**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 49> Resident 49 admitted to the facility on [DATE] with the following bowel care orders: a) Milk of Magnesia, if no bowel movement for three days, administer on day four. b) If no result from Milk of Magnesia, then Bisacodyl suppository on the next shift during waking hours c) If no result from suppository, then an Enema on the next shift, during waking hours If after the enema there was no bowel movement, then the facility was to notify the provider. The February 2025 bowel record showed Resident 49 had no bowel movement from 02/16/2025 - 02/19/2025 (four days). Review of the February 2025 MAR showed Resident 49 was not administered Milk of Magnesia on the fourth day without a bowel movement as ordered. On 03/18/2025 at 8:33 AM, Staff B, DNS, said the nurse should have administered Resident 49's Milk of Magnesia on 02/19/2025 as ordered, but failed to do so. Reference WAC 388-97-1060 (1) Based on interview and record review, the facility failed to ensure physician ordered laboratory values were obtained for 1 of 3 residents (Resident 14) who was declining, found unresponsive and had to be hospitalized , and failed to ensure the bowel protocol was followed for 2 of 7 residents (Residents 13 & 49) reviewed for bowel protocol. Resident 14 experienced actual harm when the facility failed to follow physician orders, failed to provide adequate hydration and failed to consistently monitor and document resident's change in condition and the resident developed altered mental status and sepsis (infection of the blood) and urinary tract infection (infection in the urine) and required intensive care level hospitalization. This failure placed residents at risk for unidentified and untreated sepsis, dehydration, constipation, decline, and a diminished quality of life. Findings included . <Hospitalization> Resident 14 was admitted to the facility on [DATE] with diagnoses including epilepsy (seizure disorder) and surgical aftercare following surgery on the genitourinary system. The Significant Change, Minimum Data Set Assessment (MDS, an assessment tool), dated 01/07/2025, showed Resident 14 was severely cognitively impaired and dependent on staff for cares. Review of the Electronic Health Record (EHR) showed Resident 14 was hospitalized from [DATE] to 10/18/2024 to have bilateral urethral stents placed (a thin tube was placed in each ureter to keep them open, to allow movement of urine from the kidneys to the bladder). Resident 14 was re-hospitalized from [DATE] to 10/29/2024 for acute encephalopathy (when the brain does not function as well), obstructive hydronephrosis (issue with urine draining out of kidney) status post bilateral urethral stent, complicated urinary tract infection, acute kidney injury, and possible recurrent seizure. A progress note, dated 11/09/2024, showed Resident 14 was diagnosed with hemorrhagic cystitis (inflammation of the bladder lining that causes bleeding and pain with urination). Resident 14 was placed on a 10-day course of an antibiotic. During the antibiotic period of 10 days, on 11/14/2024 a progress note reported Resident 14 required intravenous (IV) fluids for electrolyte imbalance. Review of the November 2024 MAR showed that Resident 14 on 11/12/2024 had received IV fluids for dehydration (dehydration can cause elevated sodium levels). Review of the 11/12/2025 laboratory results from 8:59 AM collection time, showed Resident 14 had an elevated sodium level of 149 (normal range listed as 135-146). Review of the 11/14/2025 laboratory result from 8:50 AM collection time, showed Resident 14 had an elevated sodium level of 154 (normal range listed as 135-146). Review of the EHR showed Resident 14 completed their 10-day course of an antibiotic on 11/19/2024. After the antibiotic had completed on 11/20/2024, a progress note showed Resident 14 was placed on an 1800 milliliter (ml) fluid restriction per day and a no added salt diet. Review of the Medication Administration Record (MAR) by the licensed nurses (LNs) and the Point of Care Fluids by the Certified Nursing Assistants (CNAs) showed the following amount of fluid consumed recorded: 11/20/2024: order started at 2:00 PM, 1,330 ml (milliliters)(400 ml recorded by LN, 93 ml by CNA) 11/21/2024: 1,480 ml (1000 ml by LN, 480 ml by CNA) 11/22/2024: 1,060 ml (700 ml by LN, 360 ml by CNA) 11/23/2024: 1,600 ml (1,000 ml by LN, 600 ml by CNA) 11/24/2024: 540 ml (300 ml by LN, 240 ml by CNA) 11/25/2024: 640 ml (240 ml by LN, 400 ml by CNA) 11/26/2024: 780 (560 ml by LN, 220 ml by CNA) 11/27/2024: 1,340 ml (980 ml by LN, 360 ml by CNA) 11/28/2024: 1,960 ml (1,000 ml by LN, 960 ml by CNA) 11/29/2024: 944 ml (200 ml by LN, 744 ml by CNA) 11/30/2024: 960 ml (600 ml by LN, 360 ml by CNA) Review of the 11/05/2024 nutritional evaluation form, completed by the