**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent documentation it was determined the facility failed to: a.) ensure the facility policy for Falls Management was followed to appropriately assess a resident and determine the causal factor of a fall and implement appropriate interventions to prevent recurrent falls for a cognitively impaired resident (Resident #23), who was identified as a high fall risk, required extensive assistance with bed mobility, and had a history of falls with injury which included an unwitnessed fall on 02/15/23 at 18:40 (6:40 PM), resulting in pain, required transfer to emergency room on [DATE], with a diagnosis of an acute comminuted (a broken bone that is broken in at least two places) mildly displaced (a gap between the broken bones) fracture of the left humeral head (left shoulder and socket). A subsequent unwitnessed fall occurred on 05/21/23 and required 911 transport to the emergency room, and resulted in a laceration to the forehead measuring 6 centimeters (cm) x 5 cm and a mild frontal scalp swelling per a computerized tomography (CT) scan, b.) ensure a complete Head to Toe Assessment was completed as required by a Registered Nurse prior to transferring Resident #23 to the bed, when reportedly Resident #23 was found on the floor on 05/21/23 at 6:00 AM, c.) provide adequate supervision to prevent recurrent falls, and d.) ensure that existing interventions to prevent falls were consistently implemented. This deficient practice occurred for 1 of 3 residents, Resident #23, reviewed for falls with injury and was evidenced by the following: On 05/22/23 at 10:40 AM, the surveyor observed Resident #23, positioned on the right side, in a bed that was against the wall and the resident was facing the wall. The surveyor observed a pad on the floor next to the bed. Resident #23 was unable to maintain a conversation with the surveyor and the resident also had a blanket covering the head. On 05/24/23 at 8:16 AM, the surveyor observed Resident #23 in bed, and was again positioned in the same manner as observed by the surveyor two days prior. At that time, the Certified Nursing Assistant (CNA) was inside the room and attempted to assist Resident #23 with the breakfast meal. The CNA stated to the surveyor that Resident #23 had a poor appetite and exited the room shortly after the surveyor entered. On 05/24/23 at 10:25 AM, (two hours later) Resident #23 was observed still in bed and was in the same position facing the wall. The B-Wing Activities of Daily Living (ADLs) worksheet (a document that direct care staff documented the resident care that was provided), could not be located by the staff to verify any documented care that had been provided to Resident #23 regarding position change or being repositioned. On 05/24/23 at 1:05 PM, the surveyor returned to the room and observed Resident #23 in bed, on his/her back with head elevated. At that time, the surveyor observed a large, black and blue in color hematoma (collection of blood) on Resident #23's right forehead. A Licensed Practical Nurse (LPN), who later identified herself as the Infection Preventionist (LPN IP) was in the room and assisted Resident #23 with the lunch meal. Upon surveyor inquiry regarding the observed injury on Resident #23's forehead, the LPN IP stated that the injury was from a fall the resident sustained and she would not elaborate further on the observed injury. On 05/24/23 at 1:25 PM, the surveyor reviewed Resident #23's electronic medical record and could not locate any documentation regarding the observed injury that the LPN IP confirmed Resident #23 sustained during a fall at the facility. According to the admission Face Sheet, Resident #23 was admitted to the facility with diagnoses which included but were not limited to; unspecified Dementia, acute kidney failure, blindness left eye, and acquired absence of right leg above the knee. A review of the Significant Change Minimum Data Set (MDS), an assessment tool used by the facility to prioritize care dated 02/28/23, revealed that Resident #23 was severely cognitive impaired. Resident #23 scored 6/15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS, which referred to activities of daily living (ADLs), revealed that Resident #23 was totally dependent on staff for care and required an extensive assistance of two-person physical assist for transfer, and one-person physical assist for care. A review of the progress notes did not contain documentation regarding the fall that the LPN IP stated occurred on 05/21/23 for Resident #23, however a fall that occurred on 02/15/23 was documented. The following entry dated 02/15/2023 timed 19:42:31 [7:42 PM], Note Text: Notified by aide that resident was on the floor. I found resident laying on the floor on the right side. I observed no head injuries and resident said [his/her] head was fine. Resident expressed that [his/her] left arm was hurting, and [he/she] was in pain. Called MD to make aware. Called for X-ray of left arm. Neuro checks in progress. Made supervisor aware. Will continue to monitor resident throughout the shift. VS [vital signs] 95/51 [blood pressure] 74 [pulse] 97.3 [temperature] 95% [oxygen saturation] 17 [respirations]. Another entry dated 02/16/23 revealed the following: Resident had increased in pain, MD was notified and [Resident #23] was sent out to the hospital. CT scan cervical spine, CT head without contrast, X-ray left humerus and X-ray left shoulder done. Resident found to have acute fracture through the left humerus surgical neck extending into the greater tuberosity, without significant displacement. Small glenohumeral hemorrhagic effusion. The surveryor reviewed the current Comprehensive Care Plan (CP) initiated 09/22/20, last revised 05/25/23 (revised four days after the fall that occurred on 05/21/23) which included 17 pages and had a Focus for ADL and functional mobility deficit related to: decreased strength, balance, endurance and coordination. I require extensive assistance/Total