**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to address unplanned significant weight loss; and ensured a comprehensive nutritional assessment was completed upon admission to maintain acceptable parameters of nutritional status for two of seven residents reviewed for nutrition (Resident (R) 83 and R13). This failure had the potential to affect other residents to not receive timely nutritional interventions. Findings include: 1. Review of R83's undated Face Sheet, located in the resident's Electronic Medical Record (EMR), indicated R83 was admitted to the facility on [DATE] with diagnoses which included type two diabetes mellitus (DM2), anemia, and fracture of right pubis. Review of R83's hospital Discharge Summary, dated 03/10/21 located in the hard copy of the medical record, indicated R83 had a right pelvic fracture, was to receive conservative treatment for the fracture, and had a weight of 135 pounds. Review of R83's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/17/21, located in the resident's EMR under the MDS tab, indicated R83 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident had severe cognitive impairment. Continued review of R83's MDS revealed the resident required supervision with set up for eating, had no oral or dental issues, and no weight loss. Review of R83's Comprehensive Care Plan, located in the resident's EMR under the care plan tab, revealed the resident had a Nutrition Care Plan related to potential for risk for altered nutritional status and/or weight loss related to DM2. The Care Plan initiated on 03/11/21 documented: dietary consult with Registered Dietician (RD) as indicated to assess nutritional plan, monitor weights, report significant changes in weight to physician and RD as indicated, and document refusal or percentage consumed. Review of R83's weight located in the EMR under the Vital Signs/Weight tab revealed on 03/15/21, the resident weighed 141.4 pounds. Review of the Monthly Charting Flow Sheet, dated 03/11/21 to 03/18/21, located in the resident's EMR under the CNA Documentation tab, documented R83 consumed 76% to 100% for five meals, 51% to 75% for eight meals, and 26% to 50% for four meals. Continued review revealed there was no documentation for four meals. Review of R83's Comprehensive Nutritional Care Area Assessment, dated 03/18/21, located in the resident's EMR under the Dietician tab, documented R83 had a score of 4 that did not indicate a nutritional issue. Continued review of the Nutritional Assessment revealed no documented evidence under the dietary risk items that R83 sometimes ate less than 75%. Review of the Registered Dietician's Note, dated 03/18/21, located under the Interdisciplinary note tab of the EMR documented R83 was 61 inches tall, 141.4 pounds, and was overweight. The RD note stated R83 received a heart healthy diet and consumed 76 % of her meals on average since admission. The RD note indicated the nursing staff stated her appetite is fair, and she is able to self-feed successfully. Review of R83's weight located in the EMR under the Vital Signs/Weight tab dated 03/22/21, indicated the resident weighed 131.4 pounds, which was a 7.07 % weight loss. On 04/01/21 at 6:30 PM the Assistant Director of Nurses (ADON) and the Surveyor reviewed R83's meal percentages dated 03/11/21 to 03/18/21. The ADON stated the meal percentage record was the only place where meal percentages were documented. The ADON stated there was no way of knowing how much R83 consumed on the days where no meal percentage was recorded. The ADON stated if there was a plus or minus of five pound in a resident's weight, the nurse directed the staff member to obtain another weight the same day. The ADON stated if the reweigh variance was valid, a referral was made to the RD, who would make recommendations. The ADON stated she could not recall if she asked the Restorative Certified Nurse Assistant (RCNA) to obtain a reweigh on R83. The ADON stated no reweigh was obtained on R83 and no referral to the RD was initiated. Review of the Monthly Charting Flow Sheet, dated 03/19/21 to 03/26/21, located in the resident's EMR under the CNA documentation tab, documented R83 consumed 76% to 100% for nine meals, 51% to 75% for two meals, and 26% to 50% for nine meals. Continued review revealed there was no documentation for four meals. Review of the Monthly charting Flow Sheet dated 03/27/21 to 03/31/21, located in the resident's EMR under the CNA documentation tab, documented R83 consumed 51% to 75% for four meals, 26% to 50% for two meals, and there was no documentation for nine meals. There were no days R83 consumed 76% to 100 % of her meals. On 04/01/21 at 6:30 PM the ADON stated she was not able to determine how much food R83 consumed on the days where no meal percentage was documented. On 03/31/21, the Surveyor asked the ADON to obtain a weight on R83. The weight dated 03/31/21 was 125.6 pounds, which was a 11.17% weight loss in 16 days. On 04/01/21 at 11:45 AM Licensed Practical Nurse (LPN) 91, stated RCNA126 usually obtained the weights on residents; however, sometimes the CNAs obtained the weights. LPN91 stated after obtaining the resident's weight, RCNA126 or the CNA would enter the weight into the computer. LPN91 stated if the resident's weight were a plus or minus of five pounds or more from the last weight, the RCNA or the CNA would obtain another weight and a nurse would verify the weight. LPN91 stated if the variance was verified, she reported the weight loss or weight gain to the ADON, who reported the issue to the RD. On 04/01/21 at 11:54 AM LPN61 stated the RCNA usually obtained weights on residents and reports a variance of plus or minus 5 pounds to her. LPN61 stated the resident is then reweighed and she verifies the weight. LPN61 stated if the weight variance is verified, she reports the weight issue to the ADON. LPN61 stated R83 ate independently, had no coughing or issues with eating and she was not aware of any weight loss issues until 03/31/21. On 04/01/21 at 11:50 AM RCNA126 stated she usually obtained the weights on residents, unless she had a resident assignment. RCNA126 stated after obtaining a resident's weight, she entered the resident's