**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 27 of 27 residents (Residents #6, #7, #9, #13, #19, #22, #24, #28, #31, #32, #33, #34, #36, #39, #40, #41, #42, #43, #44, #45, #47, #50, #51, #53, #55, #57, #59) who were reviewed for care plans. 1. The facility failed to develop a person- centered care plan for Resident #55's oral care needs related to denture use and interventions for oral, and nutritional maintenance despite a system generated warning on 11/15/24 for -7.5% change (comparison weight 08/09/24, 154.2 lbs, -8.0%, 12.4 lbs) and lab results on 09/05/24, 12/06/24, and 03/13/25 which reflected low albumin levels indicating low protein resulting in a 4.9 lbs (-3.62 %) loss in a month, a 12.3 lbs (-8.62 %) loss in 6 months, and 23.9 lbs (-15.49 %) loss in the last year 04/05/24 through 04/15/25 resulting in impaired nutritional status (significant weight loss) and frustration with not having her preferences and needs met. 2. The facility failed to care plan Residents' #6, #7, #9, #13, #19, #22, #24, #28, #31, #32, #33, #34, #36, #39, #40, #41, #42, #43, #44, #45, #47, #50, #51, #53, #57, #59 for their use of dentures. This failure placed residents that wear dentures at risk of impaired nutritional status (poor intake and significant weight loss) and not having their need for assistance met. Findings included: Review of Resident #6's significant change MDS assessment dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, vitamin B12 deficiency anemia (low levels of healthy red blood cells or hemoglobin), dental procedure status, and hypertension (high blood pressure). She had a BIMS score of 10 indicating moderate cognitive impairment. Functional abilities for oral hygiene included the ability to insert and remove dentures into and from the mouth reflected substantial/ maximal assistance. Section L Dental reflected none of the above were present when indicating if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. Review of Resident #6's care plan last revised 04/21/25 reflected Resident #6's care plan did not identify oral care related to denture use. Record review of Resident #7's Annual MDS, dated [DATE], indicated Resident #7 was a [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses of Heart Failure, Atrial Fibrillation (irregular heart rhythm), Cardiac Pacemaker, lack of coordination, and muscle weakness. His MDS reflected in Section L - Oral/Dental Status an 'x' in box 'Z. None of the above were present' when indicating if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. He had a BIMS score of 15 indicating cognition intact. Record review of Resident #7's care plan dated last revised 03/31/2025 revealed that his use of upper and lower dentures was not care planned. Record review of Resident #9's Annual MDS, dated [DATE], indicated Resident #9 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of Cerebral Infarction (stroke), Peripheral Vascular Disease (a lack of blood flow to the lower extremities), lack of coordination, and muscle weakness. Her MDS reflected in Section L - Oral/Dental Status an 'x' in box 'Z. None of the above were present' when indicating if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. She had a BIMS score of 12 indicating cognition intact. Record review of Resident #9's care plan dated last revised 03/28/2025 revealed that her use of upper and lower dentures was not care planned. Record review of Resident #13's admission MDS, dated [DATE], indicated Resident #13 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of Cerebral Infarction, Peripheral Vascular Disease, lack of coordination, and muscle weakness. Her MDS reflected in Section L - Oral/Dental Status an 'X' in box 'B indicating No natural teeth or tooth fragments. She had a BIMS score of 14 indicating cognition intact. Record review of Resident #13's care plan dated last revised 04/28/2025 revealed that her use of upper and lower dentures was not care planned. Record review of Resident #19's Annual MDS, dated [DATE], indicated Resident #19 was a [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses of Heart Failure, Atrial Fibrillation , Cardiac Pacemaker, lack of coordination, and muscle weakness. His MDS reflected in Section L - Oral/Dental Status an 'x' in box 'Z. None of the above were present' when indicating if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. He had a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #19's care plan dated last revised 03/28/2025 revealed that his use of upper and lower dentures was not care planned. Record review of Resident #22's quarterly MDS assessment, dated 03/14/2025, indicated Resident #22 was an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of high blood pressure, Alzheimer's disease (memory loss, confusion, and difficulty problem-solving), anxiety (worriness), bipolar disorder (extreme mood disorder), psychotic disorder (abnormal thinking and perceptions), edema (swelling caused by trapped fluid), disease of the pancreas, neoplasm of the digestive organs, bladder, and colon (abnormal growth of tissues in these areas). Her MDS reflected in Section GG-Functional Abilities she was dependent on staff for help with oral hygiene. Her MDS reflected in Section L - Oral/Dental Status an 'X' in box 'B indicating No natural teeth or tooth fragments. She had a BIMS score of 05, indicating severe cognitive impairment. Record review of Resident #22's care plan dated last revised 03/28/2025 revealed that her use of upper and lower dentures was not care planned. Record review of Resident #24's comprehensive MDS assessment, dated 11/15/2024, indicated Resident #24 was an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of high blood pressure, high cholesterol, gastroesophageal reflux disease, Alzheimer's disease (memory loss, confusion, and difficulty problem-solving), anxiety, depression (extreme sadness), cataracts, and lack of coordination. Her MDS reflected in Section L - Oral/Dental Status an 'x' in box 'B. No natural teeth or tooth fragments'. She had a BIMS score of 08, indicating moderately impaired cognition. Record review of Resident #24's care plan dated last revised 04/21/2025 reflected no indication that the