**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure residents were assessed to identify risk factors and provide care and services that are resident centered to prevent falls with injury and to ensure medications were administered as ordered. This was true for 2 (two) of 6 (six) residents reviewed for the Long Term Care Survey Process. Resident identifiers: #162, #10. Facility census: 60. Findings include: a) Resident #162 On 10/01/24 at approximately 03:30 PM, a record review was started for Resident #162 which reveal that Resident #162 was an [AGE] year-old female admitted on [DATE] status post hospitalization for an unwitnessed fall that occurred at home. Resident #162 was admitted with the following past medical history: -Alzheimer's Disease -Hypothyroidism -Essential Hypertension -Repeated Falls -Cognitive Communication Deficit -Parkinson's Disease -Insomnia -Depression -Tremors Resident #162 was receiving the following medications upon admission: -Carbidopa-Levodopa- diagnosis (dx): Parkinson's -Cympbalta- dx: Depression -Metoprolol Succinate Extended Release- dx: Hypertension -Rozeram- dx: Insomnia -Miralax- dx: Constipation A further review of Resident #162 admitting orders revealed an order for non-skid footwear for safety was entered upon the resident's admission with an active date of 12/11/23. Resident #162 was deemed incapacitated with long term duration due to a dx of Alzheimer's Disease on 12/13/24. Furthermore, Resident #162 scored an 8 on the Brief Interview For Mental Status (BIMS) Evaluation which indicates moderate cognitive impairment. A review of the Policy and Procedure entitled, Falls Management revealed that all patients will be assessed for risk of falls upon admission, with reassessments routinely, including post fall, to determine ongoing needs for fall prevention precautions. The policy stated, The Center will implement and document patient-centered interventions according to the individual risk factors to the patient plan of care. The Center, to the extent possible, will provide the patient and/or patient representative with opportunities to participate in the care planning process for risk reduction and fall reduction strategies. In addition, the policy states for Post-Fall Management the circumstances of the fall will be documented as well as the post fall assessment. Resident #162 progress notes were reviewed which revealed the following documented notes (typed as written): 12/11/23 at 11:30 PM Nursing Documentation Note: Patient was admitted /readmitted for the following reason(s): admission Additional details about this note: Resident resting in bed at this time. admitted from (name of hospital) due to resident having a fall. Resident alert with some confusion at this time. Pt. has a history of falls. Neurological system reviewed Mental Status: Alert. Severely impaired in decision making skills for daily routine. Highly impaired hearing. A physiatry progress note dated 12/13/24 revealed the resident had mobility and activities of daily living (ADL) deficits secondary to a fall. The note stated the resident would be getting skilled therapy services with the goal of increasing strength, endurance and self care abilities as well as working on neuromotor training, stair climbing and functional moblity trainng. On 12/16/23 at 11:30 PM a note revealed the resident was found in the floor on her right side facing the door. She was found by a nurse aide (NA). She was awake and able to answer questions and stated she was trying to get up to go home. The note revealed the resident had no regular white ankle socks and the bed was in the lowest position. On 12/18/24 a progress note revealed the fall huddle meeting was held and a new intervention was put into place for a fall mat to the right side of the bed. On 12/20/23 a progress note stated, Called to room by social worker with the resident noted lying on the floor on right side with fall mat in place. The note reflected that the resident had a laceration to the right side of the forehead. The resident was sent to the emergency department for further evalution. A note dated 12/21/23 stated the resident had been transferred to a larger area hospital due to subdural hematoma. On 12/21/24 a fall huddle meeting was held a a new intervention was placed in the room. A sign was placed to remind resident to call for assistance with transfers. On 10/02/24 at approximately 08:30 AM, Resident #162 care plan was reviewed which revealed the following: Focus: Resident is at risk for falls: cognitive loss, lack of safety awareness. Date initiated: 12/12/23 Goal: Resident will have no falls with injury throughout the next review period. Date initiated: 12/12/23 Interventions: Place glasses within reach in a consistent place and encourage use. Date initiated: 12/12/23 Bed in low position. Date initiated: 12/12/23 Fall mat to right side of bed. Date initiated: 12/18/23 Signage in room to remind resident to call for