**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff and physician interview, review of a self-reported incident (SRI), review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, and review of the facility policy, the facility failed to monitor and identify residents with weight loss and failed to ensure appropriate nutritional interventions were recommended and implemented to prevent severe weight loss and adverse outcomes. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death on 03/13/23 when Resident #61, who was at nutritional risk related to a body mass index (BMI) (A measure of body fat based on height and weight. A healthy range is 18.5 to 24.9) of 15.8 (indicating underweight), diagnosis of muscular dystrophy, and decreased ability to feed self, was not weighed from 02/14/23 through 06/30/23. There was a lack of nutritional interventions to attempt to obtain Resident #61's weight while Resident #61 had decreased meal intakes from 03/13/23 to 07/01/23. Subsequently on 07/01/23, Resident #61 was admitted to the hospital with hypoglycemia secondary to poor oral intake and weighed 65 pounds which was a severe weight loss of 36.6 percent (%). The Immediate Jeopardy continued on 04/06/23, when Resident #14 was identified with a severe unplanned weight loss of 16.87 % in a six-month period, developed an unstageable pressure ulcer on 06/30/23 to her left foot and the resident's nutritional needs and plan of care were not reassessed and/or revised as of 07/26/23. This affected two residents (#61 and #14) of three residents reviewed for change in condition. The facility identified a total of nine residents as being at nutritional risk. The facility census was 60. On 07/25/23 at 2:35 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Operations (RDO) #930 were notified Immediate Jeopardy began on 03/13/23 when Resident #61 had a severe unplanned weight loss of 35.6 percent (%) over approximately five and one-half months, from 02/13/23 to 07/01/23, and the weight loss was not identified and monitored ultimately leading to the resident being admitted to the hospital with hypoglycemia secondary to poor oral intake. Additionally, they were notified the Immediate Jeopardy continued on 04/06/23 when Resident #14 experienced a significant weight loss of 5.8 % in a one-month period of time and Registered Dietitian (RD) #920 and Dietetic Technician (DT) #925 failed to reassess the nutritional needs of the resident and failed to ensure appropriate nutritional interventions were implemented to prevent severe weight loss. Furthermore, Resident #14 developed a facility-acquired unstageable pressure ulcer with eschar (dry, back hard necrotic tissue) and slough (dead, yellowish tissue) to the resident's left foot and continued to lose weight over time subsequently experiencing a severe 16.87 % weight loss over a six-month period. The Immediate Jeopardy was removed on 07/26/23 when the facility implemented the following corrective actions: • On 07/01/23, Resident #61 was transferred to the hospital and never returned. • On 07/25/23, Resident #14 was assessed by the DON. The resident did have an in-house, acquired pressure ulcer to the left foot identified on 06/30/23. Interventions for the in-house, acquired pressure ulcer were implemented on 06/30/23. No other negative outcomes were noted. Resident #14 had an expert evaluation on 07/21/23 by Medical Director (MD) #935 in an attempt for the resident to receive hospice care for the weight loss, and no other concerns were noted. • On 07/25/23, all residents were audited by the DON for any residents that had a significant weight loss according to the facility's policy. Any resident with a significant weight change, according to the policy, will be provided immediate interventions for weight loss. • On 07/25/23, skin sweeps for all residents in the facility were completed with Wound Physician (WP) #940 and Assistant Directors of Nursing (ADONs)/Licensed Practical Nurses (LPNs) #725 and #815 with no new skin areas noted. • On 07/25/23, the DON was educated by Regional Director of Clinical Operations (RDCO) #945 on the following: Weights and documentation of weights must be completed in a timely manner, monthly weights are to be completed by the fifth of each month, reweights are to be completed by the seventh of each month and weekly weights are to be completed by the date determined based on the admission date. • On 07/25/23, ADON/LPNs #725 and #815 were educated by the DON on the following: Weights and documentation of weights must be completed in a timely manner, monthly weights are to be completed by the fifth of each month, reweights are to be completed by the seventh of each month and weekly weights are to be completed by the date determined based on the admission date. • On 07/25/23, all nurses and State Tested Nursing Assistants (STNAs) in the facility were educated by the DON/Designee on the following: Weights and documentation of weights must be completed in a timely manner, monthly weights are to be completed by the fifth of each month, reweights are to be completed by the