Registered Dietician, documented Resident 14's hydration needs as 1500 ml of fluid. The documented fluid amounts during 11/21/2024-11/30/2024 showed that Resident 14 was not meeting their daily hydration needs for 8 of 10 days reviewed. Review of a 11/21/2024 progress note showed Resident 14 had a decline in condition and needed increased assistance. Review of a 11/22/2024 progress note showed the provider had requested a nephrology (doctor whom specializes in kidney disease) referral, a urinalysis (UA, analyzes the urine) with culture and sensitivity (if an organism was present would show which one, and allow better selection of what antibiotic to use), a complete blood count (CBC, can detect infection or low red blood cells or platelets), and an abdominal x-ray. The progress note said the resident was on alert for decline and labs. A review of the 11/23/2024 progress note showed Resident 14 continued to have decline and weakness, with hematuria (blood in the urine). EHR showed the next progress note was seven days later on 12/01/2024 which documented Resident 14 was found unresponsive and unable to arouse with the following abnormal vital signs: Temperature 102.5 (fever is anything over 100.4) Heart rate 132 (60-100 generally considered normal for an adult) Blood pressure 89/59 (normal adult blood pressure typically considered 120/80) Resident 14 was then sent to the hospital. Review of the hospital update documentation showed Resident 14 arrived to the hospital with altered mental status, a fever, was hypotensive (low blood pressure) and required fluid boluses and IV Levophed (vasopressor used for treating severely low blood pressure) for pressure support. Review of the hospital Discharge summary, dated showed Resident 14 was diagnosed with a urinary tract infection and sepsis. Review of the EHR showed neither the UA or the CBC (from the 11/22/2024 progress note) were obtained/completed. One administration note for the UA and CBC showed Unable to obtain at this time will try again on 11/23/2024. No additional documentation was found. On 03/17/2025 a request was made for the facility policy on vitals. On 03/17/2025 at 10:32 AM, Staff B, Director of Nursing Services (DNS) documented via email that there was no vital signs policy. During an interview on 03/17/2025 at 12:47 PM, Staff D, Resident Care Manager (RCM), when asked what services were provided by the facility to prevent the hospitalization on 12/01/2024, said it looked like Resident 14 was placed on a fluid restriction and an abdominal x-ray was obtained. Staff D said they looked in the chart and called the hospital but there was no record of the UA or the CBC being obtained, and their expectation was it would have been drawn and collected, and acknowledged neither was done. When asked about the alert charting for decline and how long the resident should have charting done for, Staff D said they did not know and they did not have a policy specific to this area of concern. Regarding Resident 14, Staff D said they could see a lot of charting was not completed while they were on alert and they continued to decline, and their expectation was for staff to have charted on them every shift. When asked if there was documentation of Resident 14's clinical status during that time, Staff D said no. Staff D confirmed there were no vitals taken for Resident 14 between 11/23/2024 and 12/01/2024. During an interview on 03/18/2025 at 2:24 PM, Staff B, Director of Nursing Services (DNS), when asked how the facility prevented the hospitalization, stated they did not prevent it when they did not get the laboratory tests, and they could have potentially prevented the hospitalization by getting the UA. <Bowel Protocol> Review of the facility's policy titled, Bowel Protocol, dated with a revision date of 03/2018, showed that if the resident did not have a bowel movement for three days, then the nurse was to administer the physician ordered bowel program. The bowel protocol showed the residents were supposed to receive the following medications to stimulate a bowel movement: a) Milk of Magnesia, if no bowel movement for three days, administer on day four. b) If no result from Milk of Magnesia, then Bisacodyl suppository (small bullet sized medication inserted via rectum) on the next shift during waking hours c) If no result from suppository, then an Enema (liquid inserted via rectum) on the next shift, during waking hours If after the enema there was no bowel movement, then the facility was to notify the provider. <Resident 13> Resident 13 was admitted to the facility on [DATE]. Review of the Significant Change MDS, dated [DATE], showed Resident 13 was severely cognitively impaired and was dependent on staff for cares. Review of the past 30-day bowel monitor showed Resident 13 did not have a bowel movement from 02/09/2025 to 02/18/2025 (10 days). Review of the MAR showed Resident 13 had as needed bowel medications ordered, the same as from the bowel protocol and in the same order. The February 2025 MAR showed a fleet enema was given on 02/14/2025 but did not indicate whether or not there were results Review of the nursing progress notes, from 02/10/2025 to 02/18/2025, showed no alert charting for Resident 13 regarding and the intervention of the enema, lack of bowel movement, or alert charting. Review of the EHR showed no explanation of why the fleet enema was given out of order from the bowel protocol/instructions in the provider order. During an interview on 03/17/2025 at 12:35 PM, Staff D, RCM, when asked about this period without a bowel movement, looked in the EHR and said they were given an enema on 02/14/2025 and this did not follow the orders or the bowel protocol. Staff D was unable to find any documentation of refusals of less invasive routes per the bowel protocol for this time period. Staff D said their expectation once a resident was on the no bowel movement list, that staff would place on alert charting and documenting about the lack of bowel movement and treatments. During an interview on 03/17/2025 at 4:44 PM, Staff B, DNS, said their expectation for the bowel protocol was that on day four it would be started. Staff B said Resident 13's records did not meet expectations, as staff needed to follow physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 49> Resident 49 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident had moderate cognitive impairment, diagnoses of non-Alzheimer's dementia and unspecified nausea and vomiting, required setup assistance with meals and had no known significant weight loss in the previous six months. A Nutrition/Hydration care plan, revised 02/17/2025, directed staff to encourage Resident 49 to eat 50% or more of their meal; if meal intake was 50% or less, to offer a substitute meal or supplement; and to provide diet as ordered. Hospital transfer orders, dated 02/04/2025, showed Resident 49 weighed 192 lbs., was on a regular, low sodium diet, and had an orders for Ensure Plus (a liquid nutritional supplement that provides concentrated calories and protein to help gain or maintain a weight for patients with malnutrition or otherwise at nutritional risk) two times a day. One carton was to be provided with breakfast and the other with dinner. Resident 49's weight record showed the following: 02/04/2025- 193 lbs. 02/09/2025- 189 lbs. 02/10/2025- 188 lbs.; - 5 lbs. in six days. A Nutrition Evaluation Form, dated 02/10/2025, documented Resident 49 weighed 188 lbs., was on a regular, no added salt diet, and was independent with meals after setup. Staff G, RD, identified the residents who took diuretic medication (medication to draw fluid from body) as having the potential to cause fluctuations in weight, but documented the resident had no edema at that time. Resident 49's average meal intake was estimated to be 80% of breakfast, and 75% of the lunch and dinner. Staff G, RD, concluded that Resident 49's overall nutrition status was stable and adequate. Review of the evaluation form showed Resident 49's 02/10/2025 weight of 188 lbs. was used as the resident's baseline weight. Under Additional Weight History staff documented not applicable. The facility's 02/04/2025 admission weight of 193 lbs., which was consistent with the hospitals 02/04/2025 discharge weight of 192, was not acknowledged nor was the 5 lbs. weight loss the resident in the six days since admission. There was no information provided to indicate if the facility had provided the supplement or whether the resident had been drinking it. Review of Resident 49's Electronic Health Record (EHR) and physicians' orders showed the Ensure Plus order had not been transcribed and/or implemented. A progress note, dated 02/11/2025, documented Resident 49 reported being nauseas and vomiting twice. Review of the February and March 2025 MARs revealed a 02/04/2025 order for Ondansetron (anti-nausea medication) and showed it had been requested and administered on the following dates: 02/11/2025 at 3:48 PM 02/12/2025 at 8:02 AM 02/18/2025 at 3:40 PM 02/19/2025 at 9:48 AM 02/22/2025 at 11:55 AM 02/26/2025 at 11:27 AM 03/07/2025 at 10:17 AM On 03/02/2025 at 11:02 AM, Resident 49's weight was 177.8 lbs. A reweigh was obtained at 2:02 PM, and was 178 lbs. This showed a significant weight loss of 7.8% in 28 days. Review of the EHR showed Resident 49 was not reviewed in the facility's 03/04/2025 weekly nutrition meeting. No documentation was present in the record to indicate facility staff had identified the significant weight loss, notified the physician or developed and implemented any nutritional interventions to address it. On 03/09/2025 at 11:04 AM, Resident 49's weight was 172 lbs. A reweigh was obtained at 2:04 