Dependence with ADLs, transfers, functional mobility and safety awareness. The Goal for this Focus was for Resident #23 to improve ADL and functional mobility level by next review. Initiated 09/22/20, and Revised 05/25/23, with a Target Date of 08/14/23, The CP interventions included: Converse during care, Ensure that all assistive devices are in place, and Introduce yourself and explain all care. Date Initiated: 10/15/21, Date Revised: 05/25/23. Resident #23 also had a CP Focus for At Risk for falls due to Impaired balance/poor coordination, Date Initiated: 02/13/21. The Goal was Minimize risk for falls through next review, Date Initiated: 02/13/21. The following interventions were documented: Provide assistance to transfer and ambulate as needed. Initiated 02/13/23. Reinforce the need to call/ring for assistance. Initiated 02/13/23. Reinforce wheelchair safety as needed such as locking brakes. Initiated 02/13/23. Therapy evaluation and treatment as ordered. Initiated 02/13/23. On 02/15/23 Resident #23 was found lying on the floor in his/her room. The following interventions were added to the care plan: Assess for pain and medicate if needed. Initiated 02/15/23 Assessment Completed, Date Initiated 02/15/23. Continue at risk for fall intervention, Date Initiated 02/15/23. Monitor range of motion every shift x 72 hours, Date initiated 02/15/23. Neuro check x 72 hours, Date initiated 02/15/23 Notify MD [Medical Doctor] of the incident and for any significant change, Date initiated 02/15/23. Epic evaluation of meds[medications], Date initiated 02/16/23. Floor mat at bedside, Date initiated 02/16/23. Sent to Hospital for evaluation of pain. Initiated 02/16/23. Sling to shoulder. Initiated 02/17/23. Orthopedic appt [appointment] scheduled, Date Initiated 02/20/23. Pain management adjustment, Date Initiated 02/20/23. A review of the Fall Risk assessment dated [DATE], 13:30 [1:30 PM] revealed that Resident #23 was assessed as a High Fall Risk, Resident #23 received a score of 37 indicative of a high fall risk. On 05/24/23 at 11:00 AM, the surveyor requested all investigations for Resident #23. On 05/24/23 at 12:10 PM, the surveyor, again reviewed the electronic medical record. There was no documentation regarding the fall that occurred on 05/21/23. On 05/24/23 at 1:30 PM, the surveyor reviewed the CP for Resident #23. There was no revision made to the CP, including additional interventions added, after Resident #23 sustained a fall on 05/21/23. On 05/25/23 at 8:30 AM, the surveyor went to B-Wing and observed that Resident #23 was no longer in the room. The bed was stripped, and the mattress had been deflated. On 05/25/23 at 9:10 AM, the LPN assigned to the B-Wing, informed the surveyor that Resident #23 was transferred on 05/24/23 to another facility that was owned by the same company. The LPN could not offer any details as to why Resident #23 was transferred the prior evening. On 05/25/23 at 9:49 AM, the surveyor reviewed the electronic progress notes. There was no documentation in the medical record regarding Resident #23's transfer. When interviewed, the staff would not comment on who authorized or any reason for the transfer. There was no physician order for the transfer. At that time, the surveyor attempted to contact Resident #23's physician and the responsible party. Messages were left for both, and neither returned the surveyor's phone calls. The surveyor again, reviewed the electronic progress notes and noted the following entry dated 05/24/23 timed 21:37 [9:37 PM]: This note is a follow up to: 5/21/2023 7:39:00 Nursing Progress Note (Other) Focus: Effective Date: 5/24/2023, 21:10:00 [9:00 PM] Department: Nursing, Position: registered nurse, Created Date: 5/24/2023, 21:37:06 [9:37 PM], Note Text: On 5/21/23 at 7:39 AM, CNA advised me that res [resident] fell in [his/her] room. Upon arrival to res [resident] room, I observed res [resident] lying in bed. Res [resident] observed bleeding on head. Pressure dressing applied. Assessment and neuro (neurological assessment done to evaluate level of consciousness) check complete. Res [resident] was alert and oriented, responsive, PERRLA (Pupils Equal Round, Reactive to Light and Accommodation), hand grasp equal. Vital signs were taken (BP) blood pressure: 198/51 Pulse:86 Temp (temperature): 96.4 Respirations 18, Unable to obtain (SPO2) [Oxygen saturation]. 911 was called for immediate attention and MD was notified. No family listed. EMTs (Emergency Medical Transport) transferred res [resident] to [hospital name redacted] for further observation of the resident. Onboarding nurse made aware. On 05/25/23 at 10:15 AM, the surveyor again requested any investigations for Resident #23 from the Director of Nursing (DON), including any statements that were obtained from staff that worked on 05/21/23 for the 11:00 PM-07:00 AM shift [when fall occurred]. The investigation, nor any supporting documentation was provided. On 05/26/23 at 11:15 AM, the DON provided two Fall documents dated, 02/15/23 and 05/21/23 respectively. There were no statements attached to either document or that had been requested by the surveyor. There were no statements attached to the Fall documents to inform the reader who had witnessed the fall. The causal factor/s were not identified. A note entered on the Fall document dated 03/03/23 (18 days after the first fall), indicated the following: Resident was found on the floor. When asked as to what happened, he stated, I was trying to leave. On assessment c/o[complain] of left arm pain. MD [Medical Doctor] notified and ordered X-ray left arm. Resident was medicated for pain and assessed every shift while waiting for the X-ray to be done. Floor Mat was placed at bedside. To continue current at-risk care plan. Resident #23 was transferred to the Emergency Department on 02/16/23 at 10:50 AM due to complaint of pain in left arm. Resident #23 was diagnosed with a comminuted mildly displaced fracture of the left humeral head. The Fall document dated 02/15/23 timed 18:40 