Based on facility policy review, clinical record review, and staff and resident representative interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for three of six residents reviewed for nutrition or hydration (Residents 17, 28, and 58). This failure resulted in harm for Resident 17, as evidenced by significant weight loss. Findings include: Review of facility policy, titled Weight Monitoring, last reviewed January 17, 2025, read, in part, The facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates this is not possible or residents preferences indicate otherwise .the facility will utilize a systematic approach to optimize a residents nutritional status. This process includes .Monitoring the effectiveness of interventions and revising them as necessary .Residents with weight loss-monitor weight weekly .the physician should be informed of a significant change in weight and may order nutritional interventions .The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes .the interdisciplinary plan of care communicates care instructions to staff. Review of Resident 17's clinical record revealed diagnoses that included vascular dementia (a type of dementia caused by brain damage from impaired blood flow marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 17's clinical record revealed he had oral surgery on May 20, 2024, with recommendation to follow a soft diet for a week after surgery. Review of Resident 17's physician orders revealed a diet order, Regular diet, Mechanical Soft texture, Regular/Thin consistency, Soft diet is recommended for first week post extractions, with a start date of May 20, 2024, and discontinued May 27, 2024. Review of Resident 17's physician orders revealed a diet order, Regular diet, Regular texture, Regular/Thin consistency, mechanical soft meats; add gravy to meats, with a start date of May 28, 2024, and discontinued on June 16, 2024. Review of Resident 17's physician orders revealed a change to the diet order on June 16, 2024, Regular diet, Puree texture, Regular/Thin consistency. Review of Resident 17's clinical record revealed a progress note on June 16, 2024, that stated Resident was in dining room at lunch and resident was observed coughing on corn. Resident was able to clear the corn. Resident also noted to be coughing on mechanical soft ground ham. Spoke with resident and resident is ok with puree foods. Spoke with POA (power of attorney- legal representative) who was unaware that resident went back to Regular diet mechanical soft meats. POA is ok with resident being pureed. Dietary made aware. Review of Resident 17's clinical record revealed a significant weight loss of 28 pounds (-10.4%) from April 23, 2024, to October 18, 2024. Review of Resident 17's clinical record revealed a dietitian note on October 25, 2024, that read, in part, Review of monthly weight. Current weight of 241.8 pounds (October 18, 2024) triggers as a significant loss in 6 months. Weight fluctuations anticipated related to diuretic therapy. Recommending weekly weights to monitor trend. Resident continues to tolerate a regular diet, puree, thin liquids. Weight loss and intake reviewed with POA; POA is not interested in supplementation at this time. POA sees weight loss as beneficial. Care plan reviewed/updated. A follow up dietitian note was linked to the aforementioned note on October 29, 2024, that read, Per nursing, resident with decreased snacking between meals; may contribute to weight loss. Review of Resident 17's physician orders on February 5, 2025, revealed that the diuretic was not a new medication for him, and he had been on it since March 1, 2023. Review of Resident 17's physician orders revealed an order to Weigh weekly every day shift every Monday, with a start date of October 28, 2024. Review of Resident 17's clinical record failed to reveal weekly weights were obtained on the week of November 11 and 18, 2024. During an email correspondence with the Nursing Home Administrator (NHA) on February 5, 2025, at 11:49 AM, the surveyor inquired if the aforementioned weekly weights were obtained, she revealed, These weights were not obtained. On November 11, 2024, the PRN [as needed] nurse who was working didn't sign off with no explanation. On November 18, 2024, the agency nurse signed off saying it would be obtained on 3-11 shift, but the weight was then missed by 3-11. Additionally, during the email correspondence with the NHA on February 5, 2025, at 11:49 AM, she revealed [Physician notification of] weight loss missing on [Resident 17] due to communication between dietitian and POA stating she felt the weight loss was ok due to his current weight. Therefore, no notification was made to the physician. We had lots of conversation at interdisciplinary meetings around this as [Resident 17] had recently had oral surgery and was not snacking as prior. He also had been downgraded to puree diet and he was not happy with his meal options. All weight loss (anticipated and not) is discussed at QAPI (quality assurance meeting) monthly. [Resident 17's] weight loss situation did not follow normal protocol due to circumstances explained. In an additional interview with the NHA on February 5, 2025, at 1:39 PM, she stated that residents with weight loss are discussed in QAPI, and the physician