PM and was 171.6 lbs. This confirmed the resident's consistent and unplanned significant weight loss, which was now at -11.09% in 34 days without identification by facility staff, or the development and implementation of nutritional interventions. A 03/10/2025 Nutrition Hydration Skin Committee Review Form, identified the reason for review as significant weight loss of greater than 5%. The sections for weight loss of 7.5% and 10% respectively, remained unchecked. The review identified the resident had consumed 51-100% of most meals over the previous seven days, and did not receive any nutritional supplements. The Interdisciplinary Team (IDT) determined the resident's current meal and fluid intake were adequate to meet the resident's needs but recommended adding NEM to Resident 49's diet. There was no evaluation of the conditions impacting the resident's intake or effectiveness of current interventions. On 03/14/2025 at 1:07 PM, Resident 49 was observed sitting up in bed, their lunch tray was on the bedside table, which was pushed away from the edge of the bed. Observation of the tray showed the pork patty, mixed vegetables, dinner roll with packet of butter, and cake were untouched. The silverware was clean and unused. There was one cup on the tray that had a few drops of red liquid remaining in it. When asked why he had not eaten anything, Resident 49 stated, I drank the juice, but I just don't have an appetite. The resident reported it was not due to the quality of the food and reiterated I just don't have an appetite. Resident 49's tray showed a NEM diet was not provided (No whole milk was on the tray, they had drank their juice and may have drank the milk) and they ate 0% of the meal. Review of the March 2025 meal monitor showed staff documented on 03/14/2025 at 12:00 PM that Resident 49 ate 51- 75% of lunch and drank 480 milliliters (ml) of fluid, despite lunch meal service for Hall 2 being at 12:30 PM, the resident only being provided one 240 ml cup of juice on their tray and not eating any of the meal. On 03/18/2025 at 7:59 AM, Staff B confirmed there was no documentation to show the facility provided the resident Ensure Plus (or a therapeutic interchange) twice a day as ordered. When asked why Resident 49 was not reviewed for significant weight loss during the facility's 03/04/2025 weekly nutrition meeting, given on 03/02/2025 the resident showed a significant weight loss of 7.8% in 28 days, Staff B, DNS, said they did not have a nutrition meeting that week because the RD was out of town, but acknowledged Resident 49 should have still been reviewed and assessed by the rest of the nutrition IDT, but was not. Staff B shared that Resident 49 was reviewed the following week by the nutrition IDT and NEM was added to their diet. On 03/18/2025 at 8:08 AM, when informed that observation of Resident 49's meal trays showed they were not provided NEM, and interviews showed facility staff did not know what NEM on a resident's tray car meant, or what action, if any, it called for them to do. Staff B, DNS, indicated there was a need for education and acknowledged someone from the IDT should be following up on nutritional recommendations to ensure they were fully implemented, and to assess the effectiveness. When asked if that occurred for Resident 49's nutritional interventions Staff B, DNS, said no. Surveyor: [NAME], Tnesa E. <Resident 29> Resident 29 was admitted to the facility on [DATE]. The Annual MDS dated [DATE], documented Resident 29 was severely cognitive impaired. The EHR documented Resident 29 weighed 91.6 pounds on 10/01/2024. On 02/02/2025 Resident 29 weighted 87.0 pounds and on 03/02/2025 weighed 82.2 pounds. This resulted in a -5.75 % loss in 30 days and a -10.48 % loss in six months. The EHR documented Resident 29 was prescribed a therapeutic diet on 02/14/2024 to include a regular diet, regular texture with thin liquids with NEM. Resident 29 was also prescribed a calorie dense supplement three times a day and to be offered again when Resident 29 ate less than 50% of their meal. A Nutrition Assessment, dated 02/05/2025, documented Resident 29 was maintaining weight, was to continue a regular diet, regular texture with thin liquids with NEM and had no concerns at the time of the assessment. On 03/13/2025 at 12:07 PM, observations of Resident 29's meal card documented resident was on a regular diet with think liquids and beverage of choice was whole milk and resident did not have any dislike. Meal ticket did not document NEM diet. At 12:25 PM, Resident 29 was observed wheeling themselves away from the table and out of the dining room. No staff approached Resident 29 or offered an alternative meal or supplement. Resident had only eaten a few bites of beef tips (more than 75 % still on plate), 2-3 spiral noodles were eaten (more than 75% still on plate), all