNA left the resident at the table, the resident barely moved, staring straight ahead. The resident scooped his/her fork into the bowl of cereal, but when he/she lifted it out of the bowl, no cereal remained on the fork. The resident raised the utensil about chest height then moved his/her head towards the fork taking a bite. CNA A sat in a chair next to the resident. The resident slowly scooped a small amount of cereal onto his/her fork raised the utensil about chest height then moved his/her head towards the fork taking a bite. -At 03/27/25 at 8:56 A.M., CNA A encouraged the resident to eat and assisted with bites as needed. He/she placed the bacon onto the toast to make a sandwich and handed it to the resident. The resident slowly began eating the sandwich using the same method as the fork; he/she lifted his/her hands about chest height then moved his/her head towards the sandwich taking a bite. -At 9:05 A.M., the resident continued to eat small bites of the sandwich. CNA A gave the resident a drink of tea in between bites. -At 9:12 A.M., the resident continued to take bites of the sandwich, and occasionally licked his/her fingers. -At 9:23 A.M., while the resident continued to slowly take bites of the sandwich, CNA B asked the resident if he/she was done eating, and if so he/she would take the resident to his/her room. The resident mumbled then said he/she did not understand the aide. The CNA again asked the resident if he/she was finished, and he/she would take him/her to his/her room. The resident mumbled and slowly kept eating. The resident sat the sandwich on the plate and took a drink of water. CNA G entered the dining room and asked the resident if he/she was done. The resident looked at the CNA and did not respond. CNA G then took the resident's plate and scraped the remaining food into the bin next to the kitchen window. -At 9:28 A.M., CNA B said he/she would get something to wipe the resident's hands and left the dining room. -At 9:31 A.M., CNA B returned with wash cloth, pushed the resident's wheelchair back about a foot from table, wiped the resident's hands and left the dining room. -At 9:35 A.M., the cook scooted the resident's glass of tea to the edge of table and scooted the resident towards the table to reach the glass. -At 9:41 A.M., the resident grabbed the cup of tea and lifted his/her hand and cup about chest height, and tried to take a drink, but could not lift the cup to his/her lips. The resident placed the cup back onto the table. -At 9:47 A.M., the resident grabbed the small cup of tea with his/her right hand and lifted it slightly. He/she then placed his/her left around the glass and using both hands lifted the cup about chest height, still unable to reach the cup for a drink. The resident then sat the cup back on the table. -At 9:49 A.M., CNA G asked resident if he/she was done; the resident did not answer. He/she then asked the resident if he/she wanted to go to his/her room; the resident did not answer. He/she asked the resident if he/she wanted to sit in his/her recliner chair; the resident looked at the aide, then he/she wheeled the resident to his/her room. During an interview on 03/27/25, at 1:15 P.M., the DM said the following: -The CNAs documented residents' fluid intake and dietary staff documented residents' meal intake; -CNAs usually assist residents with meals but sometimes the DM assisted them as well. -Staff always brought the resident to the dining room for meals and she did not know the resident slept though lunch the day before (03/26/25). -Staff should get the resident up for all meals. -The resident had a decline and received hospice services. -Although the DM did not usually assist resident with eating, today, she saw the resident was not attempting to eat his/her lunch meal and food sat untouched in front of the resident so she sat down next to him/her and started assisting him/her with bites of food. -The resident had a diagnosis of Parkinson's and had hard time communicating. -In the past, the resident could have told staff he/she did not want to go to the dining room for a meal, but now the resident could not have communicated that. -Staff should always provide straws for the resident's drinks. -The resident had some weight loss and on 03/24/25 the RD recommended the resident have a house shake with meals; -There were two residents who need feeding assist from staff, including the resident. -When staff assist a residents with their meals they should sit down next to the resident and communicate with the resident. -Staff should not stand over the top of resident while assisting them. During an interview on 03/27/25, at 11:56 A.M., CNA B said the following: -Dietary staff documented residents' meal percentages when the resident ate in the dining room. -The CNAs documented how much assistance the resident needed for the meal in the EMR. -Every time staff assisted a resident in their room, they should offer the resident a drink. -The resident had Parkinson's disease. -Sometimes he/she needed assistance with eating and other times he/she ate independently. -The resident's hands were not steady and recently, the last few weeks to a month, he/she needed more assistance with meals and drinking fluids. -The resident could