signs the QAPI sign in sheet. No physician notification or response to the weight loss was noted in Resident 17's medical record. Review of Resident 17's weight measures revealed his weight loss continued 8.8 pounds (-3.6%) from October 18, 2024, to December 2, 2024. Review of Resident 17's clinical record revealed a dietitian note on December 4, 2024, that read, in part, Weight and intake reviewed with [POA]; she maintains wish for no supplementation at this time. Further review of Resident 17's weight measures revealed his weight loss continued 8.2 pounds (-3.5%) from December 2, 2024, to January 20, 2025. Review of Resident 17's clinical record revealed a physician note written by Employee 6 (Medical Director) on January 30, 2025, that read, Resident weight noted down some, intake good, on Lasix [diuretic medication] monitor [electro]lytes, NAD, today eating lunch. Interview with Employee 2 (Registered Dietitian) on February 5, 2025, at 1:35 PM, revealed she was concerned about Resident 17's weight loss, but the Resident's POA did not want him on supplements. During an interview with the NHA and the Director of Nursing (DON) on February 5, 2025, at 1:39 PM, revealed the weekly weights that were missed should have been obtained per physician order, and that Resident 17 has remained on a puree diet because his POA refused speech therapy services for a potential diet upgrade. The surveyor requested documentation in the medical record to indicate the refusal of speech therapy services and any physician involvement in response to weight loss prior to January 30, 2025. Interview with Resident 17's POA on February 6, 2025, at 2:58 PM, revealed she did not refuse speech therapy services and that, when supplements were discussed with her, she was concerned that Resident 17 needs more food rather than supplements, and he would eat more food if he wasn't on a puree diet. Follow-up interview with the NHA and DON on February 6, 2025, at 3:38 PM, the surveyor revealed the concern with lack of documentation to indicate speech therapy services were refused and lack of physician response to the significant weight loss, no further information was provided. The Resident was noted to have significant weight loss. The Resident was not reassessed by speech therapy after his diet was downgraded in June 2024. There was no evidence that a speech therapy consult or supplements were discussed with the physician. There were no physician progress notes that addressed Resident 17's weight loss from when his weight loss became significant in September 2024, until January 30, 2025. Review of Resident 28's clinical record revealed diagnoses that included heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 28's physician orders revealed an order for Daily weight - Notify MD if increase of 3 pounds in 24 hr or gain/loss of 5 pounds in 1 week every night shift for fluid balance management, with an original order date of October 26, 2024. Review of Resident 28's Treatment Administration Record for October revealed that on October 28, 2024, the weight and signature box were both blank; October 30, 2024, was signed as completed on night shift but the box where the weight was to be entered was marked with an X and the entries for the weight and signature boxes on day shift were blank; and October 31, 2024, was signed as completed on night shift with an X marked in the box where the weight was to be entered. Review of additional information provided by the facility revealed that Resident 28 weighed 144 pounds on October 30, 2024, and weighed 152.3 pounds on October 31, 2024, indicating an 8.3-pound weight gain in 24 hours. Review of Resident 28's progress notes failed to reveal any documentation that their physician was notified of the greater than 3-pound weight gain in 24 hours on October 31, 2024. Review of Resident 28's Treatment Administration Record for November 2024 revealed that the Resident refused their weight on November 15 and 24, 2024. All other entries for the month were signed that the weight was obtained, but the box where the weight was to be entered was marked with an X. Review of Resident 28's Treatment Administration Record for December 2024 revealed that on December 10 and 11, 2024, the weight and signature box were both blank; December 1-9, and 12-20, 2024, were signed that the weight was obtained, but the box where the weight was to be entered was marked with an X. Further review of Resident 28's Treatment Administration Record for December 2024 revealed that on December 24, 2024, the Resident weighed 146.8 pounds and on December 25, 2024, weighed 150 pounds; indicating a 3.2-pound weight gain in 24 hours. In addition, on December 28, 2024, the Resident weighed 153.5 pounds and on December 29, 2024, weighed 156.8 pounds; indicating a 3.3-pound weight gain in 24 hours. Review of Resident 28's progress notes failed to reveal any documentation that their physician was notified of the greater than 3-pound weight gain in 24 hours on December 25 or 29, 2024. Review of Resident 28's Treatment Administration Record for January 2025 revealed that the Resident refused their weight on January 11, 13, 16, 17, and 24, 2025; and on January 1 and 19, 2025, the weight and signature boxes were both blank. Further review of