PM [6:40 PM], did not provide information regarding when Resident #23 was last observed and cared for and by whom. The Fall document did not include, and documentation in the Other section including if the bed was in low or high position, if the resident was in bed or in a wheelchair when found on the floor, if the call light was activated, if the resident was incontinent, the presence of absence of any devices that would alert the staff of the fall. The Predisposing Situation Factors section had History of Falls Bruising as the only checked area. Other. Alarm Sounded, Call Light on at Time, Reaching for Something, Wanderer, Attempted Self Toileting was left blank. The fall was unwitnessed. The revised care plan for falls dated 02/15/23 failed to address the line of supervision required by Resident #23 to prevent recurrence. Another Fall document dated 05/21/23 timed 07:21 AM, revealed the following notes entered by the LPN (Licensed Practical Nurse) on duty that night: CNA notified nurse that resident fell while attempting to change [him/her]. Resident [hit his/her] head on the floor just missing the floor mat and was bleeding profusely. The Registered Nurse (RN) who went to the room to assess the resident, documented the following on the Fall document: CNA notified nurse that resident fell when attempting to change [him/her]. Resident hit [his/her] head on the floor just missing the mat and was bleeding profusely. IDT Interdisciplinary Team discussed resident upon return from ER [emergency room] and [resident] will be treated with antibiotic per MD order, family also requested hospice services. On 05/25/23 at 11:00 AM, the surveyor reviewed the assignment sheet dated 05/21/23 provided by the 07:00-3:00 PM shift which revealed that a Hospitality Aide (HA) was assigned to the B-Wing and cared for Resident #23 on the 11:00-PM-7:00 AM shift. The facility did not have a statement from the staff who cared for Resident #23 on the 11:00 PM-07:00 AM shift on 05/21/23 according to the assignment sheet provided. On 05/30/23 at 10:30 AM, the DON provided a witness statement dated 05/22/23, which was not attached to the Fall document dated 05/21/23. According to the CNA's statement, she was assigned to Resident #23 during the 11:00 PM-7:00 AM shift, not the HA per the original assignment sheet as provided to the surveyor. On 05/30/23 at 11:00 AM, the facility provided a copy of a revised CP that included 26 pages, with additional interventions added that were not included on the CP that was revised on 05/25/23, and documented the following: Focus: [Resident #23] had a fall was found lying on the floor in [his/her] room. 05/21/23 Resident fell during care when [he/she] was turned to the side of the bed, it happened so fast, staff unable to prevent fall, Date Revised: 05/25/23. The Goal was to Risks for falls will be mitigated, Date Initiated: 02/15/23, Date Revised: 05/25/23 and Target Date: 08/14/23. The following interventions were documented: 2 persons assist during care, Date Initiated 05/21/23. 911 Was called and sent to hospital for evaluation, Date Initiated 05/21/23. Neuro check Initiated, Date Initiated 05/21/23; Neuro check x 72 hours, Date Initiated 05/21/23. Complete assessment with bleeding on left side of head, Date Initiated 05/21/23. Neuro check Initiated, Date Initiated 05/21/23; Neuro check x 72 hours, Date Initiated 05/21/23. Pressure dressing applied, Date Initiated 05/21/23. Primary physician made aware of the event, Date Initiated 05/21/23; Resident returned to the facility with antibiotic- Fosfomycin x 1 dose and doxycycline x 10 days, Date Initiated: 05/21/23. On 05/30/23 at 11:30 AM, an interview with an additional CNA who worked the 07:00-3:00 PM shift on 05/21/23 on the B-wing and who was listed on the assignment sheet for the same day, confirmed that the CNA who documented the statement did not provide care for Resident #23 on 05/21/23 on the 11:00 PM-07:00 AM shift. The CNA confirmed that the HA provided care to Resident #23 when the incident occurred. On 06/01/23 at 09:35 AM, the surveyor conducted a telephone interview with the Registered Nurse who worked on the 11:00 PM-07:00 AM shift on 05/21/23. The RN revealed that she was informed around 06:45 AM by the HA, that the resident sustained a fall. She went to the room and observed the resident was in bed and was bleeding profusely from the head, the resident reported feeling cold and was confused. The RN stated she then applied a pressure dressing, assessed the resident, implemented a neuro check, and called 911. Upon inquiry, the RN stated that the CNA who documented the statement was not assigned to Resident #23. In the presence of three other surveyors and the supervisor of the survey team, the RN stated that the HA was assigned to the resident. The RN further stated that when she questioned the HA regarding the mat that was to be in place to minimize injuries from falls, the HA changed his story several times. The RN also stated that she discussed the incident with the DON. The RN stated she did not know who transferred the resident back to bed after the resident was found on the floor. She further stated that she was made aware only two days ago that the staff who cared for Resident #23 on 05/21/23 during the 11:00 PM-07:00 AM shift, was a HA and was not a Certified Nurse Aide (staff trained to assist with certain non-resident care tasks). On 06/01/23 at 11:30 AM, the survey team informed the DON that the CNA who signed the witness statement, per interview and review of the timecard, was not assigned to the 11:00 PM shift on 05/21/23. The DON stated that she was told that the CNA reported that Resident #23 fell during care, she was not aware that Resident #23 was found on the floor by the Hospitality Aide. The DON was unable to explain why the HA was documented on the assignment sheets as having a resident assignment and was assigned to provide direct care to Resident #23. On 06/01/23 at 12:25 PM, the surveyor in the presence of the survey