Based on interview and record review it was determined the facility failed to ensure a resident's ordered pain medication was available and effectively managed resident's severe pain for 1 of 1 sampled resident (#18) reviewed for pain management. This resulted in Resident 18 having unrelieved, unmanageable pain and treatment at the hospital Emergency Department. Findings include: Resident 18 admitted to the facility in 4/2023 with diagnoses including chronic pain and osteoarthritis. A 5/10/23 Behavioral Symptoms and Pain CAA revealed Resident 18 had episodes of cursing, yelling and became agitated at staff notably when she/he had extreme pain while pending hip surgery. When Resident 18's pain was managed she/he was in a pleasant mood. A message was sent to the IDT (Interdisciplinary Team) and requested a follow up with the physician for pain management improvement. A 5/13/23 physician order directed staff to administer oxycodone-acetaminophen 5-325 mg one tablet by mouth every four hours for chronic pain. A review of Resident 18's Weights and Vital Report from 6/12/23 through 6/15/23 revealed her/his pain ranged anywhere from three to a six out of 10 on a pain scale. A review of the 6/17/23 and 6/18/23 Weight and Vital report revealed the following: -On 6/17/23 Resident 18's pain level was 10 out of 10 at 7:49 PM -On 6/18/23 Resident 18's pain level was 10 out of 10 at 6:54 AM and 2:36 PM. A 6/18/23 Medication Error Report revealed on 6/17/23 Resident 18 had enough of her/his oxycodone 5-325 mg to administer at 12:00 AM on [6/18/23]. The pharmacy indicated the medication was about to run out and requested a new prescription from the provider, since they had not received the prescription they could not give a code to retrieve the medication from the Cubex (dispenses medications). Resident 18 was very painful and distraught when informed she/he took her/his last dose until a prescription could be sent to the pharmacy. It was Sunday and clinics were not open. Resident 18 rated her/his pain 10 out of 10 on a pain scale and complained of increased pain. The 6/18/23 MAR revealed Resident 18's pain level was 10 out of 10 at 12:00 AM when she/he received the last dose of her/his oxycodone. Resident 18 did not receive her/his 4:00 AM dose. A 6/18/23 Emergency Hospital Discharge Summary revealed Resident 18 was in the emergency department because the facility ran out of her/his usual pain medications and missed two doses after which her/his chronic pain increased. On exam Resident 18 moved all four extremities spontaneously, though very painful with passive range of motion of the bilateral hips. Resident 18 was treated with intramuscular fentanyl and oral oxycodone with significant improvement in her/his pain. On 6/26/23 at 2:14 PM Resident 18 stated she/he had chronic hip pain and missed dosages of her/his pain medications on 6/18/23 and was in terrible pain because the facility ran out of pain medication. Resident 18 stated she/he went to the emergency department because of her/his increased chronic pain. On 6/28/23 at 11:41 AM Staff 13 (RN) stated Resident 18 struggled with pain and discomfort and on 6/18/23 the resident missed one dose because staff was unable to refill her/his prescription. Staff 13 stated Resident 18's physician did not respond to refills or pain medication requests. Staff 13 stated they only received 14 days worth of narcotics at a time for residents and were expected to request pain medication when there were only five days remaining. On 6/29/23 at 9:52 AM Staff 12 (RN) stated she was present on 6/18/23 when the resident was crying and in pain. Staff 12 stated Resident 18 had horrible pain in her/his right hip and was waiting for a hip replacement. Staff 12 stated her/his pain medication ran out and staff were unable to fill the prescription Resident 18 went to the emergency department to address her/his pain. Staff 12 stated it was difficult at times to get prescriptions refilled because either Resident 18's physician did not respond or there were delays with the pharmacy. On 6/29/23 at 11:41 AM Staff 11 (CNA) stated Resident 18 struggled with extreme pain and receiving the regular scheduled pain medications every four hours helped her/him tremendously. On 6/29/23 at 12:55 PM Staff 14 (NA) stated Resident 18 struggled with chronic pain but if her/his pain medications were late she/he struggled with increased pain, was moody and more agitated. Staff 14 stated her/his pain was