the vegetables were still on the plate, the dinner roll had been eaten and all the juice in the cup had been drank. No milk was on the table. No NEM diet was provided or documented on meal card. At 12:26 PM, when asked what should happen when a resident ate less than 50% of their meal, Staff P, CNA, said they should be offering the resident an alternative meal or supplements. Staff P said per Resident 29's Power of Attorney, they had been directed not to offer Resident 29 an alternative or supplement meal. They had provided Resident 29 with two peach yogurts prior to lunch. On 03/14/2025 at 11:00 AM, Collateral contact 1, Resident 29's POA, was sitting in the lobby with Resident 29. Collateral contact 1 said a while back Resident 29 was having difficulty eating and the facility was in the process of conducting a nutritional assessment with Resident 29. Collateral contact 1 said they told the facility not to offer Resident 29 extra food during the assessment period because they wanted a accurate assessment on Resident 29's ability to swallow. Collateral contact 1 said they wanted Resident 29 to be offered alternative food, if Resident 29 was eating less than 50% of the meal. Collateral contact 1 said she would expect the staff to help Resident 29 choose food that was soft and easy for Resident 29 to chew, due to swallowing difficulties. Collaterals contact 1 said they facility should be cutting up large portions foods too. When observations of Resident 29's meal for March 13 and 17 were explained, including no NEM, Collateral contact 1 said they did not know Resident 29 was on an NEM diet. Collateral contact 1 asked how much Resident 29 weighed. When February and March's weights were provided, Collateral contact 1 said no one had notified them that Resident 29 had lost weight. On 03/17/2025 at 12:13 PM, observations of Resident 29's meal card documented resident was on a regular diet with think liquids and beverage of choice was whole milk and resident did not have any dislike. At 12;19 PM, Resident 29 was observed wheeling themselves away from the table and out of the dining room. No staff approached Resident 29 or offered an alternative meal or supplement. Resident had only eaten half the bowl of soup with crackers, ¼ of the ham and cheese sandwich, two bites of dessert and 90% of her juice. Left on the plate included ¾ of the sandwich, half cup or sop with crackers, a full unopened bag of chips and a full salad cup. No NEM diet was provided or documented on meal card. A Nutrition-Meal Monitor Follow Up Question Report, dated 03/01/2025-03/17/2025, documented on 03/13/2025 at 1:04 PM, Resident 29 ate between 0-25% of the meal, no alternative meal/supplement was provided. On 03/17/2025 at 1:37 PM, documented Response Not Required. Documentation showed no alternatives meals were offered for March 13th and 17th. A phone interview was completed on 03/13/2025 at 2:33 PM, with Staff G, RD. When asked about Resident 29's diet, Staff G said Resident 29's weight had been in the 80-90's for the last year and Resident 29 had just recently triggered for weight loss and they did not know if it had been struck out (meaning determined to be a false weight). Staff G said Resident 29 was on a regular, regular diet with thin liquids and NEM. Resident 29 was also receiving a calorie supplement. When observation of no NEM diet was reported and no documentation on the meal card of NEM diet, Staff G said Resident 29 should have received the NEM diet and the meal card should reflect the correct diet type to include NEM. On 03/17/2025 at 2:38 PM, Staff D, RCM, with Staff C, RCM, present, said the process for when a resident has been identified as losing weight included bringing the concerns to the weekly nutrition meeting. Staff, including the Registered Dietitain, would make recommendations, review current interventions and complete a new assessment for the resident. Staff C said it also included notifying the family and provider of the resident's weight loss. When asked about Resident 29's weight loss, Staff D said Resident 29 was not triggered for weight loss. Staff D was shown Resident 29's weight loss calculations, Staff D said they were not aware Resident 29 had lost weight. Staff D confirmed there were no progress notes or current evaluations completed for Resident 29's weight loss. Staff D said Resident 29 was on regular diet with thin liquids with NEM. Staff D said staff should be offering Resident 29 an alternative meal or supplements if the resident ate less than 50% of the meal. Staff D said it was the responsibility of the RCMs to ensure residents received the correct diet that matched the meal card. March 13th and 17th observations were explained about no NEM diet on meal card and no staff had offered Resident 29 an alternative meal. Staff D said it was the expectation that