**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) consistently identify, comprehensively assess, implement, and modify interventions for an unplanned significant weight loss of 33.4 pounds (lbs) which was 17.7% in 6 months from 04/06/23 through 10/18/2023, then an additional 8.6 lbs which was (5.25%) in 15 days from 10/18/23 through 11/01/23, b.) implement weekly weights for 4 weeks after a significant weight loss occurred; c.) monitor for effectiveness, and ensure coordination of care among the interdisciplinary team for Resident #23 and d.) obtain a re-weight to verify a significant weight loss, consistently record and monitor meal consumption, and ensure a recommended nutritional supplement was prescribed and provided to the resident prior to surveyor inquiry for Resident #23 and Resident #63. This deficient practice was identified for 2 of 4 residents reviewed for nutrition which resulted in a significant and avoidable weight loss for Resident #23 and Resident #63 and was evidenced by the following: Reference: The Academy of Nutrition and Dietitians, Position of the Academy of Nutrition and Dietitians: 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. On 11/13/23 at 10:29 AM, during the initial tour of the facility, the surveyor observed Resident #23 awake and alert, sitting in a wheelchair in the dining room with the activities department. On 11/13/23 at 12:55 PM, the surveyor observed Resident #23, awake and alert, sitting in the dining room eating lunch consisted of pork, rice, and peas. On 11/14/23 at 09:14 AM, the surveyor observed Resident #23 lying in bed with his/her eyes closed. On that same day at 9:21 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that the resident was very sleepy that morning and she had fed the resident in bed which consisted of eggs, toast, coffee, and orange juice. The CNA stated that when the resident was up in his/her chair, he/she could feed his/themselves with set up and supervision. On 11/14/23 at 12:43 PM, the surveyor observed Resident #23, awake and alert, sitting in a wheelchair in the dining area feeding him/herself lunch which consisted of chicken, scalloped potatoes, green beans, and soup. Review of Resident #23's Face Sheet (admission Record) revealed the resident was admitted with diagnoses which included but were not limited to: dementia, fracture of the right femur, repeated falls, and anxiety disorder. Review of the Electronic Medical Record (EMR) revealed a physicians' order (PO) dated 07/18/23, for a regular diet with thin liquids A review of Resident #23's Vital Sign Report in the EMR revealed the following dates/weights: 04/06/23 weight 195 lbs. (pounds) 04/11/23 weight 195 lbs. 04/18/23 weight 188 lbs. 05/02/23 weight 224 lbs. 05/07/23 weight 187.60 lbs. 07/18/23 weight 179.60 lbs. 09/14/23 weight 165 lbs. 10/18/23 weight 163.80 lbs. 11/01/23 weight 155.20 lbs. There were no further documented follow up weights or re-weights in the EMR. A review of the Registered Dietitian's (RD) admission Nutritional Assessment dated 04/10/23 at 1:15 PM, reflected that the resident was 195 lbs. on admission. It included that the resident's diet was regular with thin liquids and intake was good and usually consumed greater than 75%. The summary included that Resident #23 was at risk for unintended weight loss related to history of dementia and interventions included to continue weekly weights times 4 then monthly if stable. A review of the RD Quarterly Nutritional Progress Note, dated 07/18/23 at 4:55 PM, revealed that per available weights, Resident #23 had experienced an 8 lb. (4.3)% weight loss x 60 days and 9 lb. (4.8%) weight loss x 90 days. Weight goal at this time was for stabilization. The resident's intake was typically adequate. Will provide additional sandwich with dinner and continue to monitor po intake and encourage as needed. Continue to encourage monthly weights as ordered. A review of the RD Quarterly Nutritional Progress Note, dated 10/18/23 at 5:10 PM, revealed that Resident #23's intake had been fair to adequate. Per weights, the resident had experienced a 1.2 lb.