assistance with transfers. Date initiated: 12/21/23 Provide resident/caregiver education for safe techniques of when to use call light for assistance. Date initiated: 12/21/23 Assist resident/caregiver to organize belongings for a clutter-free environment in the resident's room and consistent furniture arrangement. Date initiated: 12/12/23. In addition, Resident #162 Standard Assessments were reviewed which revealed no Fall Risk Evaluation performed on admission or for post fall for 12/16/23 and for post fall 12/20/23. The Change in Condition Evaluation assessment for the dates of 12/16/23 and 12/20/23 were also reviewed and revealed the following information: A review of functional status evaluations dated 12/16/23 and 12/20/23 revealed in Section 2 that the resident's supine, sitting and standing blood pressures were to be entered were blank. On 10/02/24 at 09:00 AM, the Policy and Procedure entitled, Accidents/Incidents was completed which revealed that when conducting an investigation, the Administrator, DON or designee will make every effort to ascertain the cause of the accident/incident and document the root cause and initiate actions to prevent or reduce recurrence of further accident/incident. On 10/02/24 at 9:55 AM, an interview was conducted with the Director of Nursing (DON). At that time the DON acknowledged the following: 1. Fall Risk Evaluation were to be completed on admission 2. Fall Risk Evaluation were to be completed post fall 3. Nursing should document circumstances surrounding falls and were not. These circumstances include things such as incontinence and assistive devices. 4. Nursing assessments should be completed in their entirety andorthostatic blood pressure readings should be obtained. 5. No admission fall risk evaluation was completed for Resident #162, as per policy. 6. No post-fall fall risk evaluation for the dates of 12/16/23 and 12/20/23 were completed, as per policy. At this time, this Surveyor reviewed Resident #162 incident forms, dated 12/16/23 and 12/20/23, which had sections to be completed for predisposing physiological factors and predisposing situation factors with the DON. The DON acknowledged that both forms lacked required documentation such as, Resident # 162 received and antidepressant, antihypertensive, antiparkinsonian, laxative and wore glasses. In addition, the DON acknowledged, the incident form dated, 12/16/23 lacked the required documentation that Resident #162 was newly admitted within the last 7 (seven) days and that Resident #162 was wearing unsafe footwear and not the non-skid sole footwear ordered on admission. The DON then stated, the IDT team relies heavily on the nurses note and looks at trends to know which fall interventions to put in place. At that time, this Surveyor asked the DON, If you don't have the circumstances of the fall documented, how do you do that? The DON then states, You have a point. Resident #162 was noted to expire on 12/27/23 On 10/02/24 at 1:04 PM, an interview was conducted with the Director of Nursing (DON). At this time, the DON acknowledged the Center had knowledge Resident #162's history of falls at home prior to admission. When this Surveyor reviewed the 12/15/23 72 hour post admission meeting documentation with the DON, she stated when she spoke with Resident #162 daughter, the daughter stated to her, We can't keep her off the floor, that's why she is here. At this time, this Surveyor asked the DON if she asked Resident #162 daughter about circumstances surrounding Resident #162 falls at home in order to implement resident centered relevant interventions to prevent further falls, the DON stated, I am sure I did. When asked the DON to provide documentation of this, the DON acknowledged that she was unable to provide it. This Surveyor asked the DON if root causes were performed on Resident #162 falls. The DON stated, Yes. The DON acknowledged was unable to provide these root cause analysis. This Surveyor then asked the DON what the root causes where for Resident #162 falls, to which the DON acknowledged she could not provide them. This Surveyor asked how interventions to prevent falls were determined to be resident centered based on the resident's individual risk factors, relevant and appropriate for Resident #162 to which the DON acknowledged she was unable to provide that. This Surveyor then reviewed the Policy and Procedure, Falls Management and Accidents/Incidents and asked the DON to review these policies. Then DON then said, I am aware of what they say. On 10/03/24, shortly after arrival to the facility at approximately 08:25 AM, the Senior Executive Director stated to this Surveyor, We found that a risk evaluation is built into the admission assessment last night. On 10/03/24 at approximately 08:30 AM, an interview was conducted with the DON. At this time, the DON stated that Point Click Care has since been updated and changed, however, the previous admission assessments had a