more controlled with pain medications being administered on her/his regular scheduled times. On 6/29/23 at 1:17 PM Staff 2 (DNS) stated she was aware of the missed dose on 6/18/23 and faxed Resident 18's outside provider/physician multiple times with no response. Staff 2 stated Resident 18 went to the emergency department for the missed dose on 6/18/23 and her/his oxycodone order was changed from a scheduled pain medication to a PRN upon her/his return from the hospital. Staff 2 acknowledged pain medications were not in place appropriately for Resident 18 and the resident struggled with her/his pain. On 6/30/23 at 9:39 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 4 (Regional Director of Operations) acknowledged pain medications were not ordered appropriately for Resident 18 and the facility struggled with communication to ensure Resident 18's physician responded appropriately to pain medication requests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure a resident received pressure ulcer treatments for 2 of 2 sampled residents (#s 4 and 8) reviewed for pressure ulcers. This resulted in multiple avoidable Stage 2 pressure ulcers for Resident 8. This placed other residents at risk for worsening pressure ulcers. Findings include: 1. Resident 8 admitted to the facility on [DATE] with diagnoses including chronic kidney disease. The 2/25/22 admission MDS Pressure Ulcer CAA indicated Resident 8 had a pressure relief mattress, had no current skin breakdown and was to be care planned for risk of skin breakdown. Resident 8's Care Plan did not identify any pressure ulcers or interventions prior to 5/4/22. The 4/23/22 Skin Assessment indicated Resident 8 had a new pressure ulcer on the buttocks. The 4/25/22 Skin/Wound Note indicated a new skin issue, pressure sore to buttocks. The 4/26/22 Fax Communication to the physician indicated please advise on skin care per pressure sores. The physician responded by fax on 4/28/22 with please consult RN for bed sore management. Resident 8's Skin/Wound Notes indicated the following: -4/27/22 at 5:54 AM two pressure spots on the right hip, the physician was faxed. -4/27/22 at 7:40 PM two pea size purple areas on right hip, no skin is broken, appears to be bruising, per DNS barrier cream was to be applied. The 4/28/22 Progress Note indicated a CNA called the nurse into the room to observe the resident's coccyx and found residents cheeks to have multiple lateral skin lesions ranging in length from 1 cm to 3 cm. The area was cleaned and dried and then a 7 x 7 sacrum optifoam dressing was applied. The resident was put on a turning schedule which she refunded [refused] in the past. The resident agreed to get out of her/his wheelchair after each meal and had been spending most of the day in her/his power chair recently. The 4/29/22 Skin Assessment indicated Resident 8 had broken skin on the right and left buttocks and lateral lesions along the inside of her/his buttock. The 4/30/22 Fax Communication to the physician indicated the resident had multiple lateral skin lesions ranging 1 cm to 3 cm to the cheeks and a 7 x 7 optifoam dressing was applied to the sacral area. Staff will monitor and change every 72 hours or sooner if soiled. Resident put on a turning schedule which she/he had refused in the past and she/he also agreed to get out of the wheelchair after meal and had been spending most of the day in the power chair. Do you want me to keep this treatment plan or modify it? The physician responded by fax on 5/2/22 with continue as planned, recommend air cushion on power wheelchair. The 5/1/22 Skin/Wound Note indicated the resident refused to change positions in bed to relieve pressure to the right side. Staff explained the risk associated with not being repositioned and the resident still refused, writer attempted x3. On 5/4/22 at 11:18 AM Staff 10 (RN) was observed to remove a foam dressing dated 5/3 from Resident 8's coccyx area. The area was observed to be open and additional open areas were observed and were not covered with dressings. On 5/4/22 at 11:31 AM Staff 2 (DNS) entered the room to complete a skin assessment. Staff 2 stated she looked at this area a week ago and the wound was a bruise. Staff 2 measured and staged the areas and identified them as Staff 10 (RN) documented the measurements. Staff 2 measured and verbalized the identified areas as: -Stage 2 pressure ulcer on right buttock 1 cm x 6 cm; -Stage 2 right hip 1.5 cm x 1 cm; -Stage 2 right