seventh of each month and weekly weights are to be completed by the date determined based on the admission date. The facility does not utilize agency staff. All as needed (PRN) staff and/or staff off work will receive education per the DON/Designee prior to working a shift. • On 07/25/23, all nursing staff were educated by the DON/Designee regarding if any resident refuses to be weighed, it will be documented in the progress notes. • On 07/25/23, all nursing staff were educated by the DON/Designee to notify MD #935 of any resident refusing to be weighed. • On 07/25/23, the DON was educated by the Administrator that all weights must be reviewed in the ongoing weekly risk meeting attended by the DON, LPNs (#725 and #815), Social Worker (SW) #950, Minimum Data Set (MDS) Nurse #850, and Therapy Manager #845. RD #920 will identify residents at increased nutritional risk or weight changes for discussion by the Interdisciplinary Team (IDT) at the weekly meeting. Results will be shared with MD #935 and with the Quality Assurance Performance Improvement (QAPI) Committee. • On 07/25/23, the Administrator and DON reviewed the policy on weight management and there were no changes made. • On 07/25/23, to monitor ongoing compliance, all residents at increased nutritional risk and/or significant weight changes will be weighed weekly for six weeks. The DON/Designee will audit the weights weekly for six weeks to ensure there is no significant weight change without interventions or notification of MD #935. The DON/Designee will audit residents who refused to be weighed weekly for six weeks. The DON/Designee will attempt to reweigh any resident and document the second attempt. Any negative findings will be immediately corrected and reviewed in the weekly risk meeting and the monthly QAPI meeting. The next QAPI meeting will be held on 08/11/23, and the QAPI committee will determine the need for ongoing monitoring. • On 07/26/23, RD #920 and DT #925 were educated by the RDCO #945 on the process for obtaining weight information and communicating with the DON and the IDT regarding residents with identified nutritional concerns and/or unplanned weight changes. • On 07/26/23, RD #920 assessed Resident #14 and reviewed and updated Resident #14's nutritional care plan and interventions. • On 07/26/23, RD #920 reviewed all residents in the facility and compiled a list of residents at increased nutritional risk and/or significant weight change. RD #920 reviewed and update the care plans of residents at increased nutritional risk and/or significant weight change. RD #920 identified eight additional residents (#01, #13, #04, #10, #37, #20, #29, and #33) at nutritional risk and reviewed and updated their care plans and implemented interventions. • On 07/26/23, between 11:58 A.M. and 12:37 P.M., Registered Nurse (RN) #105, LPN #725, and STNAs #385, #435, and #480, verified they were educated on the process for obtaining and documenting resident weights and how to respond if a resident refused to be weighed. All staff members interviewed were knowledgeable of the content of each education provided by the facility. • On 07/26/23, the surveyor completed review of the medical records for Residents #20, #33, and #37, identified as being at nutritional risk, and revealed no concerns related to monitoring for weight changes. The resident's assessments were current and accurate, and care plans were initiated and updated with appropriate interventions to prevent weight loss/change. Although the Immediate Jeopardy was removed on 07/26/23, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #61, revealed a readmission date of 01/19/23 with diagnoses including, but not limited to, muscular dystrophy, multiple sclerosis (MS), and cardiomyopathy. Review of the facility weight records for Resident #61, revealed the resident was 67 inches tall and his weight on 12/09/22 was 100.1 pounds, weight on 01/09/23 was 100.0 pounds, and weight on 02/13/23 was 101.0 pounds. There were no subsequent weights documented for the resident. Review of the nurse's progress notes from 02/14/23 to 07/01/23 for Resident #61, revealed there were no weights or refusals to be weighed documented for the resident. Review of the nutritional progress note dated 03/13/23 for Resident #61 authored by RD #920, revealed the resident had a low BMI of 15.8 indicating the resident was underweight. The most current weight available for the resident was 101 pounds obtained on 02/13/23. Resident #61 consumed 50 to 75 % at meals and was noted with meal refusals. The resident was at nutritional and hydration risk due to refusal of food, medications, care, and a low BMI. No new recommendations were made. Review of the Minimum Data Set (MDS) assessment 3.0 dated 04/07/23 for Resident #61, revealed the resident was cognitively impaired and required extensive assistance of two staff with bed mobility and transfers and extensive assistance of one staff with eating. Review of section-K (swallowing/nutrition) revealed the resident was 67 inches in height and no weight was recorded for the resident and weight loss was