lift the cup to his/her lips and did not need straws to drink from a cup when in the dining room, but when in his/her room, he/she used a straw because his/her cup came with a plastic straw. -The CNA thought the resident lost weight based on his/her appearance. The resident looked [NAME]. -The resident's appetite varied and sometimes the resident did not eat all three meals. -If the resident was asleep at meal times, the CNA let him/her sleep, and would tell dietary to hold the resident's lunch tray. -The CNA did not know if the resident was supposed to receive house shakes, but he/she knew the resident did not have a shake with his/her breakfast. Observation on 3/27/25, at approximately 12:15 P.M., showed CNA G told CNA B that the resident was the only resident who needed to go to the dining room, if they could wake him/her up. Both CNAs entered the resident's room. The resident sat in his/her recliner with his/her eyes closed. CNA G placed his/her hand on the resident's shoulder and asked the resident if he/she wanted to get up for lunch or lay down in bed. The resident did not appear to respond to the CNA's question. One of the aides left the room and returned with the nurse. LPN F entered the resident's room and asked the resident if he/she wanted to eat, and if he/she wanted to drink. The resident mumbled, the nurse left the room, and the aides wheeled the resident's wheelchair into his/her room and shut the door. Review of the resident's progress notes dated 03/27/25, at 2:29 P.M., showed the DM documented she left a weight change notification for the physician to review. Observation on 03/27/25, at 5:00 P.M., showed the resident sat in his/her wheelchair at a dining table. On the table sat the resident's plate. The resident ate a ham sandwich and pudding and left the coleslaw. He/she drank all of the house shake and glass of water. Review of the resident meal intake record, dated 03/27/25, showed staff documented the following: Breakfast: Staff did not document meal intake; Lunch: Ate 75%, drank 100% of supplement Supper: Staff did not document meal intake for any resident. Observation and interview on 03/28/25 showed the following: -At 8:17 A.M., the resident sat in his/her wheelchair at a table in the dining room, slowly eating breakfast. LPN F sat next to resident at the table. -At 8:28 A.M., LPN F got up from the table and pushed the resident's plate away from the resident. The resident had a small plastic glass of water and a small plastic glass of tea. The resident did not have a health shake. The resident drank all of the water and most of the tea. -At 8:40 A.M., LPN F said the resident ate without assistance this morning. He/she ate half of the biscuits and gravy, all of the bacon, and most of the tomatoes and cereal. Review of the resident meal intake record, dated 03/28/25, showed the staff documented the following: -Breakfast: Ate 50%, supplement column was blank indicating a supplement was not offered. During an interview on 03/28/25, at 9:45 A.M., LPN F said the following: -The resident's decline was slow. -At times, he/she became stiff, almost catatonic. -The resident's abilities seem to change almost daily. -Today, the resident ate breakfast without assistance, only supervision, but other days he/she needed staff to assist him/her with the meal. It seemed 50/50 if he/she needed assistance or not. -The resident had difficulty bringing his/her hand up to his/her mouth. He/she needed straw to assist him/her drink fluids. He/she mumbled and spoke low and could be difficult to understand. -Occasionally the resident would be lethargic and sleep through meals. -Staff tried to get him/her up for meals, but if he/she just slumped over in his/her chair, staff transferred him/her back to bed. That seemed to occur more with breakfast than other meals. If staff could not wake him/her up enough to eat, the aides should let the nurse know and he/she tried to wake the resident. -If a resident did not go to the dining room, dietary staff also let the nurse know. -Usually, the physician wrote an order for house shakes. -The LPN did not know if the resident was supposed to have house shakes. -The DM tracked residents' weights. Interventions for weight loss included house shakes, supervision and assistance with meals, serving food preferences when able, encouraging to eat meals in the dining room, and medications to assist with appetite, if appropriate. -When staff assisted a resident with eating, they should not stand over the resident but instead get on the resident's level. That was one of the LPN's pet peeves, standing over residents. -The LPN did not know the resident had weight loss until he/she reviewed the resident's medical record the day before (03/27/25). Now that he/she knew, he/she would ensure the resident received ordered or recommended house shakes, and received the assistance and supervision as needed to ensure his/her weight loss was not due to disease progression.