coccyx 4.5 cm x 1.2 cm; -Stage 2 left coccyx 3.2 cm x 6 cm; -Right gluteal fold 0.3 cm x 0.6 cm; -Right buttock deep tissue injury 0.8 cm x 0.4 cm; -Right gluteal fold-coccyx 0.7 cm x 0.4 cm. On 5/4/22 at 12:54 PM Staff 2 stated there were no skin assessments with measurements prior to 5/4/22. On 5/4/22 at 1:53 PM Staff 10 (RN) stated she had not contacted the physician regarding Resident 8's identified pressure ulcers on 5/4/22 because she hasn't had time. On 5/5/22 at 3:19 PM Staff 2 was asked about physician notification and orders regarding the identified pressure ulcers. Staff 2 stated she asked Staff 10 to notify the physician and was unaware if the physician responded yet. The 5/5/22 fax to the physician indicated the resident had multiple Stage 2 wounds on coccyx and buttocks and please send wound orders. These are worsening since prior optifoam orders. On 5/6/22 the physician responded by fax please consult wound care nurse. On 5/6/22 at 6:08 AM Staff 13 (LPN) stated Resident 8 had multiple pressure ulcers and she/he had a large dressing covering the area on her/his hip. Staff 13 stated she completed dressing changes but could not stage pressure ulcers. She stated the physician indicated to follow nursing orders for the pressure areas. Staff 13 stated Resident 8 was up in her/his power chair during the day and would usually only lay down in bed for 30 minutes or an hour before she/he wanted to get up again. Staff 13 stated therapy was looking at getting the resident a different cushion as she/he did not like one they provided. On 5/6/22 at 11:45 AM Staff 2 stated Resident 8's pressure ulcer to the coccyx was first identified on 4/23/22, a fax was not sent to the physician until 4/26/22 and a response was not received until 4/28/22. Staff 2 acknowledged the multiple delays for notification of the physician, lack of wound monitoring, lack of wound care orders and the multiple additional Stage 2 pressure ulcers identified on 5/4/22. Staff 2 stated she followed up with the physician and the plan was to send Resident 8 to the wound clinic. Staff 2 stated the expectation was for staff to report any open skin areas and complete an incident report. Staff 2 stated she was out of the facility from 4/26/22 until 5/1/22 and the facility did not have a resident care manager or staff delegated to complete skin and wound assessments. Staff 2 further acknowledged there was no update to the residents care plan regarding the pressure ulcers until 5/4/22. 2. Resident 4 admitted to the facility in 2021 with diagnoses including an unstageable pressure ulcer of the right ankle and dementia. The 2/9/22 physician order indicated Resident 4 was to receive the following wound care: -clean with soap and water, pat dry. -apply thin layer of extra protective cream around wound. -apply a piece of purple foam in the shape of the wound to the wound bed. -cover with foam dressing. -change every 2-3 days. The 3/31/22 physician notes indicated Resident 4 had a 2 cm ulcer on the right ankle that was healing well. The note indicated to continue wound care and the wound was healing well. Non-pressure chronic ulcer of right ankle with fat layer exposed. On 5/2/22 a copy was made of Resident 4's skin sheets and wound measurements. The 4/20/22 skin sheet indicated Resident 4 had a Stage 4 pressure ulcer to the right ankle that measured 12 mm x 15 mm x 1 mm (1.2 cm x 1.5 cm x 0.1 cm). There were no additional skin and wound measurements after 4/20/22. On 5/2/22 at 2:59 PM Staff 10 (RN) stated Resident 4 had a pressure ulcer on the right ankle and the evening shift nurse or Staff 2 (DNS) was responsible for changing the dressing. Staff 10 stated the MARs/TARs indicated the resident received a dressing change on 5/1/22 at 9:43 PM by Staff 11 (LPN). An observation was made with Staff 10 of Resident 4's dressing on the right ankle. The dressing was observed to have dark brown drainage visible through the top of the bandage and it was dated 4/28[2022]. Staff 10 confirmed the dressing was dated 4/28 [2022]. On 5/2/22 at 3:16 PM Staff 2 stated Resident 4's pressure ulcer was last measured on 4/20/22 and the expectation was for measurements to be completed weekly. On 5/2/22 at 3:39 PM the surveyor asked Staff 2 (DNS) to complete a dressing change for Resident 4. Staff 2 removed the old dressing and acknowledged it was dated 4/28. Staff 2 stated there was a scant amount of serosanguineous drainage (discharge that contains blood and