not assessed. Review of the nutritional progress note dated 04/16/23 for Resident #61 authored by DT #925, revealed the most current weight available for the resident was the weight of 101 pounds obtained on 02/13/23. DT #925 made no new nutritional recommendations. Review of the care plan updated on 04/23/23 for Resident #61, revealed the resident was at risk for altered nutritional status as evidenced by being underweight related to diagnosis of muscular dystrophy and was dependent on staff for feeding. Resident has a low BMI with a need to avoid weight loss. The residents by mouth (PO) intakes were variable with suboptimal intake and a need for supplementation. The goal of the care plan was the resident will maintain or gain weight as per the nutritional plan. Interventions included: honor food preferences by providing select menus, obtain laboratory (labs) as ordered and notify physician of the results, provide additional calories/protein at meals per patient preference, provide supplements as ordered, review weights and notify the physician of significant weight change, and provide total assistance with feeding. Review of the nutritional progress note dated 05/15/23 for Resident #61 authored by RD #920, revealed the most current weight available for the resident was the weight of 101 pounds obtained on 02/13/23. RD #920 made no new nutritional recommendations. Review of MD #935 physician's progress note dated 05/17/23 for Resident #61, revealed the resident's appetite varied, and the resident was getting nutritional supplements. Resident #61 had a thin build, and the staff reported no changes. No weight loss was noted, and the resident's assessment/plan included malnutrition and a plan to encourage oral diet and supplements. However, review of the physician orders and care plan for Resident #61, revealed there were no nutritional supplements ordered for Resident #61 from 03/13/23 until 05/23/23. Review of the physician orders dated 05/23/23 for Resident #61, revealed orders for the resident to receive a regular diet, mechanical soft texture with thin liquids, Protein liquid 30 milliliters by mouth daily at 9:00 A.M. for wound healing and Ensure Plus supplement (a high calorie supplement) three times daily with meals. Review of the meal intake records dated 06/17/23 to 07/01/23 for Resident #61, revealed the resident refused four meals during the time period and his intake was variable from 25 to 100 %. Review of the nutritional progress note dated 06/19/23 for Resident #61 authored by RD #920, revealed the most current weight available for the resident was the weight of 101 pounds obtained on 02/13/23. RD #920 made the recommendation to increase resident's liquid protein supplement to twice daily and made no changes to the resident's care plan. RD #920 documented the resident's weight was stable. Review of the nurse progress note for Resident #61 dated 07/01/23 at 7:42 P.M., revealed the resident called nine-one-one (911) due to complaints of nausea. Resident #61 had refused staff's offer for an as needed (PRN) Zofran (medication for nausea and vomiting) when EMS arrived. Review of the hospital's admitting history and physical dated 07/01/23 at 11:58 P.M. for Resident #61, revealed criminal neglect was suspected, and the nurse was going to contact adult protective services. Resident #61 was bedridden with severe contractures related to muscular dystrophy and was unable to feed himself. The resident complained on admission that facility had not fed him since last Thursday due to the nursing home staff refused to feed him and his admitting diagnoses were failure to thrive and hypoglycemia (low blood glucose levels). Lab results showed the resident's blood sugar upon arrival at the hospital was 48 (low). Review of the MDS assessment 3.0 dated 07/01/23 for Resident #61, revealed the resident was discharged with a return not anticipated (DRNA) and review of Section-K, revealed the resident was 67 inches in height and no weight was recorded and weight loss was not assessed. Review of the hospitalist's (hospital physician) progress note dated 07/02/23 at 4:04 P.M. for Resident #61, revealed the resident's body weight upon admission to the hospital was 65.6 pounds with a BMI of 10.24 (underweight). Resident #61 was admitted to the hospital with hypoglycemia secondary to poor oral intake and the resident's blood sugars improved after receiving intravenous (IV) dextrose (sugar). The physician did not see any major acute medical problems requiring continued hospital stay, but the hospital needed to determine alternate placement for the resident. Review of the hospital's dysphagia evaluation dated 07/02/23 for Resident #61, revealed the resident presented to the hospital with failure to thrive and hypoglycemia with blood sugars in the forties and it appeared as if resident had not been receiving good care. The resident reported he was on a regular solid diet with thin liquids at the facility. The resident required one-on-one feeding and reported the facility staff had not fed him since last Thursday. Review of the SRI created on 