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management to all residents when staff failed to implement an effective routine pain management program, failed to accurately assess pain and medication effectiveness according to standards of practice, and failed to identify, develop, and implement interventions related to pain management for for one resident (Resident #26) who expressed severe and constant pain in his/her hands and arms in a selected sample of 13 residents. The facility had a census of 33 residents. Review of the facility's pain management policy, revised 06/26/24, showed the following information: -The facility will utilize a systemic approach for recognition, assessment, treatment and monitoring of pain. -Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. -Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments and when a significant change in condition or status occurs (such as a change in behavior or mental status, new pain or exacerbation of pain); -Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice and the resident's goal and preferences. -Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: Fidgeting, increased or recurring restlessness, facial expressions (e.g. grimacing, frowning, fright, or clenching of the jaw), behaviors such as: irritability, depressed mood, difficulty sleeping (insomnia), and negative vocalizations (e.g. groaning, crying, whimpering, or screaming); -Facility staff will be aware of verbal descriptors a resident may use to report or describe their pain. Descriptors include but are not limited to: hurting or aching, burning, numbness, tingling, shooting or radiating, and soreness, tenderness, discomfort, pins and needles; -The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. -Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission. -The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. -Non-pharmacological interventions will include but are not limited to: Environmental comfort measures, physical modalities (e.g., cold compress, warm shower/bath, massage, turning and repositioning), exercises to address stiffness and prevent contractures as well as programs to maintain joint mobility, and cognitive/behavioral interventions (e.g., music, relaxation techniques, activities, diversions, spiritual and comfort support, teaching the resident coping techniques and education about pain); -The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. -Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic therapy for pain; -Consider administering medication around the clock instead of PRN (pro re nata/on demand) or combining longer acting medications with PRN medications for breakthrough pain. -Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects. -Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen. -Facility staff will reassess resident's pain management at established intervals for effectiveness and/or adverse consequences. -If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. 1. Review of Resident #26's face sheet (a document that provides a quick snapshot of an individual's medical and personal information) showed the following information: -admission date of 01/24/25. -Diagnoses included quadriplegia (dysfunction or loss of motor and/or sensory function in both arms and legs), hereditary motor and sensory neuropathy (a group of genetic disorders affecting the peripheral nervous system, characterized by the progressive degeneration of motor and sensory nerves), need for assistance with personal cares, and altered mental status. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 01/28/25, showed the following information: -The resident had long and short term memory loss; -Used a wheelchair for mobility; -Dependent on staff for personal hygiene, dressing upper and lower body, rolling side to side in bed, and transfers; -In the last five days, received scheduled and as needed pain medication; -Did not receive non-medication interventions for pain; -Pain assessment interview not completed. Review of the resident's March 2025 Physician Order Sheet (POS) showed the following: -An order, dated 01/30/25, for acetaminophen (Tylenol) extra strength tablet 500 milligram (mg), give 2 tablets, by mouth, every 6 hours, as needed for pain related to quadriplegia; -An order, dated 02/01/25, to complete a pain scale every shift related to quadriplegia. Review of the resident's 5-day MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Used a wheelchair for mobility; -Dependent on staff for personal hygiene, dressing upper and lower body, rolling side to side in bed, and transfers; -In the last five days, received as needed pain medication; -Did not receive non-medication interventions for pain; -Pain assessment interview completed, but resident unable to answer pain presence and no other pain assessment questions were completed or answered. Review of the resident's care plan, initiated and revised on 02/14/25, showed the following information: -The resident had an activities of daily living (ADL) self-care performance deficit related to limited mobility, weakness, and stroke; -Totally dependent on 2 staff for repositioning and turning in bed; -Totally dependent on 2 staff for dressing; -Totally dependent on 1 staff for personal hygiene and oral care. -Totally dependent on 2 staff for transferring. (Staff did not care plan related to the resident's pain and interventions to address the resident's pain.) Review of the resident's March 2025 POS showed an order, dated 02/14/25, for