Resident 28's Treatment Administration Record for January 2025 revealed that on January 29, 2025, the Resident weighed 150.8 pounds and on January 30, 2025, weighed 157 pounds; indicating a 6.2-pound weight gain in 24 hours. Review of Resident 28's progress notes failed to reveal any documentation that their physician was notified of the greater than 3-pound weight gain in 24 hours on January 30, 2025. Review of Resident 28's Treatment Administration Record for February revealed that on February 1 and 4, 2025, the weight and signature boxes were both blank. Further review of Resident 28's clinical record revealed a nutrition/dietary note dated October 28, 2024, at 12:04 PM, that indicated a comprehensive nutrition assessment had been completed when Resident 28 returned from a hospital stay. The note indicated that Resident 28 had experienced a significant weight gain over 30 days, 3 months, and 6 months. There was a late entry nutrition/dietary note dated October 28, 2024, at 3:28 PM, that indicated Resident 28 had experienced a significant weight loss following hospitalization, not a significant gain as previously documented. Review of Resident 28's progress notes revealed a physician's progress note dated October 29, 2024, at 4:27 PM, which indicated that Resident 28 was seen post hospital stay and the vital signs and appetite were ok and that the Resident had minimal edema (swelling) to their bilateral legs. There was no documentation of an assessment of Resident 28's significant weight loss. Email communication received from the NHA on February 5, 2025, at 8:33 PM, indicated that she acknowledged Resident 28 had missing weights. During an interview with the NHA, DON, and Employee 2 (Dietician) on February 6, 2025, at 11:53 AM, Employee 2 confirmed that Resident 28 had a significant weight loss upon return to the facility from a hospital stay. Employee 2 indicated that the weight loss was reviewed with Resident 28's physician during the Quality Assurance Performance Improvement (QAPI) Meeting on November 15, 2024. The DON confirmed that she would expect staff to obtain and document resident weights as ordered and that staff should have notified Resident 28's physician of the greater than 3-pound weight gains as per physician order. Email communication received from the NHA on February 6, 2025, at 1:29 PM, confirmed that Resident 28's October 28, 2024, weight loss was reviewed in the facility's QAPI Meeting on November 15, 2024, at which Resident 28's physician was in attendance. She confirmed that she had no information to provide that the physician assessed Resident 28 for their weight loss. In addition, the NHA confirmed that she would expect that Resident 28's daily weights to be obtained, documented, and physician follow-up completed as indicated in the order. During a staff interview with the NHA and the DON on February 6, 2025, at 2:10 PM, the NHA acknowledged that the Resident 28's physician was not made aware of their weight loss identified on October 28, 2024, until November 15, 2024. During a final staff interview with the NHA, DON, and Employee 2 on February 6, 2025, 2:25 PM, the DON indicated that she could not give a direct expectation of physician notification of a weight loss because it is on a case-by-case basis. She said that she felt Resident 28's physician was aware that she had been hospitalized in October and that he would have been aware of treatment received at the hospital regarding her fluid status and the continued monitoring at the facility. Review of Resident 58's clinical record revealed diagnoses that included dementia, heart failure, and dysphagia (difficulty swallowing). Review of Resident 58's progress notes revealed a weight change note dated August 1, 2024, at 3:56 PM, that indicated Resident 58's weekly weights were reviewed and that Resident 58 current weight triggered as a significant loss (7.1%) over 30 days. The note also indicated that the weight fluctuations would be anticipated related to diuretic therapy. Review of Resident 58's progress notes revealed a nutrition/dietary note dated August 16, 2024, at 10:06 AM, that indicated that Resident 58's weekly weights were reviewed and that Resident 58's weight was fairly stable over approximately a 3-week span, but the Resident continued to trigger for a significant loss over 30 days. Review of Resident 58's physician progress notes that were dated August 7, 11, 15, 16, 22, and 28, 2024, all of which failed to reveal any documentation of them being aware of or evaluating Resident 58's significant weight loss. Review of Resident 58's clinical record revealed a nutrition/dietary note dated October 24, 2024, at 3:00 PM, that indicated a comprehensive nutrition assessment was completed upon the Resident's return to the facility from a hospital stay, and Resident 58 was noted to have a significant loss over 30 and 180 days following hospitalization. The note further indicated that weekly weight monitoring was in place per admission protocol, that Resident 58's oral intake was not adequate to meet needs, and supplements were added. Review of Resident 58's physician progress notes revealed notes that were dated October 25, 28, 29, and 30, 2024, all of which failed to reveal any documentation of them being aware of or