team, interviewed the CNA who signed the witness statement dated 05/22/23. The CNA stated that she was the CNA assigned to Resident #23 when the incident occurred, although her name was not listed on the schedule as being assigned to Resident #23 and contradicted the RN and LPN interviews. She stated during care Resident #23 fell, missed the mat and she yelled for help. The nurse then came into the room, assessed the resident on the floor and assisted her in transferring the resident to bed with a pulled sheet. On 06/01/23 at 12:30 PM, a review of the CNA's timecard provided by the Staffing Coordinator, revealed that the CNA who signed the witness statement worked 16 hours on 05/20/21 and reported to work on 05/21/23 at 07:02 AM. The CNA was not at the facility when Resident #23 sustained the fall. On 06/01/23 at 12:41 PM, the surveyor interviewed the Director of Nursing regarding the HA job description and inquired about who was responsible to monitor the HA. The facility had 8 Hospitality Aides assigned to the facility. The DON replied that the HAs had been working at the facility before she accepted the position as a DON, and she was not too sure of who was responsible to supervise or monitor the HAs. The DON then stated the nurses were responsible to monitor the HAs A review of the job description for the HA provided by the facility on 06/01/23 at 12:15 PM, revealed under Duties Report all pertinent information concerning resident care as directed to the appropriate supervisor/ personnel. Transport residents to activities, therapy, outside to smoke. Make beds, distributes linen as needed, and transports dirty linen to the linen room using established standards precautions. Distributes and sets up food trays for residents during meal times and collects empty trays from resident rooms and dining rooms. Monitor dining areas as assigned. Passes water pitchers Complete assignments timely, completely, and accurately. Conduct resident rounds as assigned. Answer call lights and obtain assigned staff members if direct patient care is needed. Cannot do any clinical care. On 06/02/23 at 09:53 AM, a telephone interview with the HA revealed that he worked the 11:00 PM -07:00 AM shift on 05/21/23. He stated that around 06:00 AM he went to the room to distribute linen and confirmed that he found Resident #23 on the floor bleeding (not the CNA as documented on the statement) and then he informed the nurse. The HA stated that he discussed the incident briefly with the DON on 05/21/23 and was not asked to document a statement. The surveyor then inquired regarding his name being on the schedule with a full assignment, he could not provide the rationale why he had a resident assignment. He stated that his job was to assist with task not related to direct care such as passing water, make beds, distribute linen. On 06/02/23 at 10:07 AM a telephone interview was conducted with the LPN who worked the 11:00 PM-07:00 AM shift. The LPN confirmed she worked on 05/21/23 and the HA was the person who reported the fall. The LPN continued and stated, that the RN went into Resident #23's room and assessed the resident after the fall. The LPN stated she did not go to the room, and she assisted with the paperwork for the emergent transfer. The LPN was unaware of who transferred the resident to bed. The LPN confirmed that the HA was the one assigned to and provided care for Resident #23 on the 11:00 PM-07:00 AM shift on 05/21/23. On 06/02/23 at 10:16 AM, during a second telephone interview with the RN, she stated that the HA had a resident assignment that day, and he cared for Resident #23 and confirmed that he was the one that reported the fall. The RN went on to state that when she entered the room, Resident #23 was already in bed and bleeding profusely. She did not ask who transferred the resident to bed. She was aware of the process to follow: Assessed while on the floor, ensure no head injury, implement neuro, alerted EMT (Emergency Medical Transport), notify the physician. She further stated that she discussed the fall with the DON. The surveyor reviewed Resident #23's ADLs worksheet for the month of May, left blank and there was no staff initials documented to identify who cared for Resident #23 on 05/21/23 during any of the shifts. On 06/02/23 at 11:15 AM, the DON was made aware of the discrepancy surrounding the fall dated 05/21/23. The DON was made aware of the telephone conversations with the nurses and the HA who worked the 11:00 PM-07:00 AM shift on 05/21/23. The DON stated that she was told that Resident #23 fell during care. The DON further stated since the resident was found on the floor, she considered the incident as a fall and did not investigate any further. The DON was asked to provide any additional information along with any Interdisciplinary Team Notes regarding the Fall document dated 05/21/23 for review on the exit day. On 06/05/23 at 11:34 AM, in the presence of the acting Administrator, the DON stated she went along with the information that was provided to her that Resident #23 fell during care, and that the fall was a witnessed fall, and she did not investigate. The facility did not present any further information. A review of a form titled, Accidents and Incidents-Investigation and Reporting dated 11/15/22, indicated the following: Policy Statement: 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of accidents or incidents as appropriate. 2. The following data, as applicable shall be included on the Report of Incident/Accident form: The date and the time the accident or incident took place. The nature of the injury /illness. The circumstances surrounding the accident/incident if known. Where the accident/incident took place if known. The name (s) of witnesses if any and their accounts of the incident or accident if known. The injured person's account of the accident/incident if able to communicate. Other pertinent data as necessary or required . 