hydrocodone-acetaminophen (Norco-a combination medication is used to relieve moderate to severe pain) 5-325 mg, administer one tablet by mouth every 8 hours as needed for pain-moderate related to quadriplegia and hereditary motor and sensory neuropathy. Review of the resident's nurses' notes and March 2025 Medication Administration Record (MAR) showed the following information: -On 03/13/25, at 4:13 A.M., a nurse documented the resident complained of generalized pain. Just before this nurse entered resident's room, the resident started to yell out for help. The resident said he/she was in pain. The resident fidgeted with his/her sheet, moved his/her head back and forth, side to side, and talked quickly changing subjects frequently. This nurse administered hydrocodone per physician's order. About 30 minutes later, the nurse followed up with the resident. The resident said his/her pain was not gone, but was better. -On 03/13/25, at 9:28 A.M. (Skilled Evaluation Note-new problem), a nurse documented the resident had indicators of pain (facial expressions) and vocal complaints of generalized aching pain that he/she rated as a 3. Pain occurred multiple times a day. Non-medication interventions provided relief. Staff administered as needed medication for pain. See MAR for details. -On 03/13/25, at 11:52 A.M., staff documented administering Norco for a pain level of 8, and it was effective. -On 03/13/25, at 7:41 P.M., staff documented administering Norco for a pain level of 8, and it was effective. -On 03/14/25, at 12:44 A.M. (Health Status Note), a nurse documented the resident exhibited increased pain. Administered as needed pain medication with some relief. -On 03/14/25, at 4:25 A.M., staff documented administering Norco for a pain level of 6, and it was effective. -On 03/14/25, at 9:35 A.M. (Skilled Evaluation Note), a nurse documented the resident had indicators of pain (facial expressions and non-verbal sounds) and vocal complaints of generalized aching pain that he/she rated as a 3. Pain occurred multiple times a day. Non-medication interventions provided relief. Staff administered as needed medication for pain. See MAR for details. -On 03/14/25, at 11:27 A.M., staff documented administering Norco for a pain level of 7, and it was effective. -On 03/14/25, at 12:30 P.M. (Health Status Note), a nurse documented the resident continued to have episodes of increased pain. As needed medication administered as ordered, with slight effectiveness. -On 03/14/25, at 7:56 P.M., staff documented administering Norco for a pain level of 8, and it was effective. -On 03/15/25, at 4:22 A.M., staff documented administering Norco for a pain level of 7, and it was ineffective. -On 03/15/25, at 6:08 P.M., staff documented administering Norco for a pain level of 8, and it was effective. -On 03/16/25, at 3:30 A.M., staff documented administering Norco for a pain level of 6, and it was effective. -On 03/16/25, at 6:55 P.M., staff documented administering Norco for a pain level of 8, and it was effective. -On 03/17/25, at 4:01 A.M., staff documented administering Norco for a pain level of 4, and it was effective. -On 03/17/25, at 11:31 A.M., staff documented administering Norco for a pain level of 8, and it was effective. -On 03/17/25, at 7:07 P.M., staff documented administering Norco for a pain level of 5, and it was effective. -On 03/18/25, at 4:34 A.M., staff documented administering Norco for a pain level of 4, and it was effective. -On 03/18/25, at 9:25 A.M. (Skilled Evaluation Note), a nurse documented the resident had indicators of pain (facial expressions and non-verbal sounds) and vocal complaints of generalized aching pain that he/she rated as a 3. Pain occurred multiple times a day. Non-medication interventions did not provide relief. Staff administered as needed medication for pain. See MAR for details. -On 03/18/25, at 3:32 P.M., staff documented administering Norco for a pain level of 8, and it was effective. -On 03/19/25, at 11:19 A.M. (Skilled Evaluation Note), a nurse documented the resident had indicators of pain (facial expressions and non-verbal sounds) and vocal complaints of generalized aching pain that he/she rated as a 3. Pain occurred multiple times a day. Non-medication interventions did not provide relief. Staff administered as needed medication for pain. See MAR for details. -On 03/19/25, at 4:18 A.M., staff documented administering Norco for a pain level of 5, and it was effective. -On 03/19/25, at 3:35 P.M., staff documented administering Norco for a pain level of 7, and it was effective. -On 03/20/25, at 4:06 A.M., staff documented administering Norco for a pain level of 6, and it was effective. -On 03/20/25, at 3:59 P.M., staff documented administering Norco for a pain level of 5, and it was effective. -On 03/21/25, at 4:03 A.M., staff documented administering Norco for a pain level of 6, and it was effective. -On 03/21/25, at 8:10 A.M. (Skilled Evaluation Note), a nurse documented the resident had indicators of pain (facial expressions and non-verbal sounds) and vocal complaints of generalized aching pain that he/she rated as a 3. Pain occurred multiple times a day. Non-medication interventions did not provide relief. Staff administered as needed medication for pain. See