evaluating Resident 58's significant weight loss. Review of Resident 58's Treatment Administration Record for November 2024 revealed that on November 18, 2024, it was signed that the weight was obtained, but the box where the weight was to be entered was marked with an X. Email communication from the NHA on February 5, 2025, at 8:33 PM, regarding Resident 58's identified weight losses on August 1 and 16, 2024, the dietician documented that weight was stable and that weight loss was anticipated due to diuretic therapy and this would not be considered emergent and would be discussed at QAPI. The NHA further indicated that in November 2024 and December 2024 Resident 58's weight loss remained on the dietician's report and that there was still monitoring of the weight loss. She also indicated that Resident 58's weight loss was first discussed in August QAPI meeting reports, in which Resident 58's physician participated. During a staff interview with the NHA, DON, and Employee 2 on February 6, 2025, at 12:20 PM, the NHA confirmed that they could not provide any information for Resident 58's weight being signed as completed with no weight recorded on November 18, 2024. She said that she would expect weights to have been obtained as ordered by the physician. She again indicated that weight losses were reviewed with the physician during the facility's monthly QAPI meeting. She confirmed that there was no physician documentation regarding Resident 58's weight loss. During a final staff interview with the NHA, DON, and Employee 2 on February 6, 2025, at 2:25 PM, the DON indicated that she could not give a direct expectation of physician notification of weight loss because it is on a case-by-case basis. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.2(d)(3) Medical director 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring and timely implementation of interventions to maintain acceptable parameters of nutritional status for four of 17 residents reviewed (Residents 22, 23, 45, and 57), resulting in actual harm as evidenced by continued weight loss after a significant weight loss was documented for two of 17 residents reviewed (Residents 22 and 45). Findings include: Review of facility policy, titled Weight Monitoring, dated October 2022, read, in part, The facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates this is not possible or residents preferences indicate otherwise .the facility will utilize a systematic approach to optimize a residents nutritional status. This process includes .Monitoring the effectiveness of interventions and revising them as necessary .Residents with weight loss-monitor weight weekly .the physician should be informed of a significant change in weight and may order nutritional interventions .The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes .the interdisciplinary plan of care communicates care instructions to staff. Review of Resident 22's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 22's weights revealed she weighed 127.5 pounds (lbs) on January 22, 2024; 109.8 lbs on February 2, 2024; 109.7 lbs on February 7, 2024; and 107.4 lbs on February 13, 2024. This equated to a weight loss of 17.7 pounds (-13.8%) from January 22, 2024, to February 2, 2024, and a continued weight loss of 2.4 pounds (-2%) from February 2, 2024, to February 13, 2024. Review of Resident 22's clinical record failed to reveal that a nutritional assessment was completed for Resident 22 between the dates of August 14, 2023, and March 20, 2024; and failed to reveal that any interventions were put into place for a significant weight loss between February 2, 2024 (the date a significant weight loss was noted), and February 16, 2024 (the date the physician was notified of Resident 22's weight loss). Review of Resident 22's progress notes revealed a note dated February 16, 2024, that stated, [Employee 11 (Physician)] notified of resident's 20 lb weight loss over past 3 weeks. Resident is consuming 0-25% of meals consistently, has Med Pass 2.0 ordered twice daily and receives snacks between meals three times daily. Antibiotic treatment for UTI (urinary tract infection) was completed on 2/10/24. New order received for Remeron 15 mg by mouth in the evenings. POA (power of attorney) notified of new order. Review of Resident 22's progress notes revealed a note dated February 19, 2024, that stated, Fax placed to MD in regards to obtaining weekly weights. Review of Resident 22's progress notes revealed a note dated February 20, 2024, that stated, New order for weekly weights due to weight loss. POA aware. Review of Resident 22's physician orders revealed an order for Weekly weights x 4 every day shift every Mon for 4 Administrations, with a start date of February 26, 2024. Review of Resident 22's MAR (Medication Administration Record - documentation for treatments/medication administered or monitored) and her clinical record failed to reveal a weekly weight was obtained on March 11, 2024, as per physician order. Review of Resident 22's progress notes revealed a note dated February 22, 2024, that stated, Notified by Social worker that resident's family was updated at care plan meeting about resident's weight loss and declining condition. Family will discuss hospice. During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 