residents received the correct diet, and staff would offer an alternative meal. On 03/18/2025 at 12:53 PM, when asked about Resident 29's weight loss, Staff B, DNS, with Staff E, Divisional Director/Regional RN present, said they were aware Resident 29 had lost some weight over the past year and had been trending down recently. Staff B said Resident 29 was on a regular, regular diet with thin liquids and NEM. Staff B said the NEM diet should have been documented on the meal card. Staff B said they provided documentation of Resident 29 being offered alternative meal, the Nutrition-Meal Monitor Follow Up Question Report. When asked about the observations that no staff had offered an alternative meal to Resident 29, Staff B said an alternative meal was offered, surveyor just didn't observe it. Reference WAC 388-97 -1060 (3)(h) Based on observation, interview and record review, the facility failed to ensure resident meal intake was accurately recorded, nutritional supplements were provided as ordered, weights were timely obtained and evaluated, significant weight loss was identified, and nutritional interventions were implemented and evaluated for effectiveness for 3 of 5 sampled residents (Residents 14, 49, & 29) reviewed for nutrition. Resident 14 experienced harm when they had a severe weight loss of 14.89% over six months. Resident 49 experienced harm when they had a 11.09% weight loss in 34 days before it was identified by staff. This failure placed all residents at risk of malnourishment, weakness, unidentified care needs, and a diminished quality of life. Findings included . Review of the facility's policy, titled Nutrition Hydration Skin Committee, updated 11/2012, showed the facility held the committee for evaluating residents with declining nutrition, hydration, and skin status. Residents to be reviewed could include residents with significant decline or improvement in condition, trending or significant weight change, changes in meal intake, requiring thickened liquids, having a decline in diet food texture, or due to intake and output. The committee was to meet routinely to address identified issues and track residents being monitored. For residents being reviewed, the committee was to review and revise the care plan with measurable goals and appropriate interventions. For any medically unavoidable weight loss or gain, the committee was to place a referral to the physician for request of documentation on unavoidable weight change. Review of the facility's policy, titled Weights, last revised 07/20/2024, showed new admission residents were to have weekly weights for one month. If stable, then the resident could have monthly weights. The policy provided guidelines for residents that may need weekly weights, with wording saying it was not all inclusive, for residents that had the following: a) Food intake declined and persisted b) Slow trending of weight loss or gain c) Significant weight loss or gain d) Significant change in condition If a resident had a 5-pound variance between weights, a re-weigh would be required. If the significant weight loss was still present after the re-weigh, the nurse was to document in the medical record/progress note, revise the care plan, refer to the Nutrition Hydration Committee, and to notify the provider and the resident/resident representative. Progress notes by the nurse were to include any responses by the provider. Review of the facility's policy, titled Preparation and Serving of Nutritionally Enhanced Meals (NEM), updated 11/2018, showed the facility was to add NEM designation to the resident's tray ticket, each tray would have 8 ounces (oz) of whole milk, and dietary would provide enriched cereal topping to the breakfast and extra margarine to breads, potatoes, pasta, rice, vegetables or other appropriate foods. Resident meal trays could also have extra high calorie and high protein foods to further enhance nutrition, such as yogurt, ice cream, pudding, extra egg at breakfast, and/or peanut butter. <Resident 14> Resident 14 was admitted to the facility on [DATE] and had diagnoses of weakness, major depressive disorder (depression), and dehydration. The Significant Change Minimum Data Set Assessment (MDS/an assessment tool), dated 01/07/2025, showed Resident 14 was severely cognitively impaired, dependent on staff for cares, and during the assessment period had required supervision or touch assistance for eating. Review of the weights showed: 1 month: On 02/02/2025, the resident weighed 110.8 lbs. On 03/02/2025, the resident weighed 104 pounds which is a -6.14 % Loss. 3 months: On 12/07/2024, the resident weighed 119.6 lbs. On 03/02/2025, the resident weighed 104 pounds which is a -13.04 % Loss. 6 months: On 09/01/2024, the resident weighed 122.2 lbs. On 03/02/2025, the resident weighed 104 pounds which is a -14.89 % Loss. Review