resident wore dentures or had no natural teeth. Review of Resident #28's quarterly MDS dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included muscle weakness, vitamin D deficiency, and hypertension (high blood pressure). She had a BIMS score of 12 indicating moderate cognitive impairment. Functional abilities for oral hygiene including the ability to insert and remove dentures into and from the mouth reflected independent Section L Dental reflected was not assessed to indicate if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. Review of Resident #28's care plan last revised 06/06/24 reflected Resident #28's care plan did not identify oral care related to denture use. Record review of Resident #31's Annual MDS, dated [DATE], indicated Resident #31 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of Malignant Neoplasm of the Brain (brain cancer), Anemia (low red blood cells, Muscle Weakness, and Urinary Retention. Her MDS reflected in Section L - Oral/Dental Status an 'X' in box 'B indicating No natural teeth or tooth fragments. She had a BIMS score of 12 indicating moderate cognitive impairment. Record review of Resident #31's care plan dated last revised 04/19/2025 reflected that her use of upper and lower dentures was not care planned. Record review of Resident #32's Annual MDS, dated [DATE], indicated Resident #32 was a [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses of Seizure Disorder, Depression, Cataracts (a cloudy opacity of the natural lens inside the eye), and Unspecified Intellectual Disabilities. His MDS reflected in Section L - Oral/Dental Status an 'x' in box 'Z. None of the above were present' when indicating if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. He had a BIMS score of 15 indicating cognition intact. Record review of Resident #32's care plan dated last revised 04/08/2025 reflected that his use of upper and lower dentures was not care planned. Record review of Resident #33's Annual MDS, dated [DATE], indicated Resident #33 was an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of Heart Failure, Cerebrovascular Accident (stroke), Depression, and Muscle Weakness. Her MDS reflected in Section L - Oral/Dental Status an 'X' in box 'B indicating No natural teeth or tooth fragments. She had a BIMS score of 06 indicating severe cognitive impairment. Record review of Resident #33's care plan dated last revised 03/28/2025 reflected that her use of upper and lower dentures was not care planned. Review of Resident #34's significant change MDS dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included age related cognitive decline, hypokalemia (abnormally low potassium concentration in the blood), vitamin D deficiency, and iron deficiency. She had a BIMS score of 14 indicating cognition intact. Functional abilities for oral hygiene including the ability to insert and remove dentures into and from the mouth reflected supervision or touching assistance Section L Dental reflected none of the above were present when indicating if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. Review of Resident #34's care plan last revised 04/30/25 reflected Resident #34's care plan did not identify oral care related to denture use. Record review of Resident #35's quarterly MDS dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of high blood pressure, multiple sclerosis, macular degeneration, pain in right shoulder, and depression. In Section 'N' - Medications, there was not an 'x' in the box next to Antianxiety 'Is taking' or 'Indication noted'. In section 'GG-Functional Abilities he required touching assistance with oral hygiene. He had a BIMS score of 15, indicating intact cognition. Record review of Resident #35's care plan dated last revised 03/13/2025 had no indication the resident was on an antianxiety medication or had a diagnosis of anxiety or agitation. His care plan also reflected no indication that the resident wore dentures. Record review of Resident #36's comprehensive MDS assessment, dated 04/02/2025, indicated Resident #36 was a [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses of paralysis or severe weakness on one side of the body following damage to the brain, dementia, heart failure, lack of coordination, muscle weakness, anxiety, bipolar disorder, and irregular heart rhythm. His MDS reflected in Section L - Oral/Dental Status an 'x' in box 'Z. None of the above were present' when indicating if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. He had a BIMS score of 03, indicating severe cognitive impairment. Record review of Resident #36's care plan dated last revised 03/27/2025 reflected no indication that the resident wore dentures or had no natural teeth. Record review of Resident #39's quarterly MDS assessment, dated 04/11/2025, indicated Resident #39 was an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of heart disease, heart failure, high blood pressure, high cholesterol, lung disease, abnormality of mobility, lack of coordination, and muscle weakness. Her MDS reflected in Section GG-Functional Abilities she required touching assistance from staff for oral hygiene. She had a BIMS score of 15 indicating intact cognition. Record review of Resident #39's care plan dated last revised 04/28/2025 reflected no indication that the resident wore dentures or partials. Record review of Resident #40's comprehensive MDS assessment, dated 07/19/2024, indicated Resident #40 was an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of high blood pressure, kidney disease, viral hepatitis, arthritis, non-Alzheimer's dementia, anxiety, bipolar disorder, depression (sadness), lack of coordination, muscle weakness, overactive bladder, and chronic pain. Her MDS reflected in Section L - Oral/Dental Status an 'x' in box 'Z. None of the above were present' when indicating if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. She had a BIMS score of 15, indicating intact cognition. Record review of Resident #40's progress note dated 4/2/2025 reflected a care plan meeting was held with Resident #40 regarding her broken bottom denture. It was noted that the team had concerns about her weight loss and refusal of meals until her denture