fall risk evaluation embedded in it. At this time, the DON pulled an admission assessment up on her computer and clicked on a number by the admission assessment which was a hyperlink. The DON clicked on this link, which pulled up an addendum which gave a numeric value for different risks factors based on the answers from the admission assessment. The DON stated, We accidentally found this last night. At that time, this Surveyor asked the DON if facility staff were aware of this tool and how was it utilized to develop the plan of care based on the resident's individualized risk factors. The DON stated, We didn't utilize it. In addition, this Surveyor asked the DON to review the resident's fall care plan and interventions, which were done. This Surveyor then asked the DON, based off said resident's risk factors, how did the care planned interventions address and mitigate this resident's individual risk factors. The DON stated, They don't. b) Resident #10 During a medical record review on, 10/01/24 at 2:46 PM, it was revealed that Resident #10's physician order identified an order for Sinemet Tablet 25-100 MG (Carbidopa-Levodopa) and to give 2 two tablet by mouth 5 times a day for Parkinson disease active date of 01/09/23. During further review of the Residents Medication Administration Record (MAR) it is identifeid that the following doses were not documented to have been administered per the physicians order. * 06/29/24, the 1800 hour dose is missing * 08/29/24 the 1800 hour dose is missing * 09/15/24 the 1800 hour dose is missing During an interview, with the Director of Nursing on 10/01/24 at approximately 10:40 AM, the DON acknowledged the doses were not documented as being administered per the physicians order. b) Resident #10 During a medical record 10/01/24 at 2:46 PM, Resident #10's physician order identified an order for Sinemet Tablet 25-100 MG (Carbidopa-Levodopa) and to give 2 tablet by mouth five times a day for Parkinson disease active date of 01/09/23. During further review of the Residents Medication Administration Record (MAR) it is identifeid that the following doses were not documented to have been administered per the physicians order. * 06/29/24, the 1800 hour dose is missing * 08/29/24 the 1800 hour dose is missing * 09/15/24 the 1800 hour dose is missing During an interview with the Director of Nursing on 10/01/24 at approximately 10:40 AM the DON acknowledged the doses were not documented as being administered per the physicians order. Based on record review and staff interview the facility failed to ensure residents were assessed to identify risk factors and provide care and services that are resident centered to prevent falls with injury and to ensure medications were administered as ordered. This was true for 3 (three) of 6 (six) residents reviewed for the Long Term Care Survey Process. Facility census: 60. Resident identifiers: Resident #162, Findings include: a) Resident #162 On 10/01/24 at approximately 03:30 PM, a record review was started for Resident #162 which reveal that Resident #162 was an [AGE] year-old female admitted on [DATE] status post hospitalization for an unwitnessed fall that occurred at home. Resident #162 was admitted with the following past medical history: A further review of Resident #162 admitting orders revealed that an order for non-skid footwear for safety was entered upon admission with an active date of 12/11/23. Resident #162 was deemed incapacitated with long term duration due to a dx of Alzheimer's Disease on 12/13/24. Furthermore, Resident #162 scored an 8 on the Brief Interview For Mental Status (BIMS) Evaluation which indicates moderate cognitive impairment. A review of the Policy and Procedure entitled, Falls Management revealed that all patients will be assessed for risk of falls upon admission, with reassessments routinely, which includes post fall, to determine ongoing needs for fall prevention precautions. The Center will implement and document patient-centered interventions according to the individual risk factors to the patient plan of care. The Center, to the extent possible, will provide the patient and/or patient representative with opportunities to participate in the care planning process for risk reduction and fall reduction strategies. In addition, the policy states for Post-Fall Management the circumstances of the fall will be documented as well as the post fall assessment. In addition, Resident #162 progress notes were reviewed which revealed the following documented notes (typed as written): 12/11/23 at 11:30 PM Nursing Documentation Note: Patient was admitted /readmitted for the following reason(s): admission Additional details about this note: Resident resting in bed at this time. admitted from (name of hospital) due to resident having a fall. Resident alert with some confusion at this time. System Review: Neurological system reviewed Mental Status: Alert. Oriented to Person Severely impaired in decision making skills for daily routine Vision Reviewed Hearing and Speech reviewed Highly impaired hearing. 