07/03/23, revealed the facility investigated an allegation of neglect for Resident #61 based upon reading the hospital notes and determined the facility was not able substantiate neglect. Interview on 07/21/23 at 1:14 P.M. with RD #920, verified the last recorded weight the facility had for Resident #61 was obtained on 02/13/23 for 101 pounds. RD #920 confirmed the facility had an ongoing problem obtaining and recording the resident's weights. RD #920 confirmed she visited the facility on a monthly basis and DT #925 visited the facility on a weekly basis. RD #920 indicated Resident #61 frequently refused meals and care. RD #920 confirmed she did not make any recommendations for the significant weight loss when she assessed him on 03/13/23, 05/15/23, and 06/19/23 because she had not been informed of any weight loss for the resident. Interview on 07/21/23 at 1:25 P.M. with DT #925 confirmed the last recorded weight the facility had for Resident #61 was obtained on 02/13/23. DT #925 confirmed she did not make any nutritional recommendations for Resident #61 when she assessed him on 04/16/23 because as far as she knew, his weight was stable at 101.0 pounds. DT #920 indicated Resident #61 had a low BMI and frequently refused meals and care. Interview on 07/21/23 at 2:04 P.M. with the Administrator and the DON confirmed the facility investigated an allegation of neglect for Resident #61 and reported the allegation as part of the facility submitted SRI dated 07/03/23 based on reading the hospital notes for Resident #61 dated 07/01/23 and 07/02/22. The DON confirmed Resident #61 was not a diabetic and the facility had no recent blood sugars for the resident, and hospital notes indicated resident's blood sugar was 48 upon arrival to the emergency room. The DON confirmed she was aware the resident's admitting weight at the hospital was 65 pounds which represented a 36-pound weight loss and a 35.6 % weight loss from his last recorded weight at the facility. The DON confirmed the resident did not return to the facility, and they were notified he was placed at a different facility. The DON further indicated Resident #61 had a history of refusal of care and meals at times, but confirmed the facility had no documentation of the resident's refusal of the monthly weights for March through July 2023. Interview on 07/21/23 at 2:37 P.M. with Dietary Manager (DM) #465, verified Resident #61 received a regular diet mechanical soft texture with thin liquids. DM #465 confirmed she was unaware of the resident's meal intakes or weights, but the kitchen sent trays to the nursing floor for the resident on a daily basis. Interview on 07/24/23 at 10:34 A.M. with the DON, revealed it was the STNAs responsibility to obtain the monthly weights by the fifth day of each month and the nurses should record the weights in the resident's electronic medical record (EMR) in the weight section for RD #920 and DT #925 to review during their visits to the facility. Interview on 07/24/23 at 12:50 P.M. with STNA #385, revealed Resident #61 was always very thin and very contracted and required total assistance of staff with feeding and even with providing a liquid supplement. STNA #385 indicated the resident occasionally refused meals but would usually accept a liquid supplement. STNA #385 confirmed the STNAs documented meal intakes and refusals of meals in the EMR. STNA #385 confirmed the STNAs obtained weights when requested by the nurses. STNAs would hand-write the weights on paper for the nurses to record in the EMR. If a resident refused to be weighed, the STNAs would note the refusal on paper and also report it verbally to the nurse. STNA #385 confirmed she did not recall Resident #61 refusing weights for her and she could not recall the last time she had weighed him. STNA #385 confirmed the resident had been at the facility for years and had always looked thin, but in June of 2023 he looked even thinner than usual which she had mentioned to the nurses. Interview on 07/24/23 at 1:07 P.M. with STNA #780, revealed Resident #61 could not feed himself and staff had to even hold his Ensure supplement for him. STNA #780 confirmed Resident #61 was very thin and was not a big breakfast or lunch eater but would usually accept dinner when she tried to feed him. STNA #780 confirmed STNAs were responsible to get weights when assigned by the nurses and would hand-write them on a paper to give to the nurses to record in the EMR. STNA #780 confirmed she had not been asked to obtain a weight for Resident #61 during his stay at the facility, but he looked extremely thin in June of 2023, the last time she cared for him. Interview on 07/24/23 at 2:58 P.M. with the DON, confirmed she found a handwritten list of weights in the ADONs office which was now assigned to LPN #815. Resident #61's name was on the handwritten list and under April, May and June 2023 was marked for refused under the space where his monthly weight should be. The DON confirmed the list was found on 07/24/23 and the information had not been entered into the EMR or shared with the attending physician, RD #920, or DT #925. Interview on 07/24/23 at 3:18 P.M. with ADON/LPN #815, for the second floor, indicated she had been employed by the facility since the end of June 2023. LPN #815 confirmed she and the DON were looking through papers in her office on 07/24/23 and found the handwritten list of weights for the second floor for April, May, and June 2023. LPN #815 confirmed she was aware the list of weights was in her office. LPN #815 confirmed she was new to the facility and only knew Resident #61 briefly before he was discharged from the facility. LPN #815 confirmed Resident #61 was extremely thin and had to be fed by staff and she was unaware of him refusing to be weighed. Interview on 07/25/23 at 12:29 P.M. with the DON confirmed the facility held weekly risk meetings which RD #920 and DT #925 did not attend, but they sent her a list of the residents with increased nutritional risk or weight loss concerns. The DON confirmed they had sent no information regarding concerns for Resident #61's nutritional status or weight and/or refusal of weights in May or June 2023. Interview on 07/25/23 at 2:06 P.M. with MD #935 confirmed Resident #61 was severely debilitated due to diagnosis of Muscular Dystrophy and required total assistance of staff with feeding and activities of daily living although resident frequently refused care and refused to be evaluated. MD #935 confirmed Resident #61 was not diabetic and did not have orders to have his blood sugar monitored and was unaware the resident had been admitted to the hospital on [DATE] with a diagnosis of hypoglycemia. Interview confirmed MD #935 was not notified of the resident's severe weight loss of 35.6 % from 101.0 pounds on 02/13/23 to his next recorded weight of 65 pounds on 07/01/23 upon admission to the hospital. The facility did not notify him of resident refusals of weight, nor was it documented in the resident's record. MD #935 confirmed he was the Medical Director for the facility and attended the quarterly QAPI meetings, but he never heard the facility staff discuss concerns with obtaining and monitoring resident weights. 2. Review of the medical record for Resident #14 revealed an admission date of 04/23/19 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure, with hypoxia anxiety disorder, dysphagia, bipolar disorder, and polyosteoarthritis. Review of the weight record for Resident #14 documented in the EMR, revealed the resident weighed 247.8 pounds on 01/09/23, 246 pounds on 02/10/23 and 231.6 pounds on 03/02/23. The medical record had no documented evidence of any subsequent weights for the resident. Review of the nutrition progress note dated 03/03/23 for Resident #14 authored by DT #925, revealed the resident's March 2023 weight was 231.6 pounds which represented a significant weight loss of 14.4 pounds from the previous month's weight of 246.0 pounds. This was a 5.9 % loss and DT #925 requested a reweight be obtained to confirm the weight loss. There was no evidence a reweight was obtained and no new interventions implemented and or nutrition recommendations for the 5.9 % weight loss from 03/03/23 to 04/05/23. Review of the physician orders dated 03/20/23 for Resident #14, revealed the resident was ordered to receive a regular diet, pureed texture, and thin consistency liquids. Review of the nutritional progress note dated 04/06/23 for Resident #14 authored by DT #925 revealed the most current weight available for the resident was the weight of 231.6 pounds obtained on 03/02/23. The resident was on a regular puree diet with thin liquids and was to have one-on-one feeding assistance during meals. The resident's intakes were poor, and she was consuming 0-50 % of meals and her BMI was 34.2 (obese stage). The note revealed the resident's weight for April 2023 was not available. DT #925 made recommendations for an appetite stimulant and house shakes (supplement) three times daily due to resident's nutrition and hydration risk related to diagnosis, pureed diet texture, and poor intake. Further review of the medical record revealed the house shakes three times daily were not implemented until three months later on 07/25/23 and there was no documented evidence the recommendation for an appetite stimulant was considered and/or implemented. Review of the care plan updated 04/07/23 for Resident #14, revealed the resident was at nutritional risk related to COPD, dysphagia, anxiety, obesity (BMI greater than 30), intakes less than 50 %, and mechanically altered diet related to dysphagia. Interventions included the following: assess resident for signs and symptoms of aspiration, assist resident with meals as needed, follow dysphagia guidelines as ordered, elevate head of bed as ordered, honor food preferences as able, monitor for signs and symptoms of dehydration, obtain weights as ordered, and provide diet as ordered. Review of the physician progress note dated 04/07/23 for Resident # 14, revealed the resident had increased confusion and required increased assistance with ADLs including needing to be fed. Review of the physician progress note dated 04/28/23 for Resident #14, revealed