MAR for details. -On 03/21/25, at 11:58 A.M., staff documented administering Norco for a pain level of 8, and it was effective. -On 3/21/25, at 8:01 P.M., staff documented administering Norco for a pain level of 8, and it was effective. -On 03/22/25, at 4:24 A.M., staff documented administering Norco for a pain level of 4, and it was effective. -On 03/22/25, at 6:15 A.M. (Health Status Note), a nurse documented the resident was yelling out and crying periodically throughout the shift. The resident complained of generalized pain. Administered pain medication with effective results. The resident calmed a bit. -On 03/22/25, at 10:01 A.M. (Skilled Evaluation Note), a nurse documented the resident complained of generalized aching pain that he/she rated as a 3. Pain occurred multiple times a day. Non-medication interventions did not provide relief. Staff administered as needed medication for pain. See MAR for details. -On 03/22/25, at 1:05 P.M., staff documented administering Norco for a pain level of 5, and it was effective. -On 03/22/25, at 2:59 P.M. (Health Status Note), a nurse documented the resident had no signs of pain or discomfort at this time. Earlier in the shift, the resident was yelling and tearful. -On 03/22/25, at 9:15 P.M., staff documented administering Norco for a pain level of 5, and it was effective. -On 03/23/25, at 1:19 A.M. (Health Status Note), a nurse documented the resident complained of generalized pain. Administered as needed hydrocodone per order, with some relief. -On 03/23/25, at 8:32 A.M., staff documented administering Norco for a pain level of 7, and it was effective. -On 03/23/25, at 10:37 A.M. (Skilled Evaluation Note), a nurse documented the resident complained of generalized pain that he/she rated as a 3. Pain occurred multiple times a day. Non-medication interventions did not provide relief. Staff administered as needed medication for pain. See MAR for details. During observation and interview on 03/23/25, at 5:30 P.M., the resident said it seemed like staff did not really take care of his/her problems until it became bad. His/her hands hurt and burned, and did not always work right. The resident thought he/she had a nerve issue. He/she tried to get up most days but sometimes he/she felt too stiff to get up. He/she did not get up today because of stiffness. Review of the resident's nurses notes and March 2025 MAR showed the following information: -On 03/23/25, at 8:38 P.M., staff documented administering Norco for a pain level of 3, and it was effective. -On 03/24/25, at 2:08 A.M. (Health Status Note), a nurse documented the resident's roommate turned on the call light. The roommate heard the resident crying. When the nurse entered the resident's room, the resident laid in bed with his/her eyes closed, moving his/her head and upper body back and forth in bed, moaning. The nurse was able to redirect the resident at that time. -On 03/24/25, at 2:27 A.M. (Health Status Note), a nurse documented he/she heard the resident at the nurses' station moaning/crying. When the nurse entered the room, he/she saw the resident lying in bed with eyes closed. Resident's roommate made noise while sleeping and resident opened eyes started moaning and moving upper body. Resident redirected and currently in bed resting calmly with eyes closed. -On 03/24/25, at 4:33 A.M., staff documented administering Tylenol for a pain level of 5, and it was effective. Observation on 03/24/25, at 10:31 A.M., showed the resident laid in bed, with his/her eyes closed, moving his/her head side to side, and making moaning-type noises. Review of the resident's care plan, initiated 03/24/25, showed the following: -Acute pain/chronic pain; -Administer pain medications per order, if non-medication interventions are Ineffective; -Administer prescribed medication before activity and therapy; -Determine resident's satisfactory pain level -Educate resident/representative on prescribed analgesics and/or anti-inflammatory medications; -Encourage times of rest and relaxation between care activities; -Evaluate effectiveness of pain-relieving interventions (non-medication and medication; -Evaluate for non-verbal indicators of pain; -Evaluate mood/behavior; -Evaluate pain, sleep pattern, and vital signs; -Medicate with PRN medications if non-medication interventions are ineffective -Utilize non-medication interventions for pain relief. Review of the resident's nurses notes and March 2025 MAR showed the following: -On 03/24/25, at 3:08 P.M. (Skilled Evaluation Note), a nurse documented the resident complained of generalized aching pain that he/she rated as a 3. Pain occurred multiple times a day. Non-medication interventions did not provide relief. Staff administered as needed medication for pain. See MAR for details. -On 03/24/25, at 7:51 P.M., staff documented administering Norco for a pain level of 6, and it was effective. -On 03/25/25, at 5:00 A.M., staff documented administering Norco for a pain level of 4, and it was effective. -On 03/25/25, at 9:38 A.M., staff documented administering Tylenol for a pain level of 5, and it was effective. Observation on 03/25/25, at 10:15 A.M., showed when staff rolled the resident onto his/her right side, the resident said his/her arm hurt and started