3. The Nurse Supervisor/ Charge Nurse and /or the department director or supervisor shall complete a Report of Incident/Accident form and get witness statements if any at the time of the incident. This individual will submit completed documents to the Director of Nursing Services /designee and discuss the incident at the morning management meeting. Post Fall/ Injury Resident Management In the event a resident has fallen and/ or is found on the ground, a complete head to toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present (fire, highway etc.) Remain with the resident while calling for assistance. If able, ask the resident to explain what happened and what they were attempting to do at the time of the fall (helpful for root cause analysis later). Upon arrival of the nurse, a quick head- to-toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks in the skin and/or other abnormal findings. Fall Injury Prevention-Post Fall 1. Assess the resident/ patient and immediately implement appropriate measures to prevent injury. Initiate and complete the Incident including pertinent witness statements. Review Fall Risk Assessment for any changes in fall risk, reassess post fall. On 06/05/23 at 08:35 AM, the acting administrator provided a folder with in-services that were done regarding some of the concerns addressed with the facility on 06/02/23 during a pre-exit conference. Regarding the incident of 05/21/23 the acting administrator submitted a witness statement from a CNA that was not on the schedule. No statement from the nurses who worked that night were collected even when the facility was made aware of the discrepancy and the telephone interviews with staff that worked on 11:00 PM -07:00 AM shift. The Acting Administrator also submitted an undated form titled, Falls and Falls Risk Management. Under Policy Statement the following were entered: Based on previous evaluations and current data, staff will identify interventions related to the resident's specific fall risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Under procedure #7 Falls are discussed at the clinical meeting in an attempt to determine the root cause(s). Review the fall, each morning and document in PCC (Point Click Care . However Resident 23 sustained a fall on 05/21/23. The facility did not submit the IDCP notes along with any root cause analysis that was done to identify the causal factor of the fall and rule out abuse. (Resident #23 was transferred from the floor to the bed prior to the nurse arrival to the room. There was no facility information provided regarding the transfer that occurred on 05/21/23 when the resident was found in bed, profusely bleeding, and required 2 persons physical assist for transfer.) NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is a repeat deficiency from the Standard Survey Date: 03/31/22 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to identify and consistently comprehensively assess, implement, and modify interventions, consistent with professional standards of practice a.) in response to an unplanned significant weight loss of 16.38% in less than 6 months for (Resident #128), and b.) in response to a significant weight loss of 8.6 pounds (lbs) in four days for (Resident #51). This deficient practice occurred for 2 of 5 residents reviewed for nutrition. The deficient practice was evidenced by the following: Reference: The Academy of Nutrition and Deititians, Position of the Academy of Nutrition and Dietitianss: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings, dated April 2018. Position Statement It is the position of the Academy of Nutrition and Dietitians that the quality of life and nutritional status of older adults in long-term care, post-acute care, and other settings can be enhanced by individualized nutrition approaches. The Academy advocates that as part of the interprofessional team, registered Dietitian nutritionist assess, evaluate, and recommend appropriate nutrition interventions according to each individual's medical condition, desires, and rights to make health care choices. Nutrition and dietetic technicians, registered assist registered Dietitian nutritionists in the implementation of individualized nutrition care. a.) On 05/24/23 at 10:30 AM, Surveyor #1 observed Resident #128 as he/she attended the Resident Council Meeting (RCM). During the RCM, Resident #128 stated the food was inedible and that he/she had lost weight. Resident #128 stated that everything is mushy because it was steamed like the vegetables. I've eaten very few veggies (vegetables), too overdone. Resident #128 stated that he/she had spoken to the Dietitian twice and provided food preferences and that the Dietitian informed him/her that the vegetables were frozen and steamed. Resident #128 stated he/she would be happy with one piece of celery and a carrot, just fresh and that also the fruit was all canned and served at room temperature, not cold. Resident #128 stated that he/she was also informed by the Dietitian that whole grains never going to happen. Resident #128 further stated that the protein is inedible. All six residents who attended RCM acknowledged that they were not offered an alternative menu such as the Asian menu provided to the Asian population of residents. A review of Resident #128's admission Record (an admission summary), revealed the resident was admitted on [DATE] with diagnoses which included but were not limited to; alcohol use, other psychoactive substance abuse, depression, atherosclerotic heart disease (arteries become narrowed and hardened from a buildup of plaque), hypertension (elevated blood pressure), Type 2 diabetes, hyperlipidemia (elevated lipids in the blood), folate (vitamin B) deficiency, anemia, and hyperkalemia (elevated potassium) in the blood. A review of the facility provided, Weights and Vitals Summary, dated 05/31/23, revealed the following dates / weights: 01/31/23 weight 210 lbs (pounds) 02/01/23 weight 204.5 lbs 02/08/23 weight 202 lbs 02/13/23 weight 198.5 lbs -5.0% change [comparison weight 01/31/23, 210 