serum) when she removed the bandage, there was no foam pad observed under the dressing. Staff 2 stated the wound was a Stage 4 pressure ulcer and the resident admitted with it. Staff 2 measured the area and stated it measured 1.4 cm x 1 cm x 0.4 cm. Staff 2 completed the dressing change per the order. On 5/2/22 at 3:58 PM Staff 11 (LPN) stated she documented she completed a dressing change for Resident 4 on 5/1/22 but did not complete the dressing change and must have overlooked it. On 5/3/22 at 12:07 PM Witness 4 (Clinic Wound Nurse) stated Resident 4 was being seen at the wound clinic and her/his last visit was 2/9/22. Witness 4 stated the resident had subsequent appointments scheduled but did not show up. Witness 4 further stated the facility did not bring Resident 4 back for the scheduled appointments and did not schedule future appointments. Witness 4 stated the wound measurements on 2/9/22 were 1.9 cm x 1.9 cm x 0.3 cm. On 5/3/22 at 3:09 PM Staff 2 (DNS) acknowledged Resident 4 did not have the foam pad in place when she changed the dressing on 5/2/22. On 5/3/22 at 5:02 PM Staff 2 (DNS) stated Resident 4 was not seen by the wound clinic after 2/9/22 even though the resident had future appointments set up. Staff 2 stated there was a system breakdown. On 5/6/22 at 11:48 AM Staff 2 stated the MAR/TAR indicated Resident 4 refused dressing changes on 4/10/22 and 4/16/22 and there was no indication in the clinical record to indicate the resident was reapproached for a dressing change. Staff 2 acknowledged the resident received a scheduled dressing change on 4/7/22 then refused 4/10/22 and an additional dressing change was not completed until 4/13/22. Staff 2 further acknowledged the resident did not receive the scheduled dressing change on 4/16/22 and an additional dressing change was not completed until 4/19/22. Staff 2 acknowledged staff should have reapproached the resident for a dressing change after her/his refusals on 4/10/22 and 4/16/22. Refer to F692.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to provide care and services to maintain acceptable parameters of nutritional status and ensure residents received a therapeutic diet and nutritional supplements as ordered for 2 of 4 sampled residents (#s 4 and 14) reviewed for nutrition. This resulted in Resident 14 and Resident 4 experiencing a severe weight loss. This placed other residents at risk for weight loss. Findings include: The 2001 Facility Nutrition Program Policy indicated: 1. Direct care staff, assisted by the facility's Clinical Dietitian, will evaluate each individual's physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. 2. Physician and related Health Care Practitioners (NP, PA, etc.) would help the staff identify specific factors in individual residents (medical conditions, medications, etc.) that may be affecting a resident's appetite, nutritional needs, nutrition utilization, and hydration status. 3. A facility Dietitian would help assess the nutritional needs and risks of all residents and patients in the facility, and help the facility assure that it provided appropriate meals and other nutritional interventions. 6. As part of the facility's quality improvement program, the staff, Administrator, and Medical Director would review nutrition-related outcomes and address related problems. The 12/1/20 Weight Policy indicated: 4. If there was a +/- three-pound variance from the prior weight, a re-weight would be completed within 24 hours. 6. Any residents with a +\- three-pound variance would be noted in the 24-hour report and in the care notes for further RN review. 7. The RN or designee would review monthly weights to further evaluate for any significant weight loss or gain. Significant weight loss or gain would be defined as: 5% in 30 days, 7.4% in 90 days, and 10% in 180 days. 8. Any resident with a significant weight loss or gain would be further assessed by the RN for the cause of the weight change and the physician and family would be notified as needed. 9. The service plan would be updated to reflect any changes in care and further interventions. 