(0.7%) weight loss x 30 days, a significant 15.8 lb. (8.8%) weight loss x 90 days and a significant 31.2 lbs. (16%) weight loss x 180 days. The RD recommended super cereal at breakfast and a supplement with lunch and dinner. Continue with weights as ordered. A review of the RD Significant Weight Change Nutritional Progress Note, dated 11/14/23, reflected a weight history that had been variable. Weights indicated a significant 8.6 lb. (5.3%) weight loss x 30 days, a significant 24.4 lb. (13.6%) weight loss x 90 days, and a significant 33.4 lb. (17.7%) weight loss x 180 days. Recommended a supplement three times a day and weekly weights. Encourage weights as needed/accepted. Continue with liberalized diet. No recent labs noted. This assessment was completed after surveyor inquiry. A review of the April 2023 through November 2023 Physician Orders (PO), Medication Administration records (MARs) and Treatment Administration Records (TARs) did not reveal any documentation of dietary interventions as recommended by the RD in July 2023, October 2023 and November 2023. A review of the Physicians' notes dated April through October 2023, indicated that Resident #23 had no weight change and was generally healthy. A review of the EMR from April 2023 through November 2023, did not reveal any documentation that the physician, family, or the interdisciplinary team was aware of Resident #23's significant weight loss. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 04/13/23, reflected a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated the resident's cognition was severely impaired. It further reflected independent with eating with set up assistance, weight of 195 lbs. and no weight loss or gain of 5% or more in the last month or loss or gain of 10% or more in the last 6 months. A review of the Quarterly MDS, dated [DATE], reflected a BIMs score of 3 out of 15 which indicated the resident's cognition was severely impaired. It further reflected independent with eating with set up assistance, no weight measurement was documented, and no weight loss or gain of 5% or more in the last month or loss or gain of 10% or more in the last 6 months. According to the 07/18/23 weight in the EMR, Resident #23's weight was documented as 179.60 lbs. Review of the Quarterly MDS, dated [DATE], reflected a BIMS score of 3 out of 15 which indicated the resident's cognition was severely impaired. It further reflected that the resident needed set up or clean up assistance for the task of eating. The MDS revealed a weight of 164 lbs. and weight loss of 5% or more in the last month or a weight loss of 10% or more in the last 6 months and was not on a prescribed-physician weight-loss regimen. A review of the person-centered comprehensive Care Plan revealed a Nutrition care plan created on 04/10/23, revealed a goal to maintain a weight of approximately 190-200 lbs and interventions included to honor preferences, allow staff to weigh resident and to provide diet as ordered. On 10/18/23, the RD updated the care plan and changed the goal to maintain a weight of 165.4 lbs. in the next 90 days. The updated intervention included for staff to monitor intake and encourage resident as needed/accepted. The Care Plan was not updated to address Resident # 23's significant weight loss and did not include the RD's recommended interventions for the sandwich, supplements, fortified cereal, weekly weights etc. On 11/15/23, the surveyor reviewed the ADL Verification Worksheets, provided by the facility,which revealed that the CNA's failed to consistently document daily the percentage of meals and snack intake for Resident #23 from April 6, 2023 through November 15, 2023. On 11/14/23 at 1:00 PM, the surveyor reviewed the handwritten Dietician Recommendations book from January through November 2023, which revealed a handwritten recommendation dated 11/14/23, for Resident #23 to increase the supplement to three (3) times a day for significant weight loss and to start weekly weights. No other recommendations were written by the RD for Resident #23. On 11/14/23 at 1:02 PM, the surveyor interviewed the CNA who stated that upon admission all residents would be weighed weekly x 4 weeks then monthly thereafter. When inquired regarding the process, the CNA stated that all CNAs would obtain the resident's weights, write them on a piece of paper and give to the nurses who would entered the weights in the EMR. If a resident refused their weights, we would attempted again later, inform the nurse, and the nurse would document the refusal in EMR. On 11/14/23 at 1:08 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that a resident would be weighed the day of admission, weekly x 4 weeks, then monthly. The CNA's and the nurses would assist in obtaining the weights and the nurses would document the weights in the EMR. If the nurses noted any weight loss, the nurse should notify the physician and follow their recommendations. If the RD was consulted, then the RD would give the nurse their recommendations either verbally or written down in the