lbs, -5.5%, -11.5 lbs] 02/20/23 weight 197.4 lbs -5.0% change [comparison weight 01/31/23, 210 lbs, -6%, -12.6 lbs] 02/22/23 weight 195 lbs -5.0% change [comparison weight 01/31/23, 210 lbs, -7.1%, -15 lbs] 03/06/23 weight 192.6 lbs -5.0% change [comparison weight 02/01/23, 204.5 lbs, -5.8%, -11.9 lbs]; -7.5% change [comparison weight 01/31/23, 210 lbs, -8.3%, -17.4 lbs] 04/08/23 weight 183 lbs 04/17/23 weight 177 lbs 04/24/23 weight 175.2 lbs 05/01/23 weight 176.2 lbs 05/08/23 weight 175.6 lbs. There were no further documented follow up weights or re-weights in the electronic medical record (eMR). A review of the Assessment section in the eMR did not reveal any nutritional assessments. A review of the Progress Notes (PN) in the eMR ranging from 02/01/23 through 06/01/23, revealed the following: 01/31/23, admission notes revealed weight 210 lbs. 02/01/23, the Physician's history and physical revealed a weight of 204.5 lbs. 02/15/23, a Physician's note indicated a weight of 202 lbs. 03/02/23, 31 days after admission, the first dietary note, indicated review of weights upon admission. The note included 'does not consume all vegetables in facility limiting intake of vitamins and minerals' 'resident educated .possibility of MVI (multivitamin) with mineral supplement' 'resident request [name redacted - supplement drink]' The note indicated a different supplement drink was requested by Dietitian. Food preferences reviewed and noted. There was no calculation of estimated protein or calorie needs, and determination of causal factor for the unplanned weight loss. 03/9/23, a nursing note indicated the resident was seen by the dentist and recommendations were made for periodontal scaling. 03/12/23, a Physician's note indicated a weight of 195 lbs. 04/03/23, a Physician's note indicated a weight of 192.6 lbs. 05/15/23, a Physician's note indicated a weight of 175.6 lbs 5/8 (on 5/8/23), admission weight 210 lbs. progressive wt (weight) loss from 210 lbs to 175 lbs-will sch (schedule) f/u (follow up) CBC (complete blood count), CMP (comprehensive metabolic profile), Hba1c (hemoglobin a 1 c - blood work to indicate blood sugar levels over a three-month period), TSH (thyroid-stimulating hormone), monitor po (intake by mouth) intake, dietary eval (evaluation), consider dietary supplement and Remeron (medication used for appetite stimulation). The Progress Notes did not contain any additional notes from the Dietitian, any assessment to determine the causal factor of the weight loss and interventions to prevent weight loss. The PN dated 05/15/23, by the Physician did not indicate that a weight loss plan was ordered. A review of the facility provided, Order Summary Report (OSR), dated active orders as of 05/31/23, included but was not limited to; an order dated 2/10/23 for renal/CCD (carbohydrate-controlled diet regular texture, thin consistency, for low potassium diet), and an order dated 03/02/23 for [name redacted] liquid supplement two times a day for supplement. An order dated 4/4/23, with no end date for a BMP (basic metabolic profile blood work). There were no active orders for the Remeron, the follow up blood work, po intake monitoring, or dietary evaluation requested by the physician on 5/15/23. There were no active orders for a planned weight loss. A review of the person-centered comprehensive Care Plan last review completed 05/10/23, with a print date of 05/31/23, revealed no focus area regarding Resident #128's significant weight loss, no Goals regarding the weight loss, and no interventions regarding the weight loss. A review of the most recent Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate the management of care dated 05/02/23, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 14 out of 15; which indicated the resident was cognitively intact. Section K indicated a height of 71 inches and a weight of 176. K0300 loss of 5% or more in the last month or loss of 10% or more in last 6 months was inaccurately documented as 0 NO. On 05/30/23 at 12:17 PM, during an interview with the surveyors, the Licensed Nursing Home Administrator (LNHA) informed the survey team that the Dietitian was on vacation and unavailable for interview. The LNHA further stated she would have to see who is covering and that she was unable to locate the Dietitians credentials. On 05/30/23 at 12:22 PM, the LNHA stated that the Dietitian was only gone for one week, so the facility did not need coverage. She also stated that the practice is the Dietitian would document in the eMR and that the Director of Nursing (DON) would confer with the Dietitian. On 05/30/23 at 1:29 PM, during an interview with the surveyors, the DON stated she worked with the Dietitian and that every Monday weights and reweighs would be completed. On Thursday they would have a weekly weight meeting and discuss significant weight changes and interventions. She stated the Dietitian would make recommendations for the nurses to carry over. The DON stated, we discuss what could have caused the weight change, any supplements that may be needed, review what might be appropriate, speak to dietary to see that orders were carried out, monitor weights, we assign a specific Certified Nursing Aide (CNA) to do the weights. We have to investigate what's wrong with the weights like maybe a different wheelchair was used, and we notify the doctor for orders. The DON stated that the Dietitian would ask about food preferences and that some residents ask for organic food, but we can't accommodate organic for just one and we would have to tell resident. The DON stated that the weekly weights were documented in a log and the Dietitian would document them in the eMR as well. The surveyor inquired what would happen if a CNA obtains a resident weight and there was a 10 lbs difference, what would be the process. The DON stated that the CNA assigned should know to re-weigh the resident. The DON stated the Dietitian went on vacation 5/25/23 and was expected to return 6/8/23 (15 days later) and that the DON had