1. Resident 14 admitted to the facility in 12/2021 with diagnoses including a back fracture and dysphagia (difficulty swallowing foods and liquids). Resident 14 had a 12/16/21 Nutrition Order for a regular diet, minced, moist, and thin liquids. The 12/23/21 admission MDS indicated Resident 14 was moderately cognitively impaired, had no difficulty with swallowing but reported difficulty or pain with swallowing, and the resident weighed 177 pounds. The 12/23/21 Nutrition CAA indicated Resident 14 was currently prescribed a mechanical soft diet and consumed an average of 51-70% of meals with meal substitutions and/or replacement shakes offered when the resident consumed less than 50% of any given meal. Weight, meal intakes, labs, and nutritional needs would be followed by the interdisciplinary team and the RD via NAR (Nutrition At Risk). The 3/13/22 Quarterly MDS indicated Resident 14 weighed 168 pounds with no significant weight loss noted. The Weight Summary indicated Resident 14's weights in pounds: *12/16/21: 174.6 *12/17/21: 172.8 *12/18/21: 177 *12/19/21: 176.4 *12/22/21: 177.4 *1/10/22: 171.2 *2/3/22: 168.2 *3/30/22: 154 *4/6/22: 162.8 *5/4/22: 161.8 The resident was 177.4 pounds on 12/22/21 and 154 pounds on 3/30/22. This was a 23.4-pound weight loss (8.79%) in 99 days, indicating a severe weight loss. Resident 14 weighed 161.8 pounds on 5/4/22. This was a 15.6-pound weight loss (8.79%) in 134 days from 12/22/21, indicating a significant weight loss. There were no re-weights of Resident 14 in the medical record. There was no evidence in the medical record to indicate RD or NAR assessments were completed for Resident 14 from 1/2022 until 4/25/22. There was no evidence in the medical record the RD or physician were notified of Resident 14's weight loss. The admission Dietary assessment dated [DATE] was noted as in progress in Resident 14's medical record as of 5/4/22. The assessment information included: no bacon per resident, mechanical soft texture and needs food soft and moist to chew due to no bottom teeth. The 4/25/22 Nutrition/Dietary Note indicated Resident 14 experienced a significant weight loss and was observed to be thin with sunken eyes and slow skin turgor. The resident reported the food was cold and she/he had difficulty biting off sandwiches and chewing raw/vegetables and fruits. The notes indicated Resident 14 had mild PCM (protein-calorie malnutrition) related to dysphagia, dissatisfaction with the food, and chewing difficulty related to missing lower teeth and having top dentures. Intake was estimated as 75% of estimated energy needs for calories with a 10% weight loss in three months. The plan indicated Resident 14 was to receive oatmeal and scrambled eggs for breakfast and cottage cheese with lunch and dinner. The resident was noted to accept nutritional supplements 118ml TID with meals. The resident's diet was to be regular with mechanical soft textures with all foods finely chopped/ground, gravy/sauce on all foods, no raw veggies, no raw fruits, and no bread/buns/rolls/crusts. The 4/26/22 Change of Diet Slip indicated Resident 14 was to receive a regular diet, mechanical soft with all food finely chopped/ground, gravy sauce on all foods, no raw veggies or fruits, and no breads. Meal Monitoring Sheets were reviewed from 2/1/22 through 5/4/22 and indicated the amount of times Resident 14 consumed less than 50% of her/his meal or the meal was undocumented: *2/1/22 through 2/28/22: 24 out of 84 meals. *3/1/22 through 3/31/22: 19 out of 60 meals (Resident 14 was hospitalized [DATE] until 3/14/22). *4/1/22 through 4/30/22: 49 out of 90 meals. *5/1/22 through 5/4/22: 12 out of 19 meals. There was no evidence in the medical record the resident was offered a nutritional shake when Resident 14 consumed less than 50% of any given meal. On 5/1/22 at 2:13 PM Resident 14 stated she/he did not like the food, and she/he wanted oatmeal for breakfast and did not receive it. The following observations and interviews occurred on 5/3/22: *12:37 PM Resident 14's lunch tray was observed, and the resident was eating ice cream independently in her/his bed. The tray was observed to contain a full sandwich that was not cut up, no gravy or sauce, and no cottage cheese. Resident 14 stated she/he wanted cottage cheese with her/his lunch and was unable to eat the sandwich. Resident 14 did not have a meal/diet card on her/his tray. Resident 14 was observed in bed with the head of the bed at approximately a 60-degree angle. *12:43 PM Staff 2 (DNS) stated the RD had just made the recommendation for a mechanical soft diet and the diet had not been implemented. Staff 2 stated Staff 15 (Dietary Manager) was expected to have updated the meal card. Staff 15 stated when the RD made recommendations, Staff 2 would get the order from the nursing staff and update