2:34 PM, the surveyor revealed the concern with Resident 22's weight loss not being assessed timely, interventions not being put into place timely and implemented per order, and continued weight loss without interventions. The NHA confirmed she would have expected nutrition assessments and interventions to be put into place timely and implemented following a significant weight change. The NHA further revealed nursing was responsible for notifying the physician of significant weight changes at that time, since the facility did not have dietitian coverage during the period of Resident 22's weight loss. She also revealed that there was a corporate Certified Dietary Manager that they should have consulted during that time, but that they failed to consult them. The facility failed to ensure timely evaluation and implementation of new interventions to prevent further weight loss for Resident 17 following a significant weight loss of 17.7 lbs (13.8%) in less than 14 days, resulting in harm as evidenced by an additional weight loss of 2.3 lbs (2%) before interventions were put into place. Review of Resident 23's clinical record revealed diagnoses that included dementia, hypertensive heart disease (heart condition caused by high blood pressure), and depression. Review of Resident 23's weight records revealed that they weighed 194.8 lbs on July 18, 2023; 187 lbs on September 3, 2023; and 164.2 lbs on March 1, 2024 (a loss of 12.19%). Review of Resident 23's Physician Services notes revealed a note dated February 27, 2024, which indicated the following: Resident 23 was being seen for a routine visit and review of their weight loss; the Resident had an 11.98% weight loss over the past six months; their weight had consistently declined month-to-month in that time; their nutritional supplement was increased in January 2024; the resident was on a regular diet with double portions and increased dessert portions; and their cause of weight loss was unknown as their caloric intake and meal consumption was high, but was likely unavoidable secondary to advanced dementia. The note further indicated that the practitioner's plan was to increase the nutritional supplement again, to have Resident 23 weighed weekly, and follow further recommendations of the dietician. Review of Resident 23's clinical record on March 19, 2023, at 10:31 AM, revealed that they had one nutritional assessment completed by the facility dietician on July 25, 2023, at the time of their admission to the facility. Review of Resident 23's clinical record progress notes on March 19, 2023, at 10:31 AM, revealed that the last documentation completed by a dietician was dated August 3, 2023, at which time the note indicated that they were questioning a weight that had been obtained and had requested that the resident be reweighed. During an interview with the NHA and Employee 1 (Registered Nurse Assessment Coordinator - RNAC) on March 20, 2024, at 2:24 PM, the aforementioned information from the practitioner's note was shared, as well as concern regarding the lack of nutritional assessments or any documented follow-up by a dietician. The NHA confirmed that there were no additional nutritional assessments completed on Resident 23 since they were admitted to the facility on [DATE]. She indicated that the facility was without a dietician from September 15, 2023, until March 5, 2024. She indicated that during the time the facility was without a dietician, the Director of Nursing (DON) was to be reviewing resident weights and addressing weight concerns in the interim, and that there was a corporate Certified Dietary Manager that the facility could have reached out to when needed. The NHA shared that this DON was no longer an employee at the facility, and that the facility had failed to contact the corporate Certified Dietary Manager for assistance. A follow-up review of Resident 23's clinical record on March 21, 2024, at 8:59 AM, revealed a progress note by the dietician which indicated that there was an order clarification for the weekly weight monitoring due to significant weight loss over six months. At the time of this review, there was still no documented nutritional assessment by the facility dietician. During a final interview with the NHA on March 21, 2024, at 10:29 AM, she confirmed that she would expect a resident to have a nutritional assessment completed quarterly by a dietician, at minimum, and with any nutritional change, such as weight loss. Review of Resident 45's clinical record revealed diagnoses that included dementia, dysphagia, and breast cancer. Review of Resident 45's weight records revealed the following weights: December 1, 2023, 111 lbs; January 22, 2024, 101.5 lbs; January 30, 2024, 101.6 lbs; February 20, 2024, 97.5 lbs February 21, 2024, 95.4 lbs February 22, 2024, 96.2 lbs February 26, 2024, 85.6 lbs February 27, 2024, 88.7 lbs March 1, 2024, 93.6 lbs March 5, 2024, 93.5 lbs This equated to a significant weight loss of 13.5 lbs (12.2%) between December 1, 2023, and February 20, 2024; an additional 11.9 lb weight loss between and February 20, 2024 and February 26, 2024; and a total weight loss of 17.5 lbs (15.7%) between December 1, 2023 and March 5, 2024. Review of Resident 45's clinical record revealed that