12/16/23 at 11:30 PM eINTERACT SBAR Summary for Providers: CNA called me to residents room. Resident in floor on right side facing door. Bed in lowest position, resident has regular white ankle socks on. Resident awake and able to answer questions, states she was trying to get up to go home No new pain complaints, resident has multiple bruises in various stages of healing from previous falls. ROM wnl. neuro's initiated. mpoa notified as well as NP. vitals obtained. 12/18/23 T 4:05 PM General Fall huddle meeting held. New intervention for fall mat to right side of bed 12/20/23 at 3:56 PM eINTERACT SBAR Summary for Providers Called to room by social worker, resident noted to be lying on the floor on her right side, fall mat was in place at the time of fall, resident alert, Neuro assessment complete with no issues noted, skin assessment completed, lacerated noted to right side of forehead, first aide administered, resident sent to ER for further evaluation. Relevant medical history is: Dementia 12/21/23 at 00:42 AM General Spoke with nursing staff at PMC ER, Resident transferred to CAMC General division for Subdural Hematoma 12/21/24 at 9:09 AM General Fall huddle meeting held. New intervention to place signage in room to remind resident to call for assistance for transfers On 10/02/24 at approximately 08:30 AM, Resident #162 care plan was reviewed which revealed the following fall care plan: Focus: Resident is at risk for falls: cognitive loss, lack of safety awareness. Date initiated: 12/12/23 Goal: Resident will have no falls with injury throughout the next review period. Date initiated: 12/12/23 Interventions: Place glasses within reach in a consistent place and encourage use. Date initiated: 12/12/23 Bed in low position. Date initiated: 12/12/23 Fall mat to right side of bed. Date initiated: 12/18/23 Signage in room to remind resident to call for assistance with transfers. Date initiated: 12/21/24 Provide resident/caregiver education for safe techniques of when to use call light for assistance. Date initiated: 12/21/23 Assist resident/caregiver to organize belongings for a clutter-free environment in the resident's room and consistent furniture arrangement. Date initiated: 12/12/23. In addition, Resident #162 Standard Assessments were reviewed which revealed no Fall Risk Evaluation performed on admission or for post fall for 12/16/23 and for post fall 12/20/23. The eINTERACT Change in Condition Evaluation assessment for the dates of 12/16/23 and 12/20/23 were also reviewed and revealed the following information: 12/16/23 Section 2 Functional Status Evaluation in which the resident's supine, sitting and standing blood pressures are to be entered are blank. 12/20/23 Section 2 Functional Status Evaluation in which the resident's supine, sitting and standing blood pressures are to be entered are blank. On 10/02/24 at 09:00 AM, the Policy and Procedure entitled, Accidents/Incidents was completed which revealed that when conducting an investigation, the Administrator, DON or designee will make every effort to ascertain the cause of the accident/incident and document the root cause and initiate actions to prevent or reduce recurrence of further accident/incident. On 10/02/24 at 09:55 AM, an interview was conducted with the DON. At that time the DON acknowledged the following: 1. Fall Risk Evaluation is to be completed on admission 2. Fall Risk Evaluation is to be completed post fall 3. Nursing should be documenting circumstances surrounding fall and aren't. Such as incontinence and assistive devices. 4. Nursing assessments should be completed in their entirety and that orthostatic blood pressure readings should be obtained. 5. No admission fall risk evaluation was completed for Resident #162, as per policy. 6. No post-fall fall risk evaluation for the dates of 12/16/23 and 12/20/23 was completed, as per policy. At this time, this Surveyor reviewed Resident #162 incident forms, dated 12/16/23 and 12/20/23, which has sections to be completed for predisposing physiological factors and predisposing situation factors with the DON. At this time, the DON acknowledged that both forms lacked required documentation such as, Resident # 162 was receiving and antidepressant, antihypertensive, antiparkinsonian, laxative and wore glasses. In addition, the DON acknowledged, the incident form dated, 12/16/2,3 lacked the required documentation that Resident #162 was newly admitted within the last 7 (seven) days and that Resident #162 was wearing unsafe footwear and not the ordered non-skid sole footwear on admission. The DON then stated, the IDT team relies heavily on the nurses note and look at trends to know which fall interventions to put in place. At that time, this Surveyor asked the DON if you don't have the circumstances of the fall documented, how do you do that? The DON then states, You