the meal card. Staff 15 confirmed Resident 14 did not receive a mechanical soft diet and should not have gotten a sandwich and should have received cottage cheese. Staff 15 stated she had implemented the order on the meal card, but she was training new kitchen staff and it was not implemented. Staff 2 was asked if the resident was at risk for aspiration and left the room to obtain Resident 14's last speech evaluation. *12:54 PM Resident 14 received cottage cheese and began consuming independently. *12:57 PM Staff 2 read Resident 14's 12/2021 speech evaluation which indicated the resident's self-reported swallowing difficulties were related to sitting up and eating preferences and per RD required a mechanical soft diet with gravy. The Speech Therapist recommended the resident be up in bed at 90 degrees for all meals. Staff 2 confirmed Resident 14's bed was not 90 degrees and raised the head of the resident's bed. *1:26 PM Resident 14's meal card was reviewed and indicated the resident was to receive a regular diet with mechanical soft texture. All foods finely chopped/ground, gravy/sauce on all food. No raw veggies, raw fruits, or breads, milk with every meal, and no bacon per resident. On 5/3/22 at 3:28 PM Staff 14 (RD) stated she had not worked in the facility for three months due to contractual issues and there were no NAR meetings for those months. Staff 14 confirmed the facility had been without a dietitian from 1/2022 until 4/2022. Staff 14 stated for her nutritional recommendations she would inform the Administrator, DNS, Resident Care Managers (RCMs), and dietary managers of her recommendations and they would implement them. Staff 14 stated the expectation for implementing dietary recommendations was 24 hours. Staff 14 stated Resident 14 had mechanical soft dietary orders since admission and had not been receiving those orders and this put the resident at risk for weight loss. Staff 14 stated Resident 14 did not have any problem with swallowing or choking issues per her assessments. Staff 14 stated there were issues with the facility obtaining weights and the plan had always been to reweigh residents if there was a three-pound increase or decrease from the previous weight. Staff 14 stated based on Resident 14's weights the facility would be expected to weigh the resident weekly due to the resident's significant weight loss. Staff 14 further stated she expected the head of bed to be at 90 degrees unless a more recent speech evaluation concluded the intervention was no longer needed for Resident 14. On 5/4/22 at 8:18 AM Resident 14's breakfast tray was observed to have cottage cheese and an over-easy egg cut up. Resident 14 stated she/he did not like eggs like that and never will. Resident 14 did not have oatmeal on her/his meal tray. A CNA was observed to remove the tray stating they would get the resident scrambled eggs, but the resident replied she/he wanted to go back to bed and did not have an appetite. On 5/4/22 at 8:59 AM Staff 15 (Dietary Manager) acknowledged Resident 14 did not receive oatmeal for breakfast and eggs were not scrambled. Staff 15 stated she would update the dietary card per the RD assessment and resident preferences. On 5/4/22 at 11:41 AM Staff 15 (Dietary Manager) confirmed the Dietary Assessment was noted as in progress but stated it had been completed with Staff 14 (RD) on 4/25/22. Staff 15 confirmed the assessment was expected to be completed at admission, but she had only started working at the facility a few weeks prior and the RD had not been in the facility for three months prior to 4/2022. On 5/5/22 at 11:35 AM Staff 7 (CNA) stated if a resident consumed less than 50% intake of meals staff would offer the resident an alternative or a high protein shake if ordered. Staff 7 stated staff documented the nutritional shakes or alternatives under a prn tab in the Tasks section of the medical record. Staff 7 stated Resident 14 had ongoing issues with intake and the resident liked oatmeal so she would bring the resident oatmeal and other soft foods. Staff 7 stated Resident 14 was not offered a protein shake as it was not on the resident's care plan. On 5/6/22 at 11:33 AM Staff 2 (DNS) and Staff 1 (Administrator) stated any residents who experienced a significant weight loss or gain would be discussed with Staff 14 and interventions would be put in place like a nutritional supplement. Staff 2 stated the policy was for residents who triggered for a 5% weight loss or gain would be re-weighed. Staff 1 and Staff 2 acknowledged Resident 14 experienced a severe weight loss from 12/2021 through 3/2022 of over 13% in three months. Staff 2 confirmed there were no assessments or interventions implemented for Resident 14's weight loss and the medical provider was not notified. Staff 1 confirmed there was no dietitian in the building from 1/2022 until 4/2022 to assess residents for nutrition status. Refer to F657, F710, F803, and F825. 