was to be fixed. Record review of Resident #40's care plan dated last revised 04/25/2025 reflected no indication that the resident wore dentures. Review of Resident #41's quarterly MDS dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included muscle weakness, vitamin D deficiency, and hypertension (high blood pressure). Her BIMS score had not been assessed. Functional abilities for oral hygiene including the ability to insert and remove dentures into and from the mouth reflected substantial/maximal assistance Section L Dental reflected not assessed to indicate if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. Review of Resident #41's care plan last revised 04/04/25 reflected Resident #41's care plan did not identify oral care related to denture use. Record review of Resident #42's comprehensive MDS assessment, dated 01/03/2025, indicated Resident #42 was an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of anemia, atrial fibrillation, heart failure, high blood pressure, kidney disease, high cholesterol, thyroid disorder, Alzheimer's disease (memory loss, confusion, and difficulty problem-solving), stroke, anxiety, depression (sadness), and respiratory failure. Her MDS reflected in Section L - Oral/Dental Status an 'x' in box 'Z. None of the above were present' when indicating if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. She had a BIMS score of 13, indicating intact cognition. Record review of Resident #42's care plan dated last revised 04/28/2025 reflected no indication that the resident wore dentures. Record review of Resident #43's Annual MDS, dated [DATE], indicated Resident #43 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of Hypertension (elevated blood pressure), Gastroesophageal Reflux Disease (indigestion), Thyroid Disorder, and Muscle Weakness. Her MDS reflected in Section L - Oral/Dental Status an 'X' in box 'B indicating No natural teeth or tooth fragments. She had a BIMS score of 12 indicating moderate cognitive impairment. Record review of Resident #43's care plan dated last revised 04/25/2025 reflected no indication that the resident wore dentures. Review of Resident #44's quarterly MDS dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included hypertension (high blood pressure), vitamin D deficiency, and muscle weakness. She had a BIMS score of 15 indicating cognition intact. Functional abilities for oral hygiene including the ability to insert and remove dentures into and from the mouth reflected independent Section L Dental reflected not assessed to indicate if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. Review of Resident #44's care plan last revised 03/10/25 reflected Resident #44's care plan did not identify oral care related to denture use. Record review of Resident #45's Significant change in status MDS, dated [DATE], indicated Resident #45 was an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of Hypertension (elevated blood pressure), Gastroesophageal Reflux Disease (indigestion), Lack of Coordination, and Muscle Weakness. Her MDS reflected in Section L - Oral/Dental Status an 'X' in box 'B indicating No natural teeth or tooth fragments. Staff interview reflected she had short term and long-term memory problems. Record review of Resident #45's care plan dated last revised 04/11/2025 reflected no indication that the resident wore dentures. Record review of Resident #47's comprehensive MDS assessment, dated 02/14/2025, indicated Resident #47 was an [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses of coronary artery disease, high blood pressure, gastroesophageal reflux disease (digestive disorder), benign prostatic hyperplasia (noncancerous enlargement of the prostate gland), kidney failure, diabetes, high cholesterol, thyroid disorder, seizure disorder, muscle weakness, lack of coordination, and fibromyalgia (widespread body pain). His MDS reflected in Section L - Oral/Dental Status an 'x' in box 'Z. None of the above were present' when indicating if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. He had a BIMS score of 15, indicating intact cognition. Record review of Resident #47's care plan dated last revised 04/08/2025 reflected no indication that the resident wore dentures. Review of Resident #50's annual MDS dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included iron deficiency anemia (condition where the body does not have enough red blood cells and iron), hyperlipidemia (abnormally high levels of fats in the blood), and hypertension (high blood pressure). She had a BIMS score of 14 indicating cognition intact. Functional abilities for oral hygiene including the ability to insert and remove dentures into and from the mouth reflected setup of cleanup assistance Section L Dental reflected none of the above were present when indicating if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. Review of Resident #50's care plan last revised 03/17/25 reflected Resident #50's care plan did not identify oral care related to denture use. Review of Resident #51's annual MDS dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included muscle weakness, secondary hypertension (high blood pressure), and vitamin B12 deficiency. She had a BIMS score of 09 indicating moderate cognitive impairment. Functional abilities for oral hygiene including the ability to insert and remove dentures into and from the mouth reflected substantial/maximal assistance Section L Dental reflected none of the above were present when indicating if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. Review of Resident #51's care plan last revised 06/28/24 reflected Resident #51's care plan did not identify oral care related to denture use. Review of Resident #53's quarterly MDS dated 04.04/25 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included iron deficiency anemia (condition where the body does not have enough red blood cells and iron), vitamin D deficiency, and iron deficiency. She had a BIMS score of 13 indicating cognition intact. Functional abilities for oral hygiene including the ability to insert and remove dentures into and from the mouth reflected partial/moderate assistance Section L Dental reflected was