Dietician Recommendation log and then the nurses would call the physician and obtain the order. The LPN further stated that any weight loss more than 2 lbs. weekly or monthly would be considered a significant weight loss. On 11/14/23 at 1:14 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM #1) who stated that upon admission all residents were weighed, then weighed weekly x 4 weeks then monthly thereafter. If a resident had a change in weight, loss or gain, the nurse would reweigh the resident and document the weight in the EMR. If it was a true weight loss or gain, the nurse would then notify the physician and consult the RD then follow their recommendations. The RD would see the residents on admission then quarterly thereafter. The RD would be consulted immediately for any significant weight loss or gain, and an assessment would be completed. A significant weight change would be weight loss or gain of 2 lbs daily or 4-5 lbs monthly. The nurses were supposed to document in the EMR progress notes that the physician was notified of a weight change. The RN/UM #1 stated that the first week of November 2023, she called the physician regarding Resident #23's weight of 155 lbs and consulted the RD. The RN/UM#1 confirmed that she did not document in the EMR that the physician or the RD was notified. On 11/15/23 at 11:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated that all residents are weighed on admission, then weekly x 4 weeks then monthly thereafter. The DON added, that the CNAs would obtain the resident's weights and the nurses would document the weights in the EMR. The nurses should document how the resident was weighed whether it was standing, wheelchair, a lift and what type of scale was used. The DON further stated that if a resident had a weight loss or gain weekly or monthly, I would expect the nurses to reweigh the resident to rule out that nothing was interfering with the discrepancy weight. If it was a true weight change then the nurse would notify the physician who would request a dietary consult. The nurses would then follow the physician and the RD recommendations. There should be a physician's order for any supplements and weekly weights. I would expect the nurses to notify the physician of any weight change of 3 lbs either weekly or monthly. Any significant weight change should be discussed in the morning meeting and reported to the team. If the RD recommended a sandwich, there would not be an order, dietary recommendations would come directly from the kitchen. On 11/15/23 at 11:25 AM, the surveyor interviewed the RD who stated that her role included to oversee all nutritional aspects of the residents on admission, quarterly and as needed. All new admissions would be weighed on the day of admission, then weekly x 4 weeks then monthly thereafter. The CNAs would obtain the weights then the nurses would enter the weights into the EMR. If the nurses saw any change in weight, whether a gain or loss, the nurses would reweigh the resident then notify the physician and the RD. If there was a significant weight change, I would complete an assessment, make recommendations and follow up more frequently such as monthly. The RD further stated I usually don't notify the doctor or family in my note, but any recommendations would be placed in the Dietician Recommendation book and the nurses would notify the physician. Any supplements or weekly weight recommendations would require a physician order,but for dietary recommendations such as fortified cereal or an extra sandwich would be sent to dietary and placed on the meal ticket. The surveyor then reviewed Resident #23's weight loss with the RD. The RD confirmed that in October 2023, quarterly assessment did trigger a significant weight loss and that she did not write the recommendations in the Dietician Recommendations book. Therefore, the supplements and super cereal were never carried over. I think I forgot to put them in the book. The RD further stated that the RN/UM #1 informed her that the resident had a decrease in weight for this month (November 2023) and I completed an assessment yesterday (on 11/14/23, after surveyor inquiry). On 11/15/23 at 11:59 AM, in the presence of the surveyor, the staff obtained and recorded Resident #23's weight at 160 lb. On 11/15/23 at 12:22 PM, the surveyor attempted to contact the attending physician, and was informed by the office that the physician was on vacation. On 11/15/23 at 01:40 PM, the surveyor conducted a telephone interview with the covering physician (MD). The MD stated that if he was aware of a