Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) identify and address multiple severe weight losses and consistently obtain reweights, b.) implement and monitor weekly weights, c.) evaluate and adjust nutritional interventions, e.) comprehensively assess the resident after a significant weight change and f.) revise the nutritional care plan. This was identified for 1 of 5 residents (Resident #47) reviewed for nutrition. The evidence was as follows: 1. On 2/8/23 at 11:45 AM, the surveyor observed Resident #47 lying in bed awake. The resident appeared thin, was not verbally responsive and was unable to maintain eye contact with the surveyor. The surveyor reviewed the medical records of Resident #47. Review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but not limited to unspecified protein-calorie malnutrition (protein calorie malnutrition happens when you are not consuming enough protein and calories), dysphagia (difficulty swallowing), Gastrostomy Status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and dementia in other diseases classified elsewhere, unspecified severity, with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 8/20/22 and 11/20/22, indicated that the resident's cognitive skills for daily decision making was severely impaired with total dependence of one-person physical assist for eating. A further review of the resident's MDS, Section K - Swallowing/Nutritional Status revealed that the resident had a feeding tube and significant weight loss that was not prescribed by the physician. Review of the Physician's Order (PO) dated 6/11/20, reflected that the resident had an PO for the tube feeding formula of Jevity 1.5 - one can (237 milliliter [mL]) via G-tube four times daily at 9AM, 1 PM, 5 PM, and 9 PM for a total volume of 948 mL. Review of the July 2022 through February 2023, Medication Administration Record (MAR) reflected the above corresponding PO's. Review of the resident's Monthly Record of V/S (vital signs) and Weights reflected the following weights: March 2022 127.4 lbs. April 2022 125 lbs. May 2022 122.8 lbs. June 2022 121.9 lbs. July 2022 122.1 lbs. August 2022 105 lbs. reweighed at 99.4 lb. - 22.7 pound (lb.) and 18.6% loss over one month September 2022 99.5 lbs. - 27.9 lb. and 21.9% loss over 6 months October 2022 100.8 lbs. - 24.2 lb. and 19.4% loss over 6 months November 2022 99.4 lbs. - 23.4 lb. and 19.1% loss over 6 months December 2022 95 lbs. - 26.9 lb. and 22.1% loss over 6 months January 2023 89.5 lbs. - 5.5 lb. and 5.8% loss over one month Review of the resident's progress notes from the hybrid (both paper chart and electronic medical records) medical record from July 6, 2022, through February 5, 2023, included the following documentation related to weight loss: The Quarterly Nutritional Assessment (NA) completed by the Registered Dietitian (RD), dated 8/23/22, indicated that the resident had significant weight loss in the past 6 months . Will suggest to reweigh resident and will check the reliability of the scale used. The RD also indicated that she would follow up. The Quarterly NA completed by the RD, dated 2/5/23, indicated that the resident had significant weight loss in the past 2 quarters . She also indicated that the resident was on Jevity 1.5 tube feeding. Gets 4 cans of Jevity 1.5 = gives 1420 calories and 60.4 grams protein. Resident gets 105% of the required calories .no recent laboratory reports are available except HBG and HCT which are both normal. Will continue to follow up. Review of the Quarterly IDCP (Interdisciplinary) care plan meetings dated 8/30/22 and 11/29/22 did not include documented evidence that the team was aware that the resident experienced significant weight losses. Review of the Nurses Progress notes did not include documented evidence that nursing was aware that the resident experienced significant weight losses. Review of the resident's Attending Physician (AP) Doctor's Progress Notes dated 10/8/22, 1/17/23, and 2/5/23 did not include documented evidence that the AP was aware of the resident experienced significant weight losses. Review of the resident's comprehensive care plan including the following focused areas: 1. The Nutrition- Dysphagia comprehensive care plan with an effective date of 3/1/22. 2. The G-tube feeding comprehensive care plan with an effective date of 3/1/22. 3. The Nutrition- Risk for Dehydration and weight loss with an effective date of 5/25/22. All three comprehensive focused care plan areas did not include documented evidence of the resident's significant weight losses. Further review of the G-tube feeding comprehensive care plan with an effective date of 3/1/22, indicated that the Goals will receive adequate nutrition and hydration via gtube with good tolerance over the next three months. It also indicated interventions to follow up significant labs, weight changes, skin integrity, BM. On 2/9/23 at 9:42 AM, the surveyor interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team. The DON stated that the residents were weighed monthly by the Certified Nursing Aide (CNA)'s. She also stated that the CNAs would verbally communicate the weights to the nurses. She then stated that the nurses would document the weights in the Monthly Record of V/S and Weights form in the resident's paper chart in the Dietary section. During the interview, the DON informed the survey team that the resident would be reweighed if there was a weight discrepancy such as significant weight loss. She also stated that when a resident's weight loss was confirmed, the nurse would notify the resident's AP of the resident's weight loss. The DON stated that a dietary consult was usually a physician's order. She also stated that if the AP ordered a