2. Resident 4 admitted to the facility 11/8/21 with diagnoses including a right ankle pressure ulcer and dementia. The 11/21/21 admission MDS indicated Resident 4 was rarely/never understood, had no swallowing issues, and weighed 138 pounds with no weight loss. The 11/21/21 Nutrition CAA indicated Resident 4 received protein powder in drinks and consumed meals independently with 1:1 mealtime assist to encourage increased PO intake of meals and fluids. The assessment indicated the RD was to review/recommend quarterly and prn. The assessment further indicated the resident had an extensive history of refusing meals and the resident was offered meal alternatives, supplements, and snacks as needed. The Weight Summary indicated Resident 4's weights in pounds: 11/19/21: 138 12/8/21: 121.8 12/18/21: 123 12/19/21: 118.8 12/27/21: 119 1/3/22: 124.6 1/10/22: 123.4 1/13/22: 124.8 2/6/22: 118.8 3/30/22: 128.6 4/6/22: 121 5/3/22: 120.4 Resident 4 weighed 138 pounds on 11/19/21 and weighed 120.4 pounds on 5/3/22. This was a 16.6 pound weight loss (12.4%) in less than six months, indicating a severe weight loss. There were no re-weights of Resident 4 in the Weight Summary, except on 12/18/21 the resident weighed 123 pounds and on 12/19/21 the resident weighed 118.8 pounds. An 11/15/21 Nutrition/Dietary Note indicated Resident 4 had a regular diet with regular textures and nutrition needs were met. Facility weights were pending, and staff were to alert the RD as weights became available for further assessment of nutrition/hydration needs. A 12/16/21 Nutrition/Dietary Note indicated Resident 4's admission weight was 138 and the resident currently weighed 121.8 pounds. A re-weight was requested. The note indicated if the weights were accurate then Resident 4 sustained a severe loss since admission in the past month of 16.2 pounds (11.7%). The assessment indicated due to Resident 4's significant dementia, oral intakes being impacted and were diminished to suboptimal amounts of 50-75% since admission. The plan included to provide Resident 4 with a nutritionally enhanced regular diet with a large high protein nutritional supplement TID with meals and 2cal (nutritional shake) 80cc TID between meals. The note indicated staff were to document supplement intakes and the NAR (Nutrition at Risk) IDT (Interdisciplinary Team) were to monitor skin and weight. There was no evidence in the medical record to indicate RD or NAR assessments were completed for Resident 14 from 1/2022 until 4/28/22. There was no evidence in the medical record the RD or physician were notified of Resident 14's weight loss. The 2/16/22 Care Plan indicated Resident 4 was to receive a protein shake with lunch to promote adequate nutrition for wound healing. The 2/21/22 Quarterly MDS indicated Resident 4 had no swallowing issues and weighed 119 pounds and had a loss of 5% or more in the last month or a loss of 10% or more in the last 6 months and was not on a prescribed weight loss regimen. A 3/1/22 Nutrition/Dietary Note indicated Resident 4's diet order was clarified with the dietician, including regular diet and a protein shake with meals and 4 oz of 2Cal between meals. A 4/28/22 Nutrition/Dietary Note indicated Resident 4 had a current weight of 121 pounds and a loss of 17 pounds (12%) in the past five months and a seven-pound (6%) weight loss in one month. The RD questioned the accuracy of the 128-pound weight on 3/30/22 as the resident did not have edema and was not on a diuretic. Resident 4's diet was noted as regular with an added high protein nutrition supplement 118ml TID with meals and a 2-Cal (nutrition shake) between meals. Intakes of food were noted as variable between 25-100% of meals. The note further indicated NAR (Nutrition at Risk) IDT (Interdisciplinary Team) to monitor the resident for wound healing and until weight was at goal. Meal Monitoring Sheets were reviewed from 1/1/22 through 5/4/22 and indicated the amount of times Resident 4 consumed less than 50% of her/his