of progress notes showed: On 08/12/2024, Resident 14 had a 5.4% weight loss in 30 days, that the resident was declining to eat in the dining room, and there were no new orders. On 10/30/2024, Resident 14 was reviewed by the nutrition committee related to the weight loss of 5.10% over 28 days, it was acknowledged that the resident may have lost weight due to hospitalization and illness, and a house supplement was added one time daily (it was discontinued on 12/07/2024). Between 12/07/2024 and 03/10/2025 Resident 14 was not on a calorie dense supplement/house supplement. On 03/10/2025, Resident 14 was noted to have 5.8% weight loss over 30 days. Interventions at that time included encouraging to go to dining room, offering snacks, and adding back/administering Cal dense (nutritional supplement) 60 milliliters with medication pass two times a day. On 01/06/2025, Resident 14 was reviewed by the nutrition committee for weight loss of 10.7% in less than two months. It was identified Resident 14 had poor oral intake and would at times refuse food/fluids/medications. On 01/13/2025, Resident 14 was noted to have a 15.8% weight loss in the previous three months. Provider was notified and NEM was added to diet on 01/06/2025. During an observation on 03/12/2025 at 9:42 AM, Resident 14 was seen with two drinks in front of them, a water and a thin dark brown drink, presumably coffee. No milk was seen (the facilities identified NEM intervention) At 12:56 PM, Resident 14 was seen eating lunch, without milk (the facilities identified NEM intervention) On 03/13/2025 at 12:58 PM, Resident 14 was seen eating lunch, without milk (the facilities identified NEM intervention). Resident 14's tray slip said soft bite sized regular, NEM, thin liquids. The slip had standing orders of 8 oz juice and 8 oz of beverage of choice. Dislikes did not include milk. Resident 14 was observed to have the head of their bed at 30 degrees, was leaning over their left side, and was seen to drop a small amount of food on themselves and their bed. Staff N, Certified Nursing Assistant (CNA) entered and exited Resident 14's room, said it was not good for Resident 14 to have been eating in that position but did not provide assistance. Resident 14 did not eat all of their meal. On 03/14/2025 at 8:34 AM, Resident 14 was seen with a neck pillow around their neck, ate from a red bowl, did not eat anything off their plate, and did not have milk (the facilities identified NEM intervention) with their breakfast. At 8:40 AM, Resident 14 closed their eyes and stopped attempting to eat. At 9:25 AM, a CNA entered the room, attempted to wake Resident 14 up, said they were going to take their tray, and left the cup with juice. On 03/17/2025 at 1:15 PM, Resident 14 was seen with their tray slip saying NEM, with it listing juice and beverage of choice. No milk was observed (the facilities identified NEM intervention). Resident 14 did not eat their chopped-up meat or side of beans. The record showed that Resident 14 did not have weekly weights obtained; despite having the following guidelines identified in the facilities policy as indicators a resident may need weekly weights: a) Food intake declined and persisted b) Trend of weight loss c) Significant weight loss d) Significant change in condition During a phone interview on 03/13/2025 at 2:33 PM, Staff G, Registered Dietician (RD), said Resident 14 had a significant weight loss over 30 days. Staff G said their expectation was for staff to follow the diet order with NEM, to provide Cal Dense two times a day, and that they would recommend weekly weights to catch weight loss sooner than a month away. When asked about the intervention of snacks between meals, Staff G said this was a standard for every person in the building, and under the tab to document snacks (excluding PM snack) there was no documentation. During an interview on 03/14/2025 at 9:30 AM, Staff H, CNA, said they had been working with Resident 14 since October, and that Resident 14 was not great at eating their meals, and did not eat a whole lot. Staff H, when asked about Resident 14's breakfast, said they had only eaten 0-25% of their meal, and they were unsure if Resident 14 needed an alternative as they tried to wake them, but they were hard to wake up. When asked what helps Resident 14 eat more, Staff H said sitting them up, making sure they were awake helps. When asked when Resident 14 was offered snacks, Staff H responded at around 8:00 PM. Staff H reported Resident 14 liked the chocolate flavor. At 10:59 AM, Staff I, Licensed Practical Nurse (LPN), said Resident 14 hated the Calorie Dense, and it was a vanilla flavor. Staff I went into the room to see if Resident 14 would take the Calorie Dense, Resident 14 was heard saying It's crap. Staff I asked if Resident 14 liked vanilla and was told no. Resident 14 reported