have a point. On 10/02/24 at approximately 12:00 PM, this Surveyor completed a review of the emergency room documentation for Resident #162 fall which occurred on 12/20/23. Resident #162 was sent from the Center to [NAME] Area Medical Center (CAMC) Plateau Medical Center (PMC) following the fall that occurred on 12/20/23, which revealed the following: CAMC PMC 12/20/23: Resident #162 was transferred to CAMC General for neurosurgery, higher level of care with diagnoses: 1. Traumatic Subdural Hemorrhage 2. Laceration without foreign body of scalp 3. History of falling Review of the documentation from CAMC General revealed the following: Resident #162 was admitted to the hospital to the Intensive Care Unit (ICU) with hourly neuro-checks. Resident #162 underwent a repeat Cat Scan (CT) of her head which initially slightly increased, but was then subsequently stable, at which point Resident #162 was transferred from the ICU to the floor. Resident #162 subsequently developed decreased mental status and underwent repeat CT imaging which showed increased subdural with a midline shift. Resident #162 was transferred back to the ICU after which a discussion with family was held who believed that in light of the patient's recent decision to be a Do No Resuscitate (DNR), Resident #162 would not want any invasive procedures or prolonged hospital course. The decision was made to proceed with comfort care with transition to hospice care. Resident #162 was noted to expire on 12/27/23 On 10/02/24 at 1:04 PM, an interview was conducted with the Director of Nursing (DON). At this time, the DON acknowledged that the Center had knowledge Resident #162 had a history of falls at home prior to admission. When this Surveyor reviewed the 12/15/23 72 hour post admission meeting documentation with the DON, she stated when she spoke with Resident #162 daughter, the daughter stated to her, We can't keep her off the floor, that's why she is here. At this time, this Surveyor asked the DON if she asked Resident #162 daughter about circumstances surrounding Resident #162 falls at home in order to implement resident centered relevant interventions to prevent further falls, the DON stated, I am sure I did. When asked the DON to provide documentation of this, the DON acknowledged that she was unable to provide it. This Surveyor then asked the DON if root causes were performed on Resident #162 falls. The DON stated, Yes. When asked the DON to provide documentation, the DON acknowledged she was unable to provide it. This Surveyor then asked the DON what the root causes where for Resident #162 falls, to which the DON acknowledged she could not provide them. This Surveyor then asked how interventions to prevent falls were determined to be resident centered based on the resident's individual risk factors, relevant and appropriate for Resident #162 to which the DON acknowledged she was unable to provide that. This Surveyor then reviewed the Policy and Procedure, Falls Management and Accidents/Incidents and asked the DON to review these policies. Then DON then said, I am aware of what they say. On 10/03/24, shortly after arrival to the facility at approximately 08:25 AM, the Senior Executive Director stated to this Surveyor, We found that a risk evaluation is built into the admission assessment last night. On 10/03/24 at approximately 08:30 AM, an interview was conducted with the DON. At this time, the DON stated that Point Click Care has since been updated and changed, however, the previous admission assessments had a fall risk evaluation embedded in it. At this time, the DON pulled an admission assessment up on her computer and clicked on a number by the admission assessment which was a hyperlink. The DON clicked on this link, which pulled up an addendum which gave a numeric value for different risks factors based on the answers from the admission assessment. The DON stated, We accidentally found this last night. At that time, this Surveyor asked the DON if facility staff were unaware of this tool, how was it utilized to develop the plan of care based on the resident's individualized risk factors. The DON stated, We didn't utilize it. In addition, this Surveyor asked the DON to review said resident's fall care plan and interventions, which were done. This Surveyor then asked the DON, based off said resident's risk factors, how does the care planned interventions address and mitigate this resident's individual risk factors? The DON stated, They don't.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, policy review, family interview, staff interview and medical record review the facility failed to ensure a resident who received nutrition through a Gastrostomy tube (G-tube) received sufficient caloric intake daily to prevent weight loss. Harm occurred when the resident experienced a significant weight loss and G-tube feedings were held. The G-tube feedings were held to encourage the resident to eat by mouth, but the facