**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 10/07/2024 to 10/15/2024, for two (Resident #13 and #59) of two residents reviewed, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, Resident #13 did not have documented evidence of a bowel movement for more than three days, that bowel medications were ordered and/or administered per the facility's protocol, or that a medical provider was notified. For Resident #59, who had nephrostomy tubes (thin, flexible tubes that drain urine from the kidney into a bag outside the body), there was frequently missed documentation to indicate medical orders were completed, the resident was hospitalized and treated for pyelonephritis (a kidney infection/bacterial infection that causes inflammation of the kidneys), and facility staff had not received special training to care for a nephrostomy tube. This resulted in actual harm to Resident #59 that was not Immediate Jeopardy and is evidenced by the following: The facility policy Charting and Documentation, dated April 2008, included all services provided to the resident, or any changes in the resident's condition would be documented in the resident's medical record. All observations, medications administered, services performed must be documented in the resident ' s medical records. All incidents, accidents, or changes in the resident's condition must be recorded. Documentation of procedures and treatments would include care-specific details at minimum: the date and time the procedure/treatment was provided, name and title of the individual who provided care, the assessment data and/or any unusual findings obtained during the procedure/treatment, how the resident tolerated the procedure/treatment, if the resident refused procedure/treatment, and notification of family, medical or other staff if indicated. The undated facility policy Care of a Nephrostomy Tube included instructions for the irrigation and dressing change of a nephrostomy tube and noted the procedure was a Registered Nurse only procedure secondary to needing an assessment. The facility was unable to provide documented evidence that nursing staff had received training and were competent to provide care for nephrostomy tubes. 1. Resident #59 had diagnoses including obstructive and reflux uropathy (urinary tract conditions that can cause urine to flow abnormally), chronic obstructive pyelonephritis (a kidney condition that results from repeated kidney infections and scarring), and presence of urogenital implants (a synthetic material that can be placed in the urinary organs or genitals). The Minimum Data Set Resident Assessment, dated 08/05/2024, included the resident had moderately impaired cognition, did not reject care, required assistance with toileting hygiene, and had an indwelling catheter (including nephrostomy tube). Review of the current comprehensive care plan included Resident #59 had renal failure related to kidney disease with bilateral nephrostomy tubes (last revised 10/11/2023), was incontinent of urine (last revised 01/21/2022), and had the potential for impairment to their skin integrity (last revised 08/14/2024). Interventions included, but were not limited to, monitor for signs/symptoms of infection, required extensive assistance with toileting, check and change resident every three to four hours, check placement of nephrostomy tubes and red areas as needed, and Registered Nurse to flush nephrostomy tubes daily. Physician orders initiated on 04/29/2024 included Registered Nurse to flush nephrostomy under sterile technique every shift as needed if urine output less than 100 milliliters, empty nephrostomy tube every shift for monitoring output, nephrostomy tube dressing change under sterile technique/measure length of tubing from insertion site to hub and document/check suture placement every three days for nephrostomy maintenance - Licensed Practical Nurse may change the dressing. Review of the June 2024 Treatment Administration Record revealed for 90 opportunities, the order to empty the nephrostomy tube every shift had 11 dates with blanks (no documented evidence of completion) and two dates documented as not applicable (N/A). On 06/04/2024 evening shift, urine output was documented as zero milliliters and there was no documented evidence that a Registered Nurse flushed the nephrostomy tubes. Review of the July 2024 Treatment Administration Record revealed for 93 opportunities, the order to empty the nephrostomy tube every shift had seven dates with blanks and eight dates documented as not applicable. On 07/08/2024, there was no documented evidence the nephrostomy dressing was changed, the length of tubing was measured, and suture placement was checked. Review of a progress note, dated 07/18/2024, Licensed Practical Nurse #1 documented during Resident #59's nephrostomy dressing change the right tube was leaking an excessive amount of urine, the nephrostomy may need to be replaced and the nurse manager was notified. The concern was placed in the 24-hour report book (filled out daily by a nurse at the end of each shift to communicate resident information) and acute medical book (used to communicate changes in resident condition to the medical provider). The facility was unable to provide documented evidence Resident #59 was assessed by a Registered Nurse or that a medical provider was notified. Review of the August 2024 Treatment Administration Record revealed for 77 opportunities, the order to empty the nephrostomy tube every shift had eight dates with blanks and one date documented as not applicable. On 08/09/2024 day shift was signed with code 9 (see progress note). Review of the electronic medical record revealed there was no progress note documented on this date. Urine output was documented as less than 100 milliliters on 08/09/2024 evening shift (85 milliliters), 08/22/2024 day shift (75 millimeters) and evening (zero millimeters) shifts, and there was no documented evidence that a Registered Nurse had flushed the nephrostomy tubes. Review of a progress note, dated 08/14/2024, Registered Nurse Supervisor #2 documented Resident #59's left nephrostomy dressing was soiled and there was a drainage stain on their t-shirt. Redness and irritation was observed when the old dressing was removed. Less than 100 milliliters of urine remained in the bag and the nephrostomy tube was flushed per the medical order. The medical provider was notified via the acute book. A physician order, dated 08/15/2024, included Resident #59 was sent to the hospital for further evaluation related to the left nephrostomy tube not producing any urine. Review of a Hospital Discharge summary, dated [DATE], included Resident #59 was admitted following decreased urine output for the last week, dislodgment of their nephrostomy tube that was replaced on 08/15/2024, and was found to have pyelonephritis that was treated with antibiotics for five days. The resident would be discharged to the skilled nursing facility on oral antibiotics for two additional days. Review of a provider visit note, dated 08/20/2024, Physician #1 documented Resident #59 was hospitalized for displacement of nephrostomy tube and possible pyelonephritis. The resident was treated with antibiotics, the nephrostomy tube was replaced, and returned to the facility for long term care. Current medications included, but were not limited to, two days of amoxicillin (an antibiotic) three times daily for a bladder infection and levofloxacin (broad spectrum antibiotic) once daily for infection. Review of the September 2024 Treatment Administration Record revealed for 93 opportunities, the order to empty the nephrostomy tube every shift had six blanks and there was no documented evidence the nephrostomy dressing was changed, the length of tubing was measured, and suture placement was checked on 09/15/2024 and 09/18/2024. On 09/07/2024 evening shift and 09/12/2024 evening shift, urine output was documented as zero milliliters and there was no documented evidence that a Registered Nurse flushed the nephrostomy tubes. During an interview on 10/10/2024 at 1:30 PM, Licensed Practical Nurse #1 stated they had worked at the facility since March 2024 and floated to both units. There was one resident at the facility that had nephrostomy tubes and they had not received any education or competencies on nephrostomy tube care while employed at the facility. Licensed Practical Nurse #1 stated if they found the nephrostomy tubes to be dislodged or the resident had low urine output, they would document the concerns and notify the nursing supervisor. They stated it was important to provide care and treatments per the medical orders to prevent infections. During an interview on 10/10/2024 at 2:57 PM, Licensed Practical Nurse #14 stated they worked per diem and would cover the facility as the supervisor. There was one resident in the facility that had nephrostomy tubes. If the nephrostomy tubes needed to be flushed per the medical orders, they would call the Registered Nurse who was on-call and document the concern in the acute (medical) book and in a progress note. Licensed Practical Nurse #14 stated when in their role as supervisor, they could not recall a time that a Registered Nurse came in to flush the resident's nephrostomy tubes. During an interview on 10/11/2024 at 8:57 AM, Licensed Practical Nurse Manager #2 stated Resident #59 had nephrostomy tubes and had gone out to the hospital in August 2024. A Registered Nurse needed to flush the tubes per the medical order and a Licensed Practical Nurse could not do that. If the resident's tubes needed to be flushed and a Registered Nurse was not in the building, the Licensed Practical Nurse Supervisor would contact the Registered Nurse on-call who would come in to flush the nephrostomy tubes. Licensed Practical Nurse Manager #2 stated they had worked at the facility since July 2024 and had not received any training or competencies on nephrostomy tube care. They stated it was important to complete the medical orders to prevent infections and staff should document the resident ' s urine output each shift. During an interview