not assessed to indicate if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. Review of Resident #53's care plan last revised 01/02/25 reflected Resident #53's care plan did not identify oral care related to denture use. Review of Resident #55's face sheet dated 04/30/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included cerebral aneurysm (bulge or ballooning in a blood vessel in the brain), vitamin D deficiency, depression (mental health condition causing persistent feeling of sadness and loss of interest and can interfere with daily life), hyperlipidemia (excess lipids or fats in the blood), anemia (not having enough red blood cells or when your red blood cells to not function properly), and essential (primary) hypertension (high blood pressure). Review of Resident #55's annual MDS assessment dated [DATE] reflected a BIMS score of 15 indicating cognition intact. Section GG for functional abilities reflected oral hygiene; the ability to use suitable items to clean teeth. Dentures (if applicable); the ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with the use of equipment indicated supervision or touching assistance. Eating reflected setup or cleanup assistance. MDS assessment indicated Resident #55 was currently on a mechanically altered diet. Section L dental indicated no natural teeth or tooth fragments. Review of Resident 55's care plan last revised 03/17/25 reflected, Resident #55 is at risk for weight loss related to CVA. She is on a mechanical soft diet per her request due to her having no teeth. She had a vitamin D deficiency. Interventions included, administer vitamins as ordered by physician, allow ample time to ingest meal, health shakes three times daily (initiated 06/20/23), monitor labs, monitor monthly weights, RD/dietary to assess dietary needs, and take in consideration residents likes and dislikes. The care plan did not indicate Resident #55's use of dentures. Review of Resident #55's physician orders reflected an order with a start date of 06/16/23 for health shakes three times a day between meals. Review of Resident #55's labs dated 09/06/24 reflected a low albumin level that was flagged at 3.2 mg/dL indicating low protein. Review of Resident #55's labs dated 12/06/24 reflected a low albumin level that was flagged at 3.3 mg/dL indicating low protein. Review of Resident #55's labs dated 03/13/25 reflected a low albumin level that was flagged at 3.2 mg/dL indicating low protein. Review of Resident #55's weights reflected: 04/05/24 154.3 LBS 05/10/24 150.0 LBS 06/07/24 151.0 LBS 07/05/24 151.5 LBS 08/09/24 154.2 LBS 09/06/24 146.5 LBS 09/20/24 146.9 LBS 10/04/24 142.7 LBS 11/15/24 141.8 LBS System warning reflected, -7.5% change [Comparison Weight 08/09/24, 154.2 lbs., - 8.0%, -12.4 lbs.] 12/06/24 140.1 LBS 12/16/24 140.1 LBS 01/10/25 139.3 LBS 02/06/25 139.8 LBS 03/06/25 135.3 LBS 04/04/25 130.4 LBS 04/15/25 130.4 LBS On 03/06/25, Resident #55 weighed 135.3 lbs. On 04/04/25, the resident weighed 130.4 pounds which was a -3.62 % Loss in the last month. On 10/04/24, Resident #55 weighed 142.7 lbs. On 04/04/25, the resident weighed 130.4 pounds which was a -8.62 % Loss in the last 6 months. Review of Resident #55's progress notes reflected there were no notes indicating the system generated warning for 11/15/24 was addressed related to significant weight loss. Review of the facility's weights and dietary consultants binder reflected consultant dietician reports for 11/12/24 and 11/19/24, and weight meetings dated 11/07/24, 11/15/24, 11/22/24 which did not reflect that Resident #55's weight loss or system generated alert 11/15/24 for weight loss was addressed. Review of Resident #55's progress notes revealed the most recent quarterly nutritional review note dated 03/11/25 by RDN identified the weight trended down in the quarter and stated, 12/19 diet upgraded to mech soft with thin liquids, health shakes three times a day between meals; snacks as needed and at bedtime. Intake range 50-100. No new nutrition related labs available. Continue with current plan of care. DM will honor food preferences. Goals: abnormal lab correction, weight to stabilize, maintain skin integrity, tolerance of diet. Review of Resident #55's laminated reusable daily meal ticket provided by DM I reflected: - Mechanical soft diet - Breakfast: scrambled eggs, gravy, chocolate shake, coke - Lunch: Chicken noodle soup, tea, coke - Dinner: chicken noodle soup, tea, coke Meal ticket did not identify likes/dislikes, allergies, portion sizes, or any other additional information. Review of Resident #55's Dental notes reflected delivery of the dentures occurred on 07/30/24 after adjustments, with a follow up 11/05/24 for evaluation of mouth for lesions, red spots, and sensitive area. Adjustments made. In an interview and observation on 04/29/25 at 12:00 PM with Resident #55, while eating her lunch in the dining room which was observed to consist of chicken noodle soup, Resident #55 was observed pulling some of the noodles out of her mouth. She stated the food was good but that it was all she could eat because she didn't have any teeth. An observation of Resident #55's mouth revealed no teeth and no dentures in place. Resident #55 stated she had dentures, but that the staff did not assist with putting them on. She stated she would like to be able to eat a variety of food and expressed frustration, but stated she cannot because she doesn't have teeth. In an interview and observation on 04/29/25 at 03:07 PM with Resident #55 in her room, she was observed pointing to her dentures in a case located on a shelf near her nightstand. She once again stated she did not wear them because staff have not assisted her to use them. She again expressed frustration and stated she would like to try other food items but can't with no teeth. She stated she believed she needed to put glue on them to make them stick but simply did not know how to put them on. She stated she asked staff for assistance when she first got them, but after not getting any help she simply stopped asking. She stated if she was still hungry after her soup, she would return to her room to eat her snacks which was either chocolate or cookie cakes from