resident's significant weight loss, he would want to identify the causal factor and implement interventions to address the weight loss. The MD further stated that he would expect the nurses to notify the MD if there was a significant weight loss of 5-19%. When asked if he was notified of Resident #23's significant weight loss of 31.2 lbs in the last 6 months. He stated, I do not recall. On 11/16/23 at 11:17 AM, the surveyor reviewed the documented weights in the EMR with the RN/UM #1. The RN UM #1 confirmed that when there was a discrepancy in Resident #23's weights, the nurses should have reweigh the resident and documented the reweighs in the EMR. The RN/UM#1 confirmed that there were no documented weights for the month of June 2023 and August 2023. The RN/UM #1 stated that on 05/07/23, she noticed that the 05/02/23 of 224 lbs was off so she obtained another weight on 05/07/23 of 187.6 lbs which was closer to the residents previous weight. The RN/UM #1 stated that she just put the weights in the EMR, but the RD would monitor the weights. The RN/UM#1 also confirmed that the physician, the family, and the DON were not notified of the significant weight change on 10/18/23. The RN UM #1 stated that she entered the 11/01/23 weight of 155.20 lbs in the EMR. She stated that she had notified the physician and consulted the RD, but did not document in the EMR. The RD did not complete her significant weight change assessment until 11/14/23 (after surveyor inquiry). The RN/UM #1 further stated that the CNAs do not document how the residents were weighed such as standing, wheelchair/or using a lift. The RN/UM #1 further stated if we reweigh the resident, we don't document the reweigh, we only document the correct weight. This was missed, we all missed this. On 11/16/23 at 11:53 AM, the surveyor interviewed the LPN who documented the 09/14/23 weight of 165 lbs. The LPN stated that she does not remember if she notified the RN/UM #1 of the weight change. On 11/16/23 at 1:30 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), DON and RD in the presence of the survey team. The surveyor reviewed the past six (6) months weights and the significant weight loss for Resident #23. The LNHA stated her expectation was that all residents would have maintained their weight. She would have expected if any weight changed, the nurses would notify the physician and the RD, reweigh the resident and document in the EMR. The DON and LNHA confirmed that they were not aware of Resident #23's significant weight loss until the surveyor's inquiry. The RD confirmed that the residents' weights were not monitored and there was not documentation of a weight loss trend. The RD stated that the significant weight loss should have been communicated to the DON, LNHA and the physician. If the resident was uncooperative with the procedure, that should have been documented. The DON and LNHA confirmed that supplement recommendations were not entered onto the MAR or TAR for October 2023 and November 2023 nutritional recommendations. There was no documented evidence in the EMR that Resident # 23 was eating the sandwich or consuming the supplement as recommended by the RD. The RD confirmed that she did not follow up with the resident's weights, the recommendations were not implemented and she did not notify the DON and LNHA of the significant weight loss in October 2023. The DON and LNHA stated that it was a system failure from the whole team. The LNHA and the RD stated, We missed it. 2. On 11/13/23 at 10:24 AM, during the initial tour of the Sandlewood Unit, the surveyor observed Resident #63 lying in bed with his/her eyes closed. The surveyor observed snacks at the bedside. Review of Resident #63's Face Sheet (admission Record) revealed the resident was admitted with diagnoses which included but were not limited to; wedge compression fracture, chronic pain, major depressive disorder, and schizoaffective disorder. Review of the Electronic Medical Record (EMR) revealed the following physician orders (PO): regular diet with thin liquids dated 12/10/23, a nutritional supplement 2 times a day dated 05/31/23, and Magic Cup 2 times a day dated 09/13/23. Review of the May 2023 through November 2023 MARs and TARs did not reflect the above corresponding physician's orders. A review of Resident #63's Vital Sign Report in the EMR revealed the following dates/weights: 08/09/23 weight 97.60 lbs. (pounds) 09/01/23 weight 91.20 lbs. 09/26/23 weight 92.30 10/01/23 refused. 