on 10/11/2024 at 9:25 AM, Licensed Practical Nurse #10 stated they had worked at the facility for two years and Resident #59 was on their assignment. They also stated the resident did have nephrostomy tubes and if the urine output was less than 100 milliliters, they would contact the nursing supervisor and document their findings. Licensed Practical Nurse #10 stated they had not received any training regarding nephrostomy tube care. During an interview on 10/11/2024 at 1:53 PM, the Nurse Educator/Infection Preventionist stated they had been working at the facility since March 2024 and nephrostomy tube care was simple. They stated they could not find any documented education, trainings, or competencies for nephrostomy tube care for nursing staff at that time. During an interview on 10/11/2024 at 3:34 PM, the Medical Director stated it was rare to see a resident with nephrostomy tubes in a long-term care setting. It was important for staff to follow medical orders for nephrostomy tubes, especially flushing, as there could be issues with proper drainage due to sediment. The Medical Director stated Resident #59 was recently hospitalized for an infection and could not say for certain what would happen if staff did not flush the resident's nephrostomy tubes as ordered. During an interview on 10/15/2024 at 8:51 AM, the Director of Nursing stated staff should always follow the medical orders and document once treatments were completed. If there was missing documentation, there was no way to prove the treatment was completed. They stated if treatments were not completed as ordered, Resident #59 could be at risk for an infection. The Director of Nursing stated there were no documented competencies or trainings for the nursing staff on nephrostomy tube care. 2. Resident #13 had diagnoses including dementia, diverticulosis (small, bulging pouches in the digestive tract), and adult failure to thrive with protein-calorie malnutrition. The Minimum Data Set Resident Assessment, dated 06/29/2024, included the resident had moderately impaired cognition, required moderate assistance with toilet transfers, maximal assistance with toileting hygiene, and was always incontinent of bowel. The facility policy Bowel Habits, dated 12/19/2022, included that each resident admitted to the facility would have their bowel pattern assessed, with the objective being to develop regular bowel habits and prevent fecal incontinence, impaction, and irregularity. The certified nursing assistant would mark the bowel movement in the electronic medical record every shift, and the licensed nurse would check the electronic Medication Administration Record at the start of each shift to determine if a laxative, suppository, or enema was necessary. A laxative ordered by the physician for the resident should be given on the third day that the resident had no bowel movement. Review of the Comprehensive Care Plan, revised 04/16/2024, revealed Resident #13 required extensive assistance of two (staff) with toileting. During an interview on 10/07/2024 at 1:44 PM, Resident #13's visitor stated facility staff had previously been notified that Resident #13 was bloated and it went on for three to four weeks. Review of the Bowel and Bladder Elimination report from 08/01/2024 to 10/11/2024 revealed no documented bowel movements during the following timeframes: 08/04/2024 through 08/13/2024, 08/15/2024 through 08/19/2024, 08/26/2024 through 08/31/2024, 09/14/2024 through 09/19/2024, 09/25/2024 through 09/29/2024, and 10/04/2024 through 10/07/2024. Review of active physician orders initiated on 04/15/2024 included the following medications to treat constipation: senna (a laxative) at bedtime and polyethylene glycol (a laxative) daily in the morning. There were no bowel medications ordered as needed to treat constipation. Review of the Medication Administration Records for August, September and October 2024 revealed Resident #13 was administered senna and polyethylene glycol as ordered. There was no documented evidence that as needed medications to treat constipation were ordered or administered. Review of a progress note, dated 08/24/2024, Licensed Practical Nurse #5 documented Resident #13's family member reported the resident was constipated. Licensed Practical Nurse #5 verbalized to the family member that Resident #13 had received bowel medications and they would also provide prune juice and milk of magnesium (a laxative). Review of active physician's orders for that timeframe did not include milk of magnesium. Review of interdisciplinary progress notes from 08/01/2024 to 10/11/2024 did not include documented evidence that a medical provider was notified of no bowel movement after three days or that as needed medications were administered to treat constipation. In a progress note, dated 10/06/2024, Licensed Practical Nurse #8 documented Resident #13 had complained of diarrhea with a foul smell and their daily dose of senna was subsequently held. During an interview on 10/11/2024 at 12:37 PM, Certified Nursing Assistant #1 stated they would chart residents' bowel movements in the electronic medical record and constipation would be considered if a resident went three to four days without a bowel movement. At times they would ask a resident when their last bowel movement was and would let the nurse know if a resident was constipated or had requested bowel medications. Certified Nursing Assistant #1 stated Resident #13 may have had problems with constipation due to having bowel movements that were liquid. They thought Resident #13's last bowel movement was on 10/07/2024, but they forgot to document it because the unit was short staffed. During an interview on 10/11/2024 at 12:56 PM, Licensed Practical Nurse #1 said for monitoring residents' bowel movements, they check the electronic health record or ask the residents and certified nursing assistants when the resident's last bowel movement was. A bowel movement report (no documented bowel movement in three days) was run daily by either the unit nurse manager or the nurse and the nurses' received notifications in the electronic health record if the resident did not have a bowel movement. Licensed Practical Nurse #1 stated if a resident did not have a bowel movement within 48 to 72 hours, they would verify with the resident and administer as needed medication per the facility bowel protocol. Licensed Practical Nurse #1 stated Resident #13 had normal bowel movements every day or two and did not have to administer any as needed medications for constipation. During an interview on 10/11/2024 at 2:13 PM, Licensed Practical Nurse Manager #2 stated Certified Nursing Assistants are supposed to document in the electronic medical record if the resident had a bowel movement or not. Licensed Practical Nurse Manager #2 stated they reviewed the bowel movement report daily and would notify the floor nurse of any resident that needed bowel medications. On weekends, it was the floor nurse's responsibility to review the report. Licensed Practical Nurse Manager #2 stated if a resident had no bowel movement for three days, the nurse would give bowel medications per the facility protocol and notify a medical provider if the protocol was ineffective. They stated as needed bowel medications were standard orders for all residents, but thought Resident #13 did not have them ordered because they were receiving routine laxatives daily. During an interview on 10/15/2024 at 8:51 AM, the Director of Nursing stated the nurses were supposed to run a bowel report daily and follow the facility's bowel protocol. The nurse completing the resident's admission was responsible for entering medical orders for as needed bowel medications per the protocol. The Director of Nursing stated if a resident did not have a bowel movement for three days, they would expect the nurses to follow the bowel protocol and notify a medical provider. They were not aware of any issues related to the monitoring of resident bowel movements. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey conducted from 10/7/2024 through 10/15/2024, the facility failed to ensure acceptable parameters of nutritional status for two (Residents #38 and #11) of three residents reviewed. Specifically, Resident #38 did not receive assistance at meals per their care plan, did not have their nutritional needs reassessed timely, and had poor meal intakes resulting in significant weight loss. Additionally, Resident #38 developed a stage three pressure ulcer (full thickness tissue loss) following the weight loss. Resident #11 was care planned to receive extensive assistance with meals and was observed on multiple occasions eating independently without staff assistance, did not consistently receive their Mighty Shake (nutritional supplement) as ordered with no substitutes offered or provided, and had significant weight loss. This resulted in actual harm to Resident #38 that was not Immediate Jeopardy and is evidenced by the following: Findings include: The facility's undated policy Weight documented nursing staff would weigh all residents upon admission or readmission, three days after admission, weekly for four weeks, then monthly thereafter. If there was a fluctuation of five pounds for any residents who weighed 100 pounds or more or a fluctuation of three pounds for a resident who weighed 100 pounds or less, the resident would be re-weighed for verification on the same scale and at that time. The dietitian would review weights for five percent gain or loss in one month or 10 percent gain or loss in six months. A list of significant weight changes would be distributed monthly to each nurse manager and discussed if any further interventions were necessary. Residents would be assessed on an individual basis which supplements (if needed) were to be implemented. Residents could also be placed on a fluid and solid intake sheet to better assess by mouth intake as needed. 