a specific brand that are soft and manageable for her to break down with her gums. In an interview and observation on 04/30/25 at 05:10 PM with Resident #55 in the dining room for dinner, she was observed eating chicken noodle soup. She stated she was not wearing her dentures because nobody assisted her with them and she did not wear them for lunch that day either. She stated she was eating chicken soup once again which was not so difficult to eat. But she stated she wanted more of a variety. In an interview on 04/30/25 at 05:14 PM with CNA E working on Resident #55's hall. She stated she frequently worked with Resident #55, and that to her knowledge, she was not aware of the resident having dentures. CNA E stated she believed that Resident #55 had her own teeth. She stated that CNAs do assist the residents if they have dentures and that they are responsible for assisting the residents to put them on, take them off, brush them and add the cleaning tablets. She stated a negative outcome of a resident not getting assistance with dentures would be the resident would not be able to eat their food which could lead to weight loss. When asked how she would identify if a resident wore dentures, CNA E stated she would just ask. CNA E stated she did not look at the charts or anywhere else to identify if a resident required help with dentures. In an interview on 04/30/25 at 05:30 PM with LVN B, she stated she was the nurse for Resident #55's hall and had worked with her frequently. She stated she was aware that Resident #55 had dentures, but she has never seen the resident wear them and just assumed she did not like wearing them. She stated staff would assist residents, that have dentures, to put them on and take them off. She stated that Resident #55 required supervision and touch assistance with oral care which means she would have needed assistance with her dentures. She stated the CNA's have the primary responsibility to be the ones to assist the residents who wear dentures. She stated if a resident uses dentures, that should also be in the care plan with is updated by the MDS Coordinator. She stated a potential negative outcome of not assisting a resident with dentures would be significant weight loss. LVN B stated CNAs will get a sheet at the beginning of their shift that would tell them what the resident requires assistance with. In an interview on 05/01/25 at 09:36 AM with the MDSC revealed she had been working for the facility for 7 years. She stated that she was responsible for creating and updating most items on the care plans and that in the past they had not put dentures on the care plan, and she was not sure why they did not include them. She stated that if a resident admits with their natural teeth, then gets dentures later the social worker would be responsible for updating the care plan. She stated that it was important to include on the care plan because the CNAs are the ones who help residents take care of the dentures and insert and remove the dentures. She stated that a negative outcome of denture not being care planned is that a residents' nutrition could be hindered if the resident ha issues with their denture, as well as their self-worth. In an interview on 05/01/25 at 09:56 PM with DM I, she stated Resident #55 eats the same thing every day, she stated for breakfast she will have scrambled eggs and a shake and will have chicken noodle soup for both lunch and dinner. She stated it was her responsibility to update food preferences but had not because she believed Resident #55 enjoyed the chicken noodle soup and her family would even bring it to her. DM I stated she was not aware of Resident #55 having dentures or needing them. She stated using the dentures would allow her to have more of a variety of food options. She stated they have tried pureed meals with Resident #55, but she did not like them and is currently on a grounded-up texture. In an interview and observation on 05/01/25 at 10:11 AM with CNA F, she stated it was the responsibility of the CNAs to assist residents with their dentures which included putting them on, taking them off, and helping to clean [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain acceptable parameters of nutritional status in such as usual body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicate otherwise for 1 of 4 (Resident #55) residents reviewed for weight loss. 1. The facility failed to recognize, evaluate, and address the nutritional needs of Resident #55 despite a system generated warning on 11/15/24 for -7.5% change (comparison weight 08/09/24, 154.2 lbs, -8.0%, 12.4 lbs) and lab results on 09/05/24, 12/06/24, and 03/13/25 which reflected low albumin levels indicating low protein resulting in a 4.9 lbs (-3.62 %) loss in a month, a 12.3 lbs (-8.62 %) loss in 6 months, and 23.9 lbs (-15.49 %) loss in the last year 04/05/24 through 04/15/25. 2. The facility failed to provide assistance to Resident #55 in the use of her dentures and consider her food preferences resulting in the continuation of impaired nutritional status. This failure places residents at risk for impaired nutritional status, not having their needs or preferences considered, and decreased quality of life. Finding included: Review of Resident #55's face sheet dated 04/30/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included cerebral aneurysm (bulge or ballooning in a blood vessel in the brain), vitamin D deficiency, depression (mental health condition causing persistent feeling of sadness and loss of interest and can interfere with daily life), hyperlipidemia (excess lipids or fats in the blood), anemia (when you do not have enough red blood cells or when your red blood cells to not function properly), and essential (primary) hypertension (high blood pressure). Review of Resident #55's annual MDS assessment dated [DATE] reflected a BIMS score of 15 indicating cognition intact. Section GG for functional abilities reflected oral hygiene; the ability to use suitable items to clean teeth. Dentures (if applicable); the ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with the use of equipment indicated supervision or touching assistance. Eating reflected setup or