only been with the facility for 3 months but the Dietitian was at the facility much longer. The DON stated she would provide the weight meeting information regarding Resident #128. On 05/31/23 at 12:11 PM, Surveyor #1 observed Resident #128 in his/her room with their lunch tray on top of the over bed table. Resident #128 showed the surveyor that he/she only ate a chicken thigh and not the mashed potatoes or carrots. Resident #128 stated he/she had talked to Dietitian about fresh versus canned vegetables. Resident #128 stated he/she usually only drinks the supplement drink once a day not twice. He/she further stated the Dietitian knew about the weight loss and that he/she wanted to lose some weight but not because of (facility) food choices. Resident #128 stated I just want better food choices. On 05/31/23 at 1:00 PM, the Regional Administrator #2, the DON, and the Regional [NAME] President of clinical services (RVPCS) were made aware of the above concerns. On 06/02/23 at 9:00 AM, the DON provided four photocopied untitiled pages. The DON indicated the pages were the Weight Meeting notes. The pages included, but were not limited to Resident #128's name and the following information 1/31/2023 weight 204.5 # (pounds); 2/6/2023 weight 202 #; DO: (doctor order) 2/3/23 WW (weekly weights) x 4; and 2/10/23 WW x 3. Page 2 added 2/13/2023 weight 198.5 #; 2/20/23 weight 197.4 #; and 2/17/23 WW x 2. Page 3 added 2/27/23 weight 192.6 #, 3/6/23 weight 192.6 #, 3/13/23 weight 191.8 #; and 3/3/23 WW x 1, 3/10/23 WW x 4 due to monthly weight loss, and 3/17/23 WW x 1 since weight stable. Page 4 added 4/17/23 weight 177 #; 4/24/23 weigh 175.2 #; 5/1/23 weight 176.2 #; 5/8/23 weight 175.6 #; and 4/13/23 WW x 4; 4/20/23 WW x 3; 4/27/23 WW x 2; 5/4/23 WW x 1; and 5/11/23 monitor weights monthly. There was no documentation by the physician regarding a planned weight loss, any discussion of a weight loss plan with the resident or interventions ordered. On 06/02/23 at 10:40 AM, the RVPCS stated that the weight sheets were worksheets, and they can't go by those weights. She stated that on Sunday the Dietitian would review Thursday's weights, and Tuesday she would review Thursday weights. The RVPCS further stated the weights would be in the weight meeting book and if a resident were being monitored for weight loss, that would also be in the eMR. She stated any interventions or orders would be implemented immediately. A review of the weights revealed that on 01/31/2023, the resident weighed 210.0 lbs. On 05/08/2023, the resident weighed 175.6 pounds which was a -16.38 % loss in less than 6 months. The facility was unable to explain the discrepancies in the weights documented in the eMR versus the weight meeting logs; to provide documented evidence that interventions were revised in response to the significant weight loss; to provide any additional documentation of the weight loss by the Dietitian; to provide a Dietitian assessments, food preference list; or any person-centered comprehensive care plan of focus area, goals, or interventions for Resident #128's significant weight loss. b.) On 05/22/23 at 10:25 AM, Surveyor #1 observed Resident #51 lying in bed with just a sheet on. Resident #51 appeared very thin, and the surveyor was able to observe bones under areas of his/her skin. On 05/23/23 at 12:36 PM, Surveyor #1 observed Resident #51 in a high back wheelchair in the B-unit day room. The resident had a lunch tray with beef macaroni casserole and carrots. The resident was drinking his/her juice but not eating the casserole. On 05/23/23 at 12:45 PM, the Licensed Practical Nurse (LPN) was encouraging Resident #51 to eat but the resident refused. The LPN asked if the resident wanted a peanut butter and jelly sandwich, and the resident nodded his/her head yes. During an interview at that time, the LPN stated the resident likes peanut butter and jelly and would usually eat all of the breakfast meal. The LPN stated that the facility Dietitian would be the one in charge of the resident's weight loss if any. A review of the facility provided, Weights and Vitals, dated 05/31/23, revealed the following: 03/09/23 a weight of 110 lbs. 03/14/23 a weight of 101.4 lbs. (recorded by the Dietitian); -5.0% change [comparison weight 03/04/23, 110 lbs., -7.8 %, -8.6 lbs.] and -7.5% change [comparison weight 03/04/23, 110 lbs., -7.8 %, -8.6 lbs.] 04/17/23 a weight of 100.4 lbs. (recorded by the Dietitian); -5.0% change [comparison weight 03/09/23, 110 lbs., -8.7%, -9.6 lbs.] and -7.5% change [comparison weight 03/04/23, 110 lbs., -8.7%, -9.6 lbs.] A review of Resident #51's admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, hemiplegia (paralysis of one side of the body), and hypertension. A review of the most recent Annual MDS dated [DATE], included but was not limited to a BIMS of 01 out of 15, which indicated the resident was severley cognitively impaired. Section G, Functional Status, revealed Resident #51 required limited assistance with a one-person physical assist for eating. Section K, Swallowing/Nutritional Status, revealed the resident weight as 110 lbs. and a score of 0 NO for weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. A review of the PN for Resident #51 date range 03/01/23 to 03/20/23, revealed a nursing entry on 03/08/23, that the resident's weight was 110 lbs. The next entry was dated 03/09/23, by Social Services and did not address the resident's weight. The next entry was dated 03/18/23, by nursing and did not address the resident's weight. There were no progress notes to indicate the Dietitian evaluated the resident or that the physician was notified of the resident's weight loss. A review of Resident #51's person-centered comprehensive care plan printed 05/30/23, included but was not limited to a focus area of nutritional problem related to low body mass index (BMI) date initiated 03/21/23. Interventions date initiated 03/21/23, included monitor/record/report to MD (physician) PRN (as needed) signs / symptoms of