1. Resident #38 had diagnoses including Alzheimer's dementia, moderate protein-calorie malnutrition, and depression. The Minimum Data Set Resident Assessment, dated 07/23/2024, documented the resident had impaired cognition, did not reject care, and required supervision or touching (helper provides verbal cues and/or touching assistance as resident completes the activity) assistance with meals. The resident was 72 inches tall, weighed 113 pounds, received a therapeutic and mechanically altered diet, and had no significant weight changes in the past six months. The resident had no pressure ulcers. Current physician's orders, initialed 01/15/2024, documented the resident received a heart healthy, mechanical soft (ground meat) and thin liquid consistency diet. Review of medical orders for life sustaining treatments (MOLST), dated 01/16/2024, documented the resident had an order for cardiopulmonary resuscitation (full code) and there were no limitations on medical interventions with a trial period of feeding tube and intravenous fluids if the resident could no longer eat or drink. The Comprehensive Care Plan, dated 01/30/2024, documented Resident #38 was at risk for potential sub-optimal nutrition and dehydration related to their past medical history of Alzheimer disease, depression, varied intakes, low body weight, and decreased skin integrity. Interventions included, but were not limited to, meal set up with assist and supervision as needed and accepted by the resident, encourage meal consumption, honor food preferences, and to monitor weights, intakes, skin integrity, signs and symptoms of malnutrition, significant weight loss, and intakes not meeting the resident's needs. The undated [NAME] (care plan used by the Certified Nursing Assistant for daily care) documented the resident required extensive assistance of one person with meals. In a progress note, dated 07/22/2024, Occupational Therapist #1 documented that Resident #38 required substantial/maximum assistance at meals. Review of a progress note, dated 08/01/2024, Registered Dietitian #1 documented Resident #38's July 2024 weight was 112.5 pounds. Weights since admission ranged from 106 – 116 pounds and their body mass index was 15.5, which was chronically low. The resident remained on a heart healthy diet and mechanical soft consistency with most meal intakes greater than 50 percent. The resident received Liquacel (high protein nutritional supplement) twice daily for skin integrity, disliked Ensure and Boost (nutritional supplements), and received ice cream at lunch and dinner for additional calories and protein. Review of monthly weights from January 2024 through August 2024 revealed Resident #38's weights fluctuated from 106 pounds to 117 pounds. On 9/16/2024, the resident's weight was 99.8 pounds which indicated a 14.3 percent (16.7 pound) weight loss in one month, 11.3 percent (12.7 pound) loss in three months, and a 10.9 percent (12.2 pound) loss in six months. Their body mass index was down to 13.5. On 09/17/2024, Nurse Practitioner #2 documented the resident was seen for a 60-day review and had a significant weight loss for September 2024 down to 99.8 pounds and a re-weight was pending. On 09/20/2024, Registered Dietician #1 documented the resident's weight at 99.8 pounds which was down 16 pounds this month, a re-weight was requested, the resident received ice cream at lunch and dinner, and Mighty Shakes (nutritional supplement) was added to all meals and they would follow weight trend and adjust meal plan as resident accepts. The facility was unable to provide evidence that a re-weight was obtained. On 09/20/2024, Nurse Practitioner #1 documented they were asked to see Resident #38 for a new, stage two pressure ulcer (partial thickness loss of skin) measuring 1.5-centimeters by 1-centimeter to the left buttock. The resident received Liquacel twice daily for wound healing and weighed 99.8 pounds. The resident remained a full code. During an observation on 10/07/2024 at 10:22 AM, Resident #38 was in bed with their breakfast tray on the overbed table. Their meal included ground sausage, pureed toast, scrambled eggs, orange juice, a hot beverage, and a four-ounce milkshake. The resident had consumed zero to 25 percent of their meal and beverages. Review of the resident's electronic health record did not include documented meal or fluid intakes for 10/07/2024. During continuous observations on 10/09/2024, at 8:45 AM, Resident #38 was in bed. Their meal tray was on the table well out of the resident's reach and contained eight ounces of Ensure, eight ounces of milk, two ounces of scrambled eggs, pureed toast, one ounce ground sausage, and six ounces of hot cereal. At 8:46 AM, an unidentified Certified Nursing Assistant moved the meal tray closer to the resident and left the room without offering any assistance. At 9:53 AM, Licensed Practical Nurse Manager #2 entered the resident's room and removed their meal tray. Review of the resident's electronic health record revealed the breakfast intake was documented as zero to 25 percent. During an observation on 10/09/2024 at 12:55 PM, Certified Nursing Assistant #1 provided Resident #38 their meal tray and left the resident's room. The meal included ground chicken, ice cream, pudding, eight ounces of Ensure, a hot beverage, pureed vegetables, pureed sweet potatoes, and four ounces of orange juice. No assistance was provided. At 1:47 PM, the resident had consumed zero to 25 percent of solids. Review of the resident's electronic health record revealed the meal intake was documented by Certified Nursing Assistant #5 as 76 to100 percent. During continuous observations on 10/10/2024, at 8:38 AM, Certified Nursing Assistant #6 provided Resident #38 their meal tray and left the resident's room. The meal included pureed toast, a four-ounce milkshake, a hot beverage, eggs, hot cereal, and four ounces of orange juice. At 9:03 AM, Licensed Practical Nurse Manager #2 entered the resident's room and asked how they were doing, but did not provide assistance and left the room. At 9:34 AM, the resident's meal tray was observed on the food cart to be returned to the kitchen. The resident had consumed zero to 25 percent of the meal. Review of a progress note, dated 10/10/2024, the Wound Care Nurse Practitioner documented Resident #38 had an in-house acquired stage three pressure ulcer on their right ischium (lower, back part of the hip bone) that measured 1.5-centimeters by 2-centimeters and 1/10-centimeter deep. The resident also had a stage three pressure ulcer acquired outside the facility on their right buttock that measured 3/10-centimeter by 6/10-centimeter and 1/10-centimeter deep. During an interview on 10/10/2024 at 11:52 AM, Certified Nursing Assistant #5 stated prior to assisting a resident they checked the resident's [NAME] which included the level of assistance the resident required for eating. They stated extensive assistance meant the resident needed more help, but was not totally dependent on staff for the task. If a resident required extensive assistance at meals, staff needed to watch the resident eat and provide them with assistance. If the resident refused assistance, they would let the nurse know. Certified Nursing Assistant #5 stated the nurse manager let them know who needed to be weighed and they entered the weights into the electronic medical record. If a re-weight was needed, the nurse manager would let them know. Certified Nursing Assistant #5 stated Resident #38 was independent for meals and fed themselves after set-up. Resident #38 did not allow staff to help them with their meals, but staff should check on them during the meal. Certified Nursing Assistant #5 stated Resident #38 was on their assignment 10/08/2024 and 10/09/2024, but the resident did not allow them to assist with their meal. They had not informed the nurse of this. During an interview on 10/10/2024 at 5:58 PM, Licensed Practical Nurse Manager #2 stated nursing staff should review the care plans daily and if staff had a question about the care plan they should ask the nurse. Licensed Practical Nurse Manager #2 stated nursing staff was hung up on what extensive assistance at meals meant as it is different than total assistance. They said if a resident did not receive the amount of assistance they were care planned for, it could impact their intakes at meals. Licensed Practical Nurse Manager #2 stated the therapy department determined the resident's level of assistance needed at meals, and the Registered Dietitian informed them if any re-weights were needed. Licensed Practical Nurse Manager #2 stated Resident #38 appeared to have lost weight. During an interview on 10/11/2024 at 8:57 AM, Licensed Practical Nurse Manager #2 stated it was the nurse manager's responsibility to discuss weight loss with the medical team which could be done verbally or written in the acute (medical communication) book on the unit. They could not find any documented evidence Resident #38's weight loss had been discussed with medical. During an interview on 10/11/2024 at 9:30 AM, the Director of Therapy stated Resident #38 required extensive assistance with meals, and extensive assistance meant staff were to provide hands on assistance and cueing during meals. The Director of Therapy stated therapy staff had not been notified of any changes regarding Resident #38's eating abilities. During an interview on 10/11/2024 at 10:23 AM, Registered Dietitian #1 stated they were at the facility once per week and provided coverage remotely as needed. Weights were obtained by nursing staff by the 10th of each month, after that they notified nurse managers of any missing weights and requested re-weights as needed. They asked for re-weights if a resident triggered for a significant change of five percent at one month, seven and one-half percent at three months, and 10 percent at six months. Registered Dietician #1 stated once a resident triggered for a significant weight loss, they reviewed their intakes and progress notes to get the whole picture and determined if any nutrition supplements needed to be added to their meals. They had reminded nursing staff of the importance of accurate meal intake documentation. Registered Dietitian #1 stated Resident #38 had sporadic intakes and had triggered