they liked chocolate. At 11:16 AM, when asked about what triggered the significant change MDS assessment, Staff D, Resident Care Manager (RCM), said Resident 14 had gone to the hospital, had urinary stent (thin tube to allow flow of urine) placements, blood in the urine, significant decline requiring two person assistance, slumping over during meals, refusing to go to the dining room most of the time, and a decrease in activities of daily living. When asked how the facility was reassessing interventions for effectiveness, Staff D said, resident weights. Staff D said Resident 14 should have had weekly weights and did not. When asked about the house supplement being discontinued on 12/07/2024, if there was an intervention in place at that time, Staff D said no. Regarding the NEM diet added on 01/06/2025, when asked how the facility assessed it was effective, Staff D said if there was continued weight loss, it had failed, and they needed to come up with something else. Staff D said anytime Resident 14 came up for significant weight loss, it should have been reviewed for effectiveness. Staff D said Resident 14 had not been willing to eat a whole meal but did drink fluids well with a two-handed cup. Staff D checked with dining on if milk was on Resident 14's dislikes, and said it was not on their dislikes, and they should receive whole milk due to the NEM diet. When asked about the slip mentioning NEM but not anything about whole milk, Staff D said the CNAs usually encourage milk but the resident had the right to refuse. When asked if the facility had attempted an alternative to white milk (the resident stated they liked chocolate milk), Staff D said, not to my knowledge. Staff D said the CNAs provided Resident 14 with what they liked to drink if they would not answer. When asked if there had been a discussion of an appetite stimulant for Resident 14, Staff D said no. At 12:03 PM, when asked about NEM on the resident's tray slip, Staff J, CNA, said they did not know what it meant when the slip said NEM. When asked what they do for drinks, Staff J said they did not know and asked if that was protein shakes. At 12:08 PM, when asked about NEM, Staff H, CNA, said they were not sure what it meant. When asked about what they do for drinks, Staff H said they did not know. At 12:09 PM, Staff K, CNA, when asked about NEM, said they did not know what it was and did not know what it meant for drinks. At 12:18 PM, Staff M, Registered Nurse (RN), said they had not received training on what NEM diets were or if there were specific beverages the resident should or should not receive. At 1:16 PM, Staff L, Advance Registered Nurse Practitioner, said they had been working with Resident 14 for six months. When asked about the significant weight loss, Staff L said that most recently the facility had provided them with a fax communication of a certain percentage of weight loss and that they had added a supplement to the meal, with only the previous 30 days of weight loss discussed. After being told about the past one month, three months, and six months of weight loss numbers, Staff L said they were not aware of the prolonged weight loss. Staff L said they were not aware of any attempt to add an appetite stimulant, and they might need to look into implementing something to stimulate appetite. Staff L said their expectation was that the facility provided everything Resident 14 needed to maintain a healthy weight for life purposes, the diet promoted decreased skin breakdown, and the facility provided the nutrients needed for their diet. During an interview on 03/18/2025 at 2:04 PM, Staff B, Director of Nursing Services (DNS), said their expectation for residents with significant weight loss was that the nutrition hydration committee followed them, and the provider and registered dietician would be notified. Regarding significant weight loss, Staff B said weights should be done weekly times 4, and for Resident 14 they should have been changed back to weekly and were not. When asked about the role CNAs have with NEM diets, Staff B said the meal try slip should direct the aids to serve whole milk, which would allow them to participate in NEM without knowing what it was. When told about the observations of Resident 14 without whole milk and no mention of whole milk on the meal tray slips, Staff B said their expectation was that the meal tray slip would have said milk on it. When asked about snacks between meals and how the facility evaluated it for effectiveness, Staff B said the only documentation they could find was the bedtime snack, and Resident 14 was only receiving a bedtime snack since 11/05/2024. When asked how the facility was evaluating the effectiveness of the NEM diet added on 01/06/2025, Staff B said NEM was not happening as they were not giving the whole diet (not giving whole milk).