their last nutritional assessment was completed by a dietician on September 20, 2023, at the time of their admission to the facility. Review of Resident 45's clinical record progress notes revealed a note by the facility dietician dated March 6, 2024, at 1:09 PM, which indicated that their weekly weights were reviewed and that their current weight on March 5, 2024, triggers as a significant loss of 6.9% x 30 days. Resident continues to tolerate a Regular diet, regular texture, thin liqs [liquids] PO [oral] intake is not adequate to meet estimated needs at ~ [approximately] 30 % ave[rage] w[ith]/ 9 meal refusals. Resident continues to receive and accept Medpass [a nutritional supplement] 240 mL [milliliters] BID [twice a day], ~[approximately] 100% ave[rage]. Recommending to increase Medpass to 240 mL TID [three times a day] to provide additional calories and protein. Order added on (2/17) to encourage fluids. Weekly wt [weight] monitoring to continue. Care plan updated. In addition, there was a progress note dated March 6, 2024, at 1:37 PM, which indicated that Resident 45's responsible party was notified of their weight change and new recommendations. The documentation did not indicate if Resident 45's physician was made aware of the weight loss. Further review of Resident 45's clinical record progress notes failed to reveal any documentation regarding Resident 45's weight loss, including physician notification and responsible party notification between February 20, 2024, when the resident started triggering for weight loss, and March 6, 2024. The last documentation of Resident 45's physician being made aware of any weight loss was on December 19, 2023, during which time the resident was experiencing a COVID-19 infection and additional orders were given for nutritional supplementation. During an interview with the NHA on March 20, 2024, at 10:24 AM, the aforementioned concerns were shared regarding Resident 45's weight loss identification, lack of dietician involvement, and lack of documentation that the physician or responsible party were notified of the weight loss that triggered on February 20, 2024, and of ongoing weight loss triggered with each weight obtained thereafter. The NHA confirmed that there were no other nutritional assessments completed for Resident 45 since they were admitted to the facility on [DATE]. She indicated that the facility did not have a dietician during this timeframe, and that nursing was attempting to identify and address weight concerns. During another interview with the NHA and Employee 1 on March 20, 2024, at 2:24 PM, the aforementioned concerns were all shared again. The NHA indicated that the facility was without a dietician from September 15, 2023, until March 5, 2024. She indicated that during the time the facility was without a dietician, the DON was to be reviewing resident weights and addressing weight concerns in the interim, and that there was a corporate Certified Dietary Manager that the facility could have reached out to when needed. The NHA shared that this DON was no longer an employee at the facility and that the facility had failed to contact the corporate Certified Dietary Manager for assistance. During an interview with the NHA on March 21, 2024, at 10:29 AM, she confirmed that she would expect a resident to have a nutritional assessment completed quarterly by a dietician, at minimum, and with any nutritional change, such as weight loss. During a final interview with the NHA on March 21, 2024, at 1:24 PM, the NHA confirmed that Resident 45's physician and responsible party should have been notified when they began triggering for weight loss at the end of February 2024. The facility failed to ensure timely evaluation and implementation of new interventions to prevent further weight loss for Resident 45 following a significant weight loss of 13.5 lbs. (12.2%), resulting in harm as evidenced by an additional weight loss which totaled 17.5 net pounds (15.7%) before interventions were put into place. Review of Resident 57's clinical record revealed diagnoses that included dementia, major depressive disorder, and vitamin D deficiency. Review of Resident 57's weight measures revealed she had a significant weight gain of 9.4 lbs. (+10.6%) from October 17, 2023, to November 3, 2023. Review of Resident 57's clinical record on March 20, 2024, failed to reveal that a nutritional assessment was completed for Resident 57 between the dates of September 15, 2023, and present. During an interview with the NHA on March 20, 2024, at 2:34 PM, the surveyor revealed the concern that Resident 57 did not have a nutritional assessment completed following a significant weight change. The NHA confirmed she would expect nutrition assessments to be conducted timely following a significant weight change. The NHA further revealed nursing was responsible for notifying the physician of significant weight changes at that time, as the facility did not have dietitian coverage during the period of Resident 57's weight gain. She also revealed there was a corporate Certified Dietary Manager that they should have consulted during that time, but failed to do. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(6) Management. 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services.