meal or the meal was undocumented: *1/1/22 through 1/31/22: 54 out of 96 meals. *2/1/22 through 2/28/22: 35 out of 84 meals *3/1/22 through 3/31/22: 36 out of 96 meals. *4/1/22 through 4/30/22: 42 out of 90 meals. *5/1/22 through 5/5/22: 5 out of 15 meals. There was no evidence a health shake or 2Cal shake were ordered or documented in Resident 4's medical record. The following observations and interviews were conducted regarding Resident 4 on 5/3/22: *12:39 PM Staff 8 (CNA) was observed passing meal trays to the dining room. *12:42 PM Resident 4 was observed eating a sandwich independently alone at a table in the corner of the dining room. Resident 4 attempted to get up and Staff 8 asked the resident if she/he wanted to drink her/his juice. The sandwich was observed as untouched, and it appeared as though the resident had consumed some of the soup. Resident 4 did not consume her/his juice. Staff 8 asked Resident 4 if she/he wanted more and the resident stated no. There was no health shake observed at Resident 4's table and no shake was offered by staff. *12:48 PM Staff 8 (CNA) was asked if Resident 4 received a health shake with meals. Staff 8 stated he had seen the resident receive one before but was unsure if the resident received them with meals. Staff 8 stated the resident liked the health shakes and would consume them. Staff 8 further stated if a resident received a health shake staff would document the shake as liquids in Resident 4's medical record and not as a health shake. *1:10 PM Staff 7 (CNA) stated Resident 4 received health shakes in the morning and would consume the shake. *1:13 PM Staff 15 (Dietary Manager) stated Resident 4 received a health shake at every meal and it was put on the meal tray. Staff 15 stated she did not see Resident 4's health shakes come back so she assumed the resident drank the health shake. *5:28 PM Staff 9 (CNA) stated she had seen Resident 4 receive health shakes but was unsure if the shakes were on Resident 4's care plan. Staff 9 further stated there was no section in the medical record to document supplements so there was no way to document if Resident 4 received/consumed the health shake. On 5/3/22 at 3:28 PM and 3:43 PM Staff 14 (RD) stated she had not worked in the facility for three months due to contractual issues and there were no NAR meetings for those months. Staff 14 confirmed the facility had been without a dietitian from 1/2022 until 4/2022. Staff 14 stated per the facility weights, Resident 4 experienced a significant weight loss, and her expectation was if a resident's weights were fluctuating the facility would reweigh the resident to ensure weights were correct. Staff 14 stated there were issues with the facility obtaining weights and the plan had always been to reweigh residents if there was a three-pound increase or decrease from the previous weight. Staff 14 stated she would expect the facility to provide the health shakes at the meals as part of the diet order and to specify to how much was consumed and then the documentation was to be entered as a task and documented by the CNAs. Staff 14 further stated if a supplement was provided between meals like 2Cal then the supplement would be entered as a specific order and documented on the MAR by nursing staff. On 5/5/22 at 11:35 AM Staff 7 (CNA) stated if a resident consumed less than 50% intake of meals staff would offer the resident an alternative or a high protein shake if ordered. Staff 7 stated staff documented the nutritional shakes or alternatives under a prn tab in the Tasks section of the medical record. Staff 7 stated staff offered Resident 4 ice cream and or shakes if the resident ate less than 50% of her/his meal. On 5/6/22 at 11:33 AM Staff 2 (DNS) and Staff 1 (Administrator) stated any residents who experienced a significant weight loss or gain would be discussed with Staff 14 and interventions would be put in place like a nutritional supplement. Staff 2 stated the policy was for residents who triggered for a 5% weight loss or gain would be reweighed. Staff 1 and Staff 2 acknowledged Resident 4 experienced a severe weight loss of 16.6 pounds (12.4%) in less than six months. Staff 2 confirmed there were no assessments or interventions implemented for Resident 4's weight loss and the medical provider was not notified. Staff 1 confirmed there was no RD in the building from 1/2022 until 4/2022 to assess residents for nutrition related concerns. Refer to F657, F710, and F803.