dietary consult, the nurses would verbally communicate this to the RD. On 2/14/23 at 12:32 PM, the surveyor interviewed the assigned CNA for Resident #47. She stated that the CNAs were responsible for weighing all the residents once a month, by the fifth of the month. She further stated that the nurses assigned the CNAs the residents who needed to be weighed and the CNA's would verbally communicate the residents' weights to the nurse, or would write it on the daily assignment sheets. The CNA stated that she was not aware that Resident #47 had weight losses. On 2/14/23 at 12:46 PM, the survey team interviewed the RD in the presence of the LNHA. The RD informed the survey team that the residents' weights were taken by the nursing staff every first week of the month. She stated that the Unit Manager (UM) nurse would report to her which residents had a weight loss of 5 lbs. or more and stated, I have continuous communication with nursing about residents that have lost weight. During the interview, the RD stated that when a resident had a significant weight loss, they would do a 3-day calorie count to determine if the resident's intake was meeting his/her needs and stated, we always do that. She further stated that she would discuss the calorie count results that were kept in the resident chart with the nurse, and she would explain how the results were related to the weight loss, which were documented in the medical record. On that same date and time, the RD informed the survey team that they did not have weight meetings. She stated that she would make recommendations and that there would be continuous follow up for any significant weight losses. She further stated that they would evaluate the residents on a quarterly basis whether there was an improvement or not. In addition, she stated that she reviewed the residents' weights monthly, reviewed the weight loss trends, and that she would follow up every month to ensure that the interventions were effective. She stated, weight is the most significant, sensitive yardstick of nutritional assessment of the patient. The RD stated that if a resident experienced a significant weight loss, monitoring weekly weights for four weeks would be warranted. She further stated that she would recommend to start a calorie count, nutritional supplements, and weekly weights by communicating to the nurses and the AP. On 2/15/23 at 10:28 AM, the surveyor interviewed the resident's AP in the presence of the survey team, who stated that she visited the resident every month. She also stated that after visiting the resident, she documented the encounter in the resident's paper medical records. During the interview, she acknowledged that she noticed a lot of weight loss for Resident #47. The AP acknowledged that she had not increased the resident's tube feed (TF) formula order prior to the surveyor's inquiry. She further acknowledged that she could have increased the TF and stated, I am not saying that I don't want to give her food. The AP could not verify when and who in the facility notified her that the resident had significant weight losses. The AP stated that if the resident had a significant weight loss, I would have documented that in the medical record. On 2/15/23 at 10:52 AM, the Unit Manager/Registered Nurse (UM/RN) stated that she would notify the resident's AP of a confirmed weight loss and that the AP would order a dietary consult. In addition, she also stated that the notification of weight loss and discussions had with the AP and RD should be documented in the resident's electronic medical records. She further stated that the RD would conduct her nutrition assessment and recommend a 3-day calorie count, and that she would notify the AP of the RD's recommendations. In addition, the UM/RN stated that if a resident was not getting enough calories to maintain their weight, she would expect recommendations from the RD. During the interview with the UM/RN, who further stated that when she returned to work last month she was informed that Resident #47 had a gradual significant weight loss over the last 6 months. She also stated that she did not notify the resident's AP regarding the resident's significant weight losses. On 2/15/23 at 12:42 PM, the LNHA, Regional RN#1 (RRN#1), DON, and MDS Coordinator met with the survey team. The RRN#1 confirmed that the RD did not have documented evidence in Resident #47's hybrid medical records to address the significant weight losses. She further confirmed that there was no documented evidence that the RD conducted follow-up assessments. During that same interview, the RRN#1 further stated that the AP acknowledged that she was aware of the resident's significant weight losses but there was no documented evidence in the resident's hybrid medical record that the AP addressed Resident #47's significant weight losses. The RRN#1 stated, that's a problem. On 2/16/23 at 11:05 AM, the LNHA, RRN#1, RRN#2, DON, and the Infection Control Preventionist Nurse (ICPN) met with the survey team. The RRN#1 acknowledged that the resident's bolus TF PO was never changed since 2019 to the present, until surveyor inquiry. She further stated that the resident suddenly, had a lot of weight loss in one month, and was wasting, and the AP never addressed the significant weight losses until after surveyor inquiry. She also acknowledged that resident's significant weight losses were not addressed in the resident's comprehensive care plans. On 2/16/23 at 11:47 AM, the survey team met with the LNHA, RRN#1, RRN#2, DON, and ICPN. There was no additional information provided. Review of the facility policy HMNR Role of the Registered Dietitian dated 12/2022, included that the Purpose was To ensure that the RD's