for a significant weight loss in September 2024. They added milkshakes to all three meals and requested a re-weight, but it had not been obtained. Registered Dietitian #1 stated if a resident did not receive assistance per their care plan, it could impact their intake at meals. They were not aware the resident had developed pressure ulcers. During an interview on 10/11/24 at 3:35 PM, the Medical Director stated they expected medical staff to be made aware of significant weight changes. Typically, the Registered Dietitian informed medical of significant weight changes and medical could also review weights in the electronic health record. The Medical Director stated Resident #38 had advanced dementia and was a full code, and while the family was not leaning towards starting tube feedings or intravenous fluids, this was not documented anywhere. Resident #38 should receive the assistance with meals per their care plan. After reviewing the electronic health record at this time, the Medical Director stated they did not see any medical interventions regarding the resident's weight loss. 2. Resident #11 had diagnoses that included dementia, dysphagia (difficulty swallowing), and heart failure. The Minimum Data Set Resident Assessment, dated 08/30/2024, revealed Resident #11 had severely impaired cognition and required moderate assistance (helper assists with less than half the effort) with eating. The Comprehensive Care Plan, dated 09/18/2024, and [NAME], dated 10/11/2024, included Resident #11 required extensive assistance with meals and received a mechanically soft, pureed diet. Review of current Physician's orders included a regular pureed consistency diet and a Mighty Shake three times a day. During an observation on 10/09/2024 at 1:24 PM, Resident #11 was in bed, eating lunch independently. No facility staff entered the resident's room during the meal and there was no Mighty Shake on the resident's lunch tray as listed on the meal ticket. During an observation on 10/10/24 at 12:52 PM, Resident #11 was in bed, eating lunch independently. No facility staff entered the resident's room during the meal. During an observation at 1:08 PM, Certified Nursing Assistant #1 picked up Resident #11's lunch tray and stated based on the items left on the tray, Resident #11 had consumed less than 25 percent of the meal. Review of weights from April 2024 through August 2024 revealed Resident #11's weight fluctuated from 100 pounds in April 2024 to 96 pounds in August 2024 and to 88 pounds in September 2024 and October 2024. Review of a progress note dated 09/20/2024, Registered Dietician #1 documented Resident #11's meal intakes were between 25 to 50 percent, and weights reviewed from August 2024 to September 2024 revealed the resident was down approximately nine pounds. Registered Dietician #1 noted there was a new scale on the unit which may have affected some difference in numbers. Review of the electronic health record did not include documented evidence that a reweight had been obtained. Review of documented of meal intakes from 08/16/2024 to 10/10/2024 revealed for 168 meal opportunities, staff had documented no documentation for 72 meals, zero to 25 percent for 20 meals, and 26 to 50 percent for 25 meals. During an interview on 10/10/2024 at 1:13 PM, Certified Nursing Assistant #1 said the [NAME] in the resident's room included the level of assistance a resident needed. They reviewed Resident #11's [NAME] at that time, and stated extensive assist of one (staff member) was listed which meant the resident needed help with opening items but was capable of lifting and eating. During a follow-up interview at 1:34 PM, Certified Nursing Assistant #1 said they had not sat with or assisted Resident #11 with their meals. During an interview on 10/10/2024 at 1:38 PM, Licensed Practical Nurse Manager #2 said the [NAME] on the back of the resident's room door indicated what level of assistance they needed. They said staff should also know based on the morning huddle (meeting) and the assignment sheets, which residents required assistance with meals. Licensed Practical Nurse Manager #2 said an extensive assist of one with meals meant the staff should open all food items (on the tray), feed the residents by cueing them to eat but did have to sit with the residents. Instead, staff should go back and forth to check on the resident. Licensed Practical Nurse Manager #2 said Resident #11 would not eat food, only took fluids, and did not receive assistance with meals other than opening items and cueing. During an interview on 10/11/2024 at 12:56 PM, Licensed Practical Nurse #1 said if listed as extensive assistance, staff should be with the resident for the entire meal. During an interview on 10/15/2024 at 8:51 AM, the Director of Nursing stated extensive assistance at meals meant staff should physically assist the resident for the entire meal. The Director of Nursing said there was an issue with staff not assisting residents with meals but thought it had been resolved a few months prior. 10 NYCRR 415.12(i)(1)