whimpering. Certified Nurse Aide (CNA) A said therapy was working with the resident's arms which caused him/her pain almost all of the time. Review of the resident's nurses notes showed the following information: -On 03/25/25, at 11:28 A.M. (Skilled Evaluation Note), a nurse documented the resident complained of generalized pain that he/she rated as a 3. Pain occurred multiple times a day. Non-medication interventions did not provide relief. Staff administered as needed medication for pain. See MAR for details. -On 03/25/25, at 5:02 P.M., staff documented administering Norco for a pain level of 8, and it was effective. -On 03/26/25, at 5:10 A.M., staff documented administering Norco for a pain level of 4, and it was effective. -On 03/26/25, at 7:38 A.M. (Skilled Evaluation Note), a nurse documented the resident complained of generalized pain that he/she rated as a 3. Pain occurred multiple times a day. Non-medication interventions did not provide relief. Staff administered as needed medication for pain. See MAR for details. Review of the resident's nurses notes and March 2025 MAR showed the following information: -On 3/26/25, at 6:48 P.M., staff documented administering Norco for a pain level of 8, and it was effective. -On 03/27/25, at 1:22 A.M. (Health Status Note), a nurse documented the resident actively participated in therapy. The resident continued to ask for pain medications about every 5 to 6 hours after receiving them. He/she complained of generalized pain in his/her arms and back. -On 03/27/25, at 4:07 A.M., staff documented administering Norco for a pain level of 6, and it was effective. -On 03/27/25, at 10:01 A.M. (Skilled Evaluation Note), a nurse documented the resident complained of generalized pain that he/she rated as a 3. Pain occurred multiple times a day. Non-medication interventions did not provide relief. Staff administered as needed medication for pain. See MAR for details. -On 03/27/25, at 12:01 P.M., staff documented administering Norco for a pain level of 8, and it was effective. During an interview on 03/27/25, at 1:50 P.M., the resident said he/she had issues with pain, mostly in his/her hands. He/she even yelled out at staff at times due to the pain, especially when the aides touched his/her hands during cares. The aides got upset when he/she yelled. He/she did not like acting that way, it was not his/her usual behavior. He/she tried to apologize when he/she acted that way and would remind the aides that he/she hurt and to be careful. Observation and interview on 03/27/25, at 3:25 P.M., showed the following: -CNA D and CNA E entered the resident's room to provide incontinence care. -The resident said he/she had trouble with his/her fingertips, they really hurt. When the aides rolled the resident to either side, the resident winced in pain. Review of the resident's nurses notes showed the following information: -On 03/27/25, at 11:39 P.M. (Health Status Note), a nurse documented the resident utilized hydrocodone for some effective pain relief and often asked for it early. -On 03/28/25, at 4:22 P.M. (Health Status Note), a nurse documented the resident yelled out multiple times throughout shift. He/she clenched his/her fist and grinded her teeth when staff provided incontinent care. The resident cried and was easily consoled by staff The resident claimed he/she was in pain. As needed Hydrocodone was effective but not for the full 8 hours. Observation and interview on 03/28/25, at 9:45 A.M., showed the following: -LPN F, CNA G and CNA A entered the resident's room to provide incontinence care. When the aides rolled the resident side to side, the resident said his/her hands hurt and each time the aides touched him/her, the resident winced and/or groaned. -LPN F said the resident had pain but he/she could not give him/her any pain medication for another two and a half hours. The LPN said he/she did not think the physician understood how the resident could have pain since he/she was a quadriplegic. It was difficult for the staff to get an order for hydrocodone, he/she only had Tylenol when he/she admitted . The resident's pain was worse than when he/she admitted . The LPN thought his/her nerves were waking up causing more pain. Staff tried to make the resident as comfortable as they could and administered Tylenol between the hydrocodone. During an interview on 03/28/25, at 12:36 P.M., Certified Medication Technician (CMT) H said the following: -When a resident complained of pain, he/she asked the resident the location and severity of the pain. -Sometimes he/she did not ask the resident to rate his/her pain using the 0 to 10 pain rating scale because he/she did not want the resident to think he/she only cared about a number. -If he/she administered pain medication, he/she followed up with the resident about an hour later to find out the effectiveness of the medication. -He/she asked the resident if the medication was effective, but usually did not ask specifically about the location or severity of the pain because he/she did not want to remind the resident of the pain they experienced prior to the administration of the pain medication. -For some residents, he/she knew their pain was not completely gone and would assign a number, usually a 2 out