are in adherence with rules and regulations set forth by the Centers for Medicare and Medicaid Services (CMS). In addition, it included Create a proper diet that fits all nutritional needs for residents/patients.; Participate in interdisciplinary care planning.; and Perform follow up assessment quarterly or more often if needed for long term care residents. Review of the facility policy HMNR Registered Dietitian Documentation dated 12/2022, included that the Purpose was .To ensure consistency in the documentation of nutrition care by Registered Dietitian's. To support and justify nutrition care. To document the results of nutrition care. In addition, it included the following: Nutrition Assessment and Consultation - Evaluation of nutrition/medical history lab values, anthropometric (measurements and proportions of the human body, such as weight) measurements . Action or recommendations with desired outcomes/measurable goal. To be entered in the [electronic medical record] under assessments .; Follow-up Evaluation . Effectiveness of nutritional intervention as it relates to goals. Monitor (review, measure status and timeliness), evaluate (compare with previous status, intervention goals and reference standards, and document progress (using defined indicators) . Re-assessment - Significant changes in lab values, anthropometric measurements, nutrient needs, . Care plan . Review of the facility policy HMNR Resident/Patient Weights dated 7/2022, included that the Purpose was To monitor the resident's/patient's nutritional status and appropriately respond to significant weight changes. In addition, it included the following: Weight can be a useful indicator of nutritional status .Weight goals should be based on a resident's/patient's usual body weight or desired body weight . Resident/patient weights will be monitored over time to identify weight loss/gain, verify weight measurements when changes in weight occur, and reassess weight interventions when appropriate . Facility scales will be calibrated annually or more often as needed by the Maintenance director/supervisor . Any resident/patient with a weight change of five (5) pounds or more will be re-weighed for accuracy . Any resident/patient with a significant weight change will be referred to the Dietitian for assessment . All resident/patient weights will be reviewed by nursing and dietary to determine significant change . Residents/patients with a recent history of weight loss or risk for weight loss may be weighed weekly as determined by the dietitian and or physician . Appropriate, individualized resident/patient interventions will be initiated to prevent and/or address significant unplanned weight changes . Residents/patients identified with significant weight loss/gain will be reviewed during nutrition rounds or facility weight meeting . The Dietitian will document in the medical record any resident/patient weight changes and interventions initiated, as well as in the care plan . Nursing or designee will notify the physician and or family/representative of any significant resident/patient weight changes. Review of the facility policy Tracking Weight Changes with a revised date of 12/21, included Weights will be documented for all individuals, for the purpose of assessing significant and gradual weight changes. In addition, it included the following: The facility will be responsible for obtaining accurate weights on a regular basis, and for keeping accurate records . A copy of the weight records will be forwarded to the appropriate professional each month: weight team leader, registered dietitian nutritionist (RDN) or designee, nursing supervisor, etc. The RDN or designee will review monthly weights and calculate significant change over one, three and six months . A copy of all significant weight losses and gains will be given to the interdisciplinary care team for appropriate review and documentation . All individuals with significant weight changes will be reweighed to assure accuracy of the weight prior to reporting to the staff, physician or family . The care plan team will review and document on all . significant weight changes, with appropriate referrals to the physician and RDN or designee. The RDN or designee will review all significant weight losses, . will make referrals and take action as necessary (including follow up documentation). The individual, family (or representative), physician and RDN or designee will be notified of any individual with an unintended significant weight change of 5% in one month, 7.5% in three months, or 10% in six months . Individuals with significant unintended weight changes will be added to weekly weights for a minimum of 4 weeks or until weight stabilizes. Review of the facility policy HMNR Care Plan dated 12/2022, included that the Purpose was To develop and implement a care plan for each resident/patient that includes the interventions needed to provide effective and person-centered . care of the resident/patient that meet professional standards of quality care. In addition, it included the following: The comprehensive care plan must describe . The services that are to be furnished to attain or maintain the resident/patient highest practicable physical, mental, and psychosocial well-being. Furthermore, it included that the care plan should be Prepared by an interdisciplinary Team, that includes but is not limited to - the attending physician or non-physician practitioner, a registered or licensed practical nurse . a Registered Dietitian . The care plan should also be Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive, significant change, quarterly, and annual review assessments. NJAC 8:39-11.2(e)(2) (i), 17.1(c), 17.4(a)(3), 27.1(a)