malnutrition: significant weight loss: 3 lbs. in 1 week, > (over) 5% in 1 month, > 7.5% in 3 months, > 10% in 6 months. There was no evidence in the eMR that the physician was notified of the weight loss of 8.6 lbs. in March 2023. On 05/30/23 at 12:17 PM, during an interview with surveyors, the LNHA stated she would have to see who was covering for the Dietitian who was on vacation from 05/27/23 and to return on 06/03/23. The facility Dietitian was unavailable for interview. On 05/30/23 at 1:29 PM, during an interview with the surveyors, the DON stated the weekly weight documented in a log and the Dietitian would document the weights in the eMR. Surveyor #1 requested the weight meeting notes. On 05/31/23 at 10:07 AM, the DON stated that she was still looking for the weight meeting information. The DON acknowledged she could not locate any documentation to immediately address the 8.6 lbs. weight loss in 4 days and stated she did not know why Resident #51 was not reweighed. On 05/31/23 at 11:10 AM, the DON provided an untitled paper and stated it was the weight meeting notes with resident names. Resident #51's name was included. The paper included monthly weight difference -3.6#/30 days -4.4#/6 months; monthly weight 3/2023 weight 98.6#, 2/2023 weight 102.2#, 9/2022 weight 103#; Date weekly weight 2/20/23 weight 102.2# w/c (wheelchair), 3/6/23 weight 98.6#, 3/13/23 weight101.2#. Interventions included 2/14/23 [name redacted] supplement drink four times a day, 2/17/23 WW x 4, 2/24/23 WW x 3, 3/3/23 WW x 2, 3/10/23 WW x 1, 3/17/23 monitor weights monthly. The interventions did not address the 8.6 lbs. weight loss in 4 days and the weights listed were either different or not documented in the eMR. There were no documented weights for 02/17/23, 02/24/23, 03/03/13, or 03/10/23. On 05/31/23 at 11:10 AM, the facility provided, Nutritional Assessment-Quarterly, dated 03/22/23, which was reviewed and included but was not limited to; current weight 108#. The assessment was signed by the Dietitian on 04/08/23. The eMR did not include a documented weight of 108 lbs. The facility provided hand written, paper weight meeting notes which reflected a weight for 03/13/23 of 101.2 lbs. Surveyor #1 reviewed the weight logs on Resident #51's unit. An entry dated weekly weights March 14, 2023 indicated Resident #51's weight was 101.2 lbs. An entry dated April Monthly Weights indicated Resident #51's weight as 97.4 lbs. An entry dated Weekly weights May 1, 2023 indicated Resident #51's weight as 98.2 lbs. An entry dated Weekly weights 05/08/23 indicated Resident #51's weight as 97.4 lbs. An entry dated Weekly weights 05/15/23 indicated Resident #51's weight as 98.2 lbs. All of the entries were left blank in the area for staff to initial as having weighed the resident. The 03/14/23 weight was not documented in the eMR. The April weight in the eMR was 04/17/23, 100.4 lbs. and 04/24/23, 100.6 lbs. The 05/01/23 weight was not documented in the eMR. The 05/09/23 weight was not documented in the eMR. The 05/15/23 weight in the logbook was 98.2 lbs. and the eMR had a documented weight of 103.0 lbs. indicating a 4.8 lb. discrepency. On 06/01/23 at 10:05 AM, Surveyor #1 informed the facility of the weights which did not coincide with the eMR and Resident #51's 8.6 lbs. weight loss, and no documented reweigh or immediate interventions, as stated by the DON, upon discovery of a significant weight loss. At that time, the facility was unable to provide additional information. On 06/02/23 at 9:39 AM, during an interview with Surveyor #1, the LPN working on B-Wing stated that if there was a large discrepancy in a resident's weight, the staff would first re-weigh the resident and then inform the DON and physician. Upon reviewing the weight on 03/13/23, the LPN stated that weight was entered by the Dietitian, and she would be the one responsible for comparing and reviewing the weights. The LPN further stated that if there was a re-weigh completed on 03/13/23, it would be located in the eMR. The LPN accessed the eMR in the presence of the surveyor and was unable to find a documented re-weigh for Resident #51. On 06/02/23 at 10:40 PM, during an interview with the surveyor team, the RVPCS stated that the weight sheets were worksheets and you can't go by those weights. A review of the facility provided, Dietitian job description, reviewed 06/10/22, included but was not limited to; communicates with medical staff, nursing and other department personnel; must be able to relate information concerning a resident's condition; conduct nutrition assessments of patients referred by healthcare providers; maintains nutritional care plans, reviews medical records, documents findings; collects patient information and records patient information; effectively and efficiently completes all paperwork requirements for billing and medical records compliance; evaluates how patients respond to their diets; and works to ensure patient satisfaction. A review of the facility provided, Weight Assessment, Management and Intervention Procedure, undated, included but was not limited to Weight Assessment 1. The nursing staff will measure resident weight, weight will be placed in unit weight book for Dietitian review; 2. Any weight change of 3% or more since the last weight will be retaken for confirmation; 3. The Dietitian will respond within 24-72 hours of receipt of notification; 4. the threshold for significant unplanned and undesired weight loss will be based on: a. 1 month - 3% weight loss is significant; greater than 5% is severe; 6 months- 10% weight loss is significant; greater than 10% is severe; 5. If the weight change is desirable, this will be documented. Analysis 1. The interdisciplinary team will identify conditions and medications that may be causing weight loss or increasing the risk of weight loss. 2. The Dietitian will discuss undesired weight gain with the resident and/or family; 3. A weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement. NJAC 8:39-17.1 (c); 17.2(d)