the resident was experiencing a decline in condition physically and cognitively and had lost weight recently. The nursing staff asked if resident qualified for hospice due to weight loss and dysphagia. The assessment/plan for the resident's weight loss/malnutrition, indicated the resident did not want a feeding tube and staff should encourage oral diet and supplements. Review of the hospice assessment dated [DATE] for Resident #14, revealed the nurse assessed the resident for appropriateness of hospice services per the order/request of the resident's physician. The assessment revealed the resident was appropriate for hospice services due to diagnoses of cerebrovascular disease, dysphagia, and weight loss. The note revealed the assessment of weight loss for Resident #14 was based on the most current available weight of 231.6 pounds obtained on 03/03/23. Additional record review revealed the resident was never admitted to hospice due to MD #835 noting the resident was cognitively impaired and was not able to make decisions and when the family was consulted, they didn't want to be involved in the resident's care. The facility was in the process of obtaining a court ordered guardian. Review of the MDS assessment 3.0 dated 05/19/23 for Resident #14, revealed the resident was cognitively impaired and required extensive assistance of one to two staff with ADLs. Resident #14 required extensive assistance of one staff with eating. Review of Section K of the MDS, revealed the resident was 69 inches tall, and no weight was recorded for the resident and weight loss was not assessed. Review of the social service progress note dated 05/30/23 for Resident #14, revealed the resident was declining and unable to make decisions for herself but might be appropriate for hospice. Social services contacted the resident's emergency contact regarding hospice services without success. Review of the physician progress note dated 06/23/23 for Resident #14, revealed the resident had dysphagia and continued on a puree diet and had to be fed by staff. The resident's appetite was poor, and the resident had lost some weight recently. Staff should encourage oral diet and supplements. The assessment/plan for the resident's weight loss/malnutrition, indicated the resident refused a feeding tube and staff to encourage oral diet and supplements. Review of the nurse progress note dated 06/30/23 for Resident #14, revealed an STNA notified the nurse of an area to the resident's left plantar foot. Skin preparation was applied, and the resident was added to the wound physician rounds. Review of the wound physician progress note dated 06/30/23 for Resident #14, revealed the resident had a newly identified unstageable pressure ulcer (obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage III or Stage IV pressure injury will be revealed) with onset date of 06/30/23 on the left plantar foot which measured 2.5 centimeters (cm) in length by 2.2 cm in width with the wound bed obscured by 70 % eschar and 30 % slough. Observation of wound care for Resident #14 on 07/21/23 at 12:49 P.M. per LPN #815, revealed the resident was resting on a pressure reduction mattress with padding to the footboard. Observation revealed the resident had a dime-sized pressure ulcer to her left plantar foot with minimal amount of slough observed to wound bed. Observation of the lunch meal for Resident #14 on 07/21/23 at 1:04 P.M., revealed the resident was served a puree diet in her room and fed by STNA #455 with the head of her bed elevated. Resident #14 was totally dependent on staff for feeding and was not able to participate in a meaningful interview due to cognitive impairment. The resident consumed approximately 75% of the meal. Interview on 07/21/23 at 1:25 P.M. with DT #925 confirmed the last recorded weight the facility had for Resident #14 was obtained on 03/03/23 and she requested a reweight to confirm the significant weight loss in the one-month time period. DT #925 confirmed when she assessed Resident #14 on 04/06/23, the facility had not obtained a re-weight. DT #925 confirmed she had not assessed Resident #14's nutritional status since that time and heard the resident was going to be signing up for hospice. DT #925 confirmed she made recommendations for Resident #14 to be started on an appetite stimulant medication and to receive house shakes three times daily due to the presumed weight loss. DT #925 was unsure if her recommendations had been implemented. DT #925 was unaware Resident #14 had a pressure ulcer. Interview on 07/24/23 at 2:58 P.M. with the DON confirmed she found a handwritten list of weights in the ADON's office which was now assigned to LPN #815. Resident #14 was on the handwritten list and the following weights were listed for Resident #14: April 2023 was 221.0 pounds, May 2023 weights were 215.6 pounds and 211.4 pounds, and June weight was 206.0 pounds. The DON confirmed the list was found on 07/24/23 and the information had not been entered into the EMR or shared with the attending physician, RD #920 or DT #925. The DON confirmed the facility had not[TRUNCATED]