10/03/23 weight 105 lbs. 11/01/23 other weight 11/06/23 weight 92.20 lbs. There were no further documented follow up weights or re-weights in the EMR. Review of the Quarterly MDS, dated [DATE], revealed that Resident #63 had a BIMs score of 11 which indicated the resident had moderate impaired cognition and had a poor appetite. Section K indicated a height of 62 inches and a weight of 91 lbs and had a loss of 5% or more in the last month or loss of 10% or more in last 6 months. Review of the Nurse Practitioners (NP) note, dated 09/11/23, revealed that Resident #63 had moderate protein-calorie malnutrition, weight of 91.2 lbs. The note further included to restart Remeron for appetite stimulant. The NP documented that the family was notified. Review of the Quarterly Nutritional Progress Note, dated 09/12/23 at 5:30 PM, reflected that Resident #63 intake was variable. Resident #63's current diet was regular with thin liquids and a supplement twice a day. The assessment further revealed that the resident had a significant 7.2 lb (7.3%) weight loss x 30 days. No skin issues or recent labs noted. The resident was receiving a supplement and Remeron (medication used to stimulate appetite) which was reinitiated on 09/12/23. Review of Resident #63's Comprehensive Care Plan for nutrition identified the weight loss and had interventions updated which included the following: I will consume supplements as ordered and I will follow diet as ordered. On 11/16/23 at 10:04 AM, the surveyor interviewed the LPN who stated that Resident #63 preferred to stay in bed, needed assistance with meals. On 11/16/23 at 11:35 AM, the surveyor interviewed the LPN who stated monthly weights were completed the first week of each month and if there was a weight loss or gain, the nurse would reweigh the resident. The surveyor reviewed the documented weights in the EMR with the LPN who stated a reweigh should have been done on 10/03/23 for the discrepancy weight of 105 lbs. On 11/16/23 at 11:58 AM, the surveyor and the RN/UM #1 reviewed the weights documented in the EMR on 10/03/23 as 105 lbs and stated the resident should have been reweigh and documented the weight in the EMR. The RN/UM #1 stated that she documented the weight as an error and the reweigh of 92.8 lbs on 11/14/23. On 11/16/23 at 1:30 PM, the surveyor, in the presence of the survey team, interviewed the DON, LNHA and RD. The DON stated that Resident #63 was not reweigh when there was a discrepancy of the weight on 10/03/23. The RD confirmed there was no follow up from September 2023, when a significant weight loss was identified. The DON stated that the RN/UM #1 should have been overseeing all the weights. The DON and LNHA confirmed that the nutritional supplements ordered were not transcribed onto the MAR and TAR. There was no documented evidence that Resident # 63 received the nutritional recommendations from May 2023 through November 2023. A review of the facility provided, Specialist Dietitian I job description, dated 2019, included but was not limited to; responsible for nutrition screening, assessment, diagnosis, intervention , monitoring, evaluation, and plan of care : communicate effectively with the interdisciplinary team, residents, and families; meal rounds, and evaluate and coordinate nutrition formulary per regulatory guidelines. A review of the facility provided, Resident Weights and Weight Changes policy, revised 11/07/17,reflected that significant weight changes will be reviewed by the DON/designee and referred to the dietician and physician if indicated. A reweigh must be obtained within 48 hours if a weight change meets the following criteria: 1 month- 5% body weight change or 6 months-10 % body weight change. The DON/designee or dietician will assess the weight change and make a notation in the medical record as to the plan of action for the weight change-diet counseling, physician notification, dietician notification, etc. The Dietician recommendations will be recorded in the medical record or on the designated form. The resident care plan will be adjusted to reflect the dietary recommendations. A review of the facility provided, Clinical Nutrition Services policy, revised 01/22, revealed that when recommendations are made which require a physician's order, the Registered Dietician Nutritionist (RDN)will follow up within 7 days to verify a response to the recommendations. The RDN monitors and evaluates the patient's response to care which include any or all of the following: nutrition assessment, meal rounds and or care plan rounds/meeting. The results of monitoring and evaluation are documented in the patient's medical record by the RDN. NJAC 8:39-17.1 (c); 17.2(d)