weight into the computer. RCNA126 stated if the resident's weight was a plus or minus of five pounds, she reweighed the resident and have the nurse verify the reweigh. Interview on 04/01/21 at 11:40 AM with CNA44 revealed when she weighed a resident, she entered the resident's weight into the computer. CNA44 stated if there was a difference of a plus or minus of 10 pounds, she reweighed the resident, entered the weight into the computer and then notified the ADON that there was a significant weight change. Interview on 04/01/21 at 12:01 PM with CNA20 revealed the RCNA usually was the one who weighed the residents. CNA20 stated if the RCNA was assigned an assignment, the CNA was responsible for obtaining the weight. CNA20 stated she reports the weight to the nurse and if a reweigh was needed, she reweighed the resident. CNA20 also stated she does not have the nurse verify the weight if a resident was reweighted. Continued interview on 04/01/21 at 6:30 PM, the ADON stated there were computer issues on 03/29/21 and 03/30/21 and the Charting/Flow Sheets were printed out for each resident for the staff to manually document each residents' meal percentages. The ADON and the Surveyor reviewed the meal percentages for both days and although other information regarding R83 was documented, there was no meal percentages documented for the breakfast and lunch meals. The ADON stated the physician and family member were not notified regarding R83's weight loss and additional interventions were not initiated until 03/31/21. The ADON stated R83 had significant weight loss and the facility did not follow their policy. Review of the Monthly Charting Flow Sheet, dated 04/01/21, documented R83 consumed 51% to 75% for breakfast and 0 to 25 % for lunch. On 04/01/21 at 9:58 AM, the Registered Dietitian (RD) stated although she had not observed R83 eating a meal, the staff reported R83 had a good appetite and reported no eating concerns. The RD stated she based meal consumption of a resident on talking with the resident and staff and meal percentage documentation. The RD stated she was not aware of the missing meal percentages on the Monthly Charting Flow sheet. The RD also stated a resident who did not consume at least 75% of meals would be noted on the Comprehensive Nutritional Care Assessment, which could increase a resident's risk for nutritional issues. The RD stated although R83 had a shocking unexplained significant weight loss, she was not below her ideal body weight. The RD stated interventions for R83's weight loss were not initiated until the reweigh was obtained on 03/31/21. Review of the facility's policy titled, Weight Management dated March 2021, documented .a reweigh will be obtained for any weight change of plus or minus five pounds from the previous weight unless other parameters have been ordered by the physician. All reweighs will be obtained immediately. The reweigh process will be visualized by a licensed nurse. The physician and the resident or resident representative will be notified by the resident's nurse of any significant unexpected and or unplanned weight changes . 2. R13. Review of the Minimum Data Set (MDS) with an ARD date of 01/11/21 revealed the resident was holding food in her mouth and coughing or choking while eating; no height and weight was obtained. Review of the Care Plan dated 01/05/21 revealed the resident had a potential risk for altered nutritional status and/or weight loss related to Parkinson's disease with a goal to consume 50% of her meals and plans dated 01/05/21 for a dietary consult with RD as indicated to assess nutritional status and monitor weights as indicated; report significant changes in weight to MD, RD as indicated. Review of physician's orders dated 01/10/21 revealed the resident had mechanical soft heart healthy diet, with thin liquids ordered and on 02/15/21 a regular diet with thin liquids. Review of the Comprehensive Nutritional Care Area Assessment dated 01/12/21 revealed the resident had diagnoses of Parkinson's, dementia, depression/anxiety, and hypothyroidism, noted the resident had no recent labs, and no weights recorded d/t [due to] COVID precautions and resident confusion .Weight and height is unknown due to not coming from a hospital, COVID precautions and resident confusion. The form documented the resident was on a Heart Healthy, mechanical soft diet and was eating an average of 49% of her meals and noted swallowing difficulties were noted by the speech language pathologist. R13's Nutritional Assessment was not person-centered and incomplete and omitted information regarding the resident's caloric needs and nutritional requirements based on height weight, lab values and accepted nutritional parameters. In addition, there were no further Nutritional Assessments in the resident Electronic Medical Record (EMR0 or chart located in the nurse's station. Review of the resident's weights revealed on 01/15/21 the resident weighed 123.1 pounds (lbs.), on 01/19/21 the resident weighed 119.00 lbs, on 02/02/21 the resident weighed 119.4 lbs, and on 03/03/21 the resident weighed 115.4 lbs that represented a 6.18% weight loss since admission. During an interview on 04/01/21 at 10:17 AM, the Registered dietician (RD) acknowledged that the Comprehensive Nutritional Assessment requires completion by the resident's admission ARD date and this was not accomplished for this resident. The RD stated the facility did not have an admission height and weight because the resident was a direct admission from the Assisted Living Facility (ALF) on campus. The RD sated that the facility was in full lockdown because of COVID precautions and the resident's weight was obtained as soon as possible; she provided no explanation for not completing the nutritional assessment. Review of the facility policy titled Nutritional Assessment developed 01/07 and revised on 04/01/21 directs that a complete and comprehensive nutritional assessment is conducted for each Health Care resident and that a plan of care is implemented to address any impairment or alterations in that person's nutritional status. The Registered Dietitian conducts this evaluation with assistance and input from dietary personnel.