cleanup assistance. MDS assessment indicated Resident #55 was currently on a mechanically altered diet. Section L dental indicated no natural teeth or tooth fragments. Review of Resident 55's care plan last revised 03/17/25 reflected, Resident #55 is at risk for weight loss related to CVA. She is on a mechanical soft diet per her request due to her having no teeth. She has a vitamin D deficiency. Interventions included, administer vitamins as ordered by physician, allow ample time to ingest meal, health shakes three times daily (initiated 06/20/23), monitor labs, monitor monthly weights, RD/dietary to assess dietary needs, and take in consideration residents likes and dislikes. The care plan did not indicate Resident #55's use of dentures. Review of Resident #55's physician orders reflected an order with a start date of 06/16/23 for health shakes three times a day between meals. Review of Resident #55's labs dated 09/06/24 reflected a low albumin level that was flagged at 3.2 mg/dL indicating low protein. Review of Resident #55's labs dated 12/06/24 reflected a low albumin level that was flagged at 3.3 mg/dL indicating low protein. Review of Resident #55's labs dated 03/13/25 reflected a low albumin level that was flagged at 3.2 mg/dL indicating low protein. Review of Resident #55's weights reflected: 04/05/24 154.3 LBS 05/10/24 150.0 LBS 06/07/24 151.0 LBS 07/05/24 151.5 LBS 08/09/24 154.2 LBS 09/06/24 146.5 LBS 09/20/24 146.9 LBS 10/04/24 142.7 LBS 11/15/24 141.8 LBS System warning reflected, -7.5% change [Comparison Weight 08/09/24, 154.2 lbs., - 8.0%, -12.4 lbs.] 12/06/24 140.1 LBS 12/16/24 140.1 LBS 01/10/25 139.3 LBS 02/06/25 139.8 LBS 03/06/25 135.3 LBS 04/04/25 130.4 LBS 04/15/25 130.4 LBS On 03/06/25, Resident #55 weighed 135.3 lbs. On 04/04/25, the resident weighed 130.4 pounds which was a -3.62 % Loss in the last month. On 10/04/24, Resident #55 weighed 142.7 lbs. On 04/04/25, the resident weighed 130.4 pounds which was a -8.62 % Loss in the last 6 months. Review of Resident #55's progress notes reflected there were no notes indicating the system generated warning for 11/15/24 was addressed related to significant weight loss. Review of the facility weights and dietary consultants binder reflected consultant dietician reports for 11/12/24 and 11/19/24 and weight meetings dated 11/07/24, 11/15/24, 11/22/24 which did not reflect that Resident #55's weight loss or system generated alert 11/15/24 for weight loss was addressed. Review of Resident #55's progress notes revealed the most recent quarterly nutritional review note dated 03/11/25 by RDN identified the weight trend down in the quarter and stated, 12/19 diet upgraded to mech soft with thin liquids, health shakes three times a day between meals; snacks as needed and at bedtime. Intake range 50-100. No new nutrition related labs available. Continue with current plan of care. DM will honor food preferences. Goals: abnormal lab correction, weight to stabilize, maintain skin integrity, tolerance of diet. Review of Resident #55's laminated reusable daily meal ticket provided by DM I reflected: 3. Mechanical soft diet 4. Breakfast: scrambled eggs, gravy, chocolate shake, coke 5. Lunch: Chicken noodle soup, tea, coke 6. Dinner: chicken noodle soup, tea, coke Meal ticket did not identify likes/dislikes, allergies, portion sizes, or any other additional information. Review of Resident #55's Dental notes reflected delivery of the dentures occurred on 07/30/24 after adjustments, with a follow up 11/05/24 for evaluation of mouth for lesions, red spots, and sensitive area. Adjustments made. In an interview and observation on 04/29/25 at 12:00 PM with Resident #55, revealed while eating her lunch in the dining room which was observed to consist of chicken noodle soup, Resident #55 was observed pulling some of the noodles out of her mouth. She stated the food was good but that it was all she could eat because she didn't have any teeth. An observation of Resident #55's mouth revealed no teeth and no dentures in place. Resident #55 stated she does have dentures but that she staff did not assist with putting them on. She stated she would like to be able to eat a variety of food and expressed frustration but stated she cannot because she doesn't have teeth. In an interview and observation on 04/29/25 at 03:07 PM with Resident #55 in her room, she was observed pointing to her dentures in a case located on a shelf near her nightstand. She once again stated she did not wear them because staff have not assisted her to use them. She expressed once again frustration and stated she would like to try other food items but can't with no teeth. She stated she believed she needed to put glue on them to make them stick but simply did not know how to put them on. She stated she asked staff for assistance when she first got them, but after not getting any help, she simply stopped asking. She stated if she was still hungry after her soup, she would return to her room to eat her snacks which was either chocolate or cookie cakes from a specific brand that are soft and manageable for her to break down with her gums. In an interview and observation on 04/30/25 at 05:10 PM with Resident #55 in the dining room for dinner, she was observed eating chicken noodle soup. She stated she was not wearing her dentures because nobody assisted her with them and stated she did not wear them for lunch that day either. She stated she was eating chicken soup once again which was not so difficult to eat. But she did say she wanted more of a variety. In an interview on 04/30/25 at 05:14 PM with CNA E working on Resident #55's hall. She stated she frequently worked with Resident #55 and that to her knowledge she was not aware of the resident having dentures. CNA E stated she believed that Resident #55 had her own teeth. She stated that CNA's do assist the residents if they have dentures and that they are responsible for assisting the residents to put them on, take them off, brush them and add the cleaning tablets. She stated a negative outcome of a resident not getting assistance with dentures would be the resident would not be able to eat their food which could lead to weight loss. When asked