of 10 for the effectiveness. Some residents automatically gave her a pain rating score, but others did not. -It could be difficult for staff to determine the severity and location of the resident's pain. He/she typically went by other indicators of pain such as yelling and grimacing to determine severity. -The resident also shook his/her head side to side which was either an indicator of pain or anxiety or both. -If the resident had any of signs of pain, the CMT reviewed the MAR to determine which medication he/she could administer to the resident. If it was not yet time for the hydrocodone, he/she administered acetaminophen. The CMT did not think the resident's pain was effectively controlled with his/her current medications. During an interview on 03/28/25, at 12:47 P.M., LPN F said the following: -The resident had pain all over but mostly in his/her hands. -The LPN thought the resident had burning and aching pain. The resident was not always able to describe the pain (location, type severity) to him/her, but the LPN also did not generally ask the resident to describe it. -The LPN did not think the resident's pain was controlled. He/she had breakthrough pain and needed more pain medication five to six hours after he/she received hydrocodone. The order was for every eight hours. Sometimes staff administer Tylenol in between the hydrocodone to help his/her pain. -The physician was aware the resident had continued pain. He/she called the physician's office who just told him/her to add the resident's name to the physician's list and he would see him/her on his/her next visit. But when he visited, he wrote no new orders for pain management. -He/she did not know where the disconnect was. Most staff noticed the resident's pain was not well controlled. The resident cried each time staff moved him/her. Staff tried to soothe him/her and offer distraction which helped sometimes. -Yesterday (03/27/25) the nurse practitioner (NP) was at the facility and the LPN told the NP about the resident's pain and anxiety. The NP said she would look into it, but wrote no new orders. During an interview on 03/28/25, at 12:55 P.M., CNA G said the following: -When a resident complained of pain he/she told the nurse. -The resident cried sometimes, but the CNA did not know if the resident cried due to pain or because he/she was sad. -The resident did not like staff to move him/her and sometimes said ow so the aide knew at least sometimes, the resident had pain. -The resident could move his/her arms a little and that was where he/she seemed to hurt when he/she complained of pain. During an interview on 03/28/25, at 12:55 P.M., CNA A said the following: -The resident had pain constantly and it was not well-controlled. Any time staff moved the resident, the resident had pain. The CMTs and nurses tried to stay on top of his/her pain by administering medications when they could. -When a resident complained of pain the CNA told the nurse or CMT. During an interview on 03/28/25, at 4:18 P.M., the Director of Nursing (DON) said the following: -The nurses and CMTs assessed residents' pain every shift and as needed by asking the resident about their pain. -If the resident could not speak or was confused, the staff determined pain by observing nonverbal signs of pain such as facial expressions, noises such as moaning, and other non-verbal signs. -The nurses and CMTs reassessed the effectiveness of pain medications 30 minutes to one hour after administration, and used the same method, verbal or nonverbal signs, to determine effectiveness. -If pain medication did not relieve or help a resident's pain, staff checked the resident's orders for additional pain medication. If the resident did not have other pain medication, the nurses contacted the physician. -The resident always had pain, everywhere. -When he/she admitted to the facility, he/she only had Tylenol ordered. -Staff contacted the physician and he ordered hydrocodone. -The DON thought the hydrocodone was effective at relieving the resident's pain based on her observations of the resident and by reviewing the resident's nurses' notes. The DON tried to review all residents' notes daily. During an interview on 03/28/25, at 6:20 P.M., the Administrator said when staff assessed residents' pain, they should ask the resident the location of the pain and use a numerical or nonverbal scale to determine severity. If a resident's pain was not controlled with existing interventions, including pain medication, staff should contact the physician. During an interview on 04/03/25, at 3:58 P.M., the resident's physician said the following: -When he visited the resident on 03/20/25, the resident did not show any sign of distress and staff did not tell him the resident had a problem with pain control. Staff should have told him and they knew how to contact him. -On 03/28/25, a nurse contacted the physician and reported the resident had increased pain. That was the first time the physician heard of the resident's increased pain. -He ordered Neurontin (used to treat nerve pain) 100 mg two times a day to start. -He would not have let the resident have continued unrelieved pain had he known. -The physician did not know the resident had a diagnosis or history of neuropathy.