how she would identify if a resident wore dentures, CNA E stated she would just ask. CNA E stated she did not look at the charts or anywhere else to identify if a resident required help with dentures. In an interview on 04/30/25 at 05:30 PM with LVN B, she stated she was the nurse for Resident #55's hall and has worked with her frequently. She stated she was aware that Resident #55 had dentures, but she has never seen the resident wear them and just assumed she did not like wearing them. She stated that staff would assist residents that have dentures to put them on and take them off. She stated that Resident #55 required supervision and touch assistance with oral care which means she would have needed assistance with her dentures. She stated the CNA's have the primary responsibility to be the ones to assist the residents who wear dentures. She stated if a resident uses dentures, that should also be located in the care plan with is updated by the MDS Coordinator. She stated a potential negative outcome of not assisting a resident with dentures would be significant weight loss. LVN B stated CNAs will get a sheet at the beginning of their shift that would tell them what the resident requires assistance with. In an interview on 05/01/25 at 09:56 PM with DM I, she stated Resident #55 eats the same thing every day, she stated for breakfast she will have scrambled eggs and a shake and will have chicken noodle soup for both lunch and dinner. She stated it was her responsibility to update food preferences but has not because she believed Resident #55 enjoyed the chicken noodle soup and her family would even bring it to her. DM I stated she was not aware of Resident #55 having dentures or needing them. She stated using the dentures would allow her to have more of a variety of food options. She stated they have tried pureed meals with Resident #55 but she did not like them and is currently on a grounded up texture. In an interview and observation on 05/01/25 at 10:11 AM with CNA F she stated it was the responsibility of the CNA's to assist residents with their dentures which included putting them on, taking them off and helping to clean them. CNA F stated she was not sure if dentures were listed anywhere on a resident's record, but if they were verbal, she would ask if they wore dentures. She stated that at the beginning of their shift, CNA's are given a sheet which tells them a residents transfer requirements (x1 or x 2 assist etc.) she stated prior to today it did not include dentures or assistive devices listed. In an observation of the sheet CNA F was provided at the beginning of her shift for the day, it reflected the residents' names, their transfer requirements, and a section for dentures that was highlighted. CNA F stated she was not aware that Resident #55 had dentures and assumed she did not have them because she never saw them. CNA F stated a negative outcome of not assisting a resident with dentures would be the resident would not be able to chew their food which could lead to weight loss. In an interview on 05/01/25 at 10:23 AM with RDN she stated Resident #55's weight has had a downward trend but stated she did not have any notes or could say what she attributed the weight loss to. She stated after reviewing the residents' chart she saw that Resident #55's fluid intake was good, she was not on hospice, and not on Lasix, but did not see any notes related to her weight loss. RDN stated she believed Resident #55 weight loss may have been a matter of her being more active. RDN stated it was the responsibility of the DM to update any food preferences for resident meals. RDN stated she was not aware of Resident #55 wearing dentures and after reviewing her chart she could not find information on Resident #55 having dentures. She stated that if a resident had dentures and did not get assistance wearing them that it could contribute to weight loss. RDN stated she would need to in-service staff at the facility to ensure that care staff are taking care of residents who need assistance with dentures, updating food preferences, and monitoring for changes. She stated sometimes residents will say they are ok but really have concerns that need to be addressed. RDN stated she did not participate in weight meetings but does her own monitoring of weights and will also get notification from the facility of they have concerns. In an interview on 05/01/25 at 10:35 AM with Resident #55's family, she stated Resident #55 has not had teeth since her admission into the facility. She stated the reason she wanted dentures was to be able to eat a variety of food which is what initially prompted the dental consult in 2024 to get them. Resident #55's family stated that they have tried to put the resident on a puree diet to give her more of a variety but that the resident did not like that. She stated Resident #55 has told her she wants her dentures to fit so she can eat different foods. In an interview on 05/01/25 at 10:44 AM with the DON, she stated it was the responsibility of the CNAs to assist residents with their dentures to put them on and take them off or clean them, but that nurses could also assist. She stated she believed that dentures were marked on the sheets CNAs get to assist them with care but was not aware it did not indicate denture use prior to today. She stated, a lot of the residents and staff have been here so long they usually know who has them and will just ask any of the new residents if they have dentures. DON stated a negative outcome of not getting assistance with dentures would be the inability to chew food which could result in weight loss. She also stated if the resident didn't wear their dentures for an extended period of time it would result in them no longer fitting. The DON stated she has never seen Resident #55 with dentures and was not aware she had any. She stated it was the responsibility of the MDS coordinator to update the care plans with dentures and her expectation that they are accurate and that residents get the help with dentures if they need it. She stated a negative outcome of dentures not being in the care plan staff would not have the accurate information to care for the resident. In a follow up interview on 05/01/25 at 02:47 PM with the RDN she stated the overall weight the resident has lost can be seen as significant. She stated she has asked the facility to get a dental consult to get Resident #55's dentures refitted since they need readjustments after not being worn for so long. RDN stated she is at the facility 2x a month and not usually there for weight meetings. She stated she will contact the facility if she has questions and will pull monthly weights to review and discuss with the DON. She stated if the facility has concerns, they would contact her as well. When asked what interventions were in place concerning Resident #55's weight loss, she stated that they have been doing protein health shakes but was unsure when they started. She stated Resident #55 was also allowed snacks PRN and HS. In a follow up interview on 05/02/25 at 12:25 PM with DON, she stated monthly weights are monitored to determine if a resident is having significant weight loss. She stated if significant weight loss was occurring the resident should have been placed on daily or weekly weights and started on protein shakes. She stated more frequent weights are used to monitor if the protein health shakes are working to help with the weight loss. She stated other interventions could also include appetite stimulants. She stated labs are also considered to help determine nutritional status. She stated weekly weights are then documented in the weight binder. She stated if a resident is identified as having weight loss it was also her expectation that the weight trend downward was documented in the care plan with interventions. In an interview on 05/02/25 at 12:37 PM with the ADM she stated weight loss should be reflected in the care plan if it is significant and continues to decline. She stated she would expect that the interventions used should be updated if health shakes or anything else put in place was not working. The ADM stated that even if a resident is within normal weight ranges, weight should be addressed so that they do not go underweight. She stated it was her expectation that a resident's care plan is updated as needed because people's needs change. She stated, it should reflect care from head to toe and said she expects it to include dentures and assistive devices, in addition to the weight loss interventions. She stated a negative outcome of the care plan not being updated is residents would not get the care they need, and we are required to give them what they need. The ADM stated the items identified with Resident #55 did not meet her expectations and upset her. She stated weight loss should have been monitored, and that if the resident had asked for help with her dentures staff should have assisted. She stated knowing Resident #55, she would have asked for help and after not receiving it would not have felt worthy or deserving of assistance and stopped asking. Review of the facility Weight assessment and Intervention policy last revised on March 2022 reflected: Policy statement: Resident weights are monitored for undesirable or unintended weight loss or gain. 1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes: a. the resident's target weight range (including rationale if different from ideal body weight); b. the resident's calorie, protein, and other nutrient needs compared with the resident's current intake; c. the relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. whether and to what extent weight stabilization or improvement can be anticipated. Care Planning 1. Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. the identified causes of weight loss; b. goals and benchmarks for improvement; and c. time frames and parameters for monitoring and reassessment. Interventions 1. Interventions for undesirable weight loss are based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating; d. Environmental factors that may inhibit appetite or desire to participate in meals; e. Chewing and swallowing abnormalities and the need for diet modifications; f. Medications that may interfere with appetite, chewing, swallowing, or digestion; g. The use of supplementation and/or feeding tubes; and h. End of life decisions and advance directives. 2. Interventions for undesired weight gain consider resident preferences and rights. A weight loss regimen will not be initiated for a cognitively capable resident without his/her approval and involvement. 3. If a resident declines to participate in a weight loss goal, the dietitian will document the resident's wishes, and those wishes will be respected. Review of the undated facility Provision of Quality Care policy reflected: Policy: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. 5. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 6. A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan. 7. Responsibility for interventions on the care plan will be clearly identified. 8. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. Review of the undated Care of Dentures facility policy reflected: Policy: It is the practice of this facility to provide denture care to residents in order to avoid gingival infection and irritation as per current standards of practice. 5. Determine which nursing staff member will provide denture care. It is usually the nurse aide assigned to the resident. 6. Ask the resident if they have a preference for denture care and products used. If resident is unable to care for their own dentures, dentures will be cleaned for them during routine oral care. 7. Ask the resident if the dentures feel as though they fit, and if there is any tenderness of the gums or mouth. 8. If resident is unable to remove dentures independently, perform hand hygiene and apply gloves. To remove upper denture, grasp at the front with thumb and index finger and pull downward. To remove lower denture, gently lift it from the jaw, and rotate one side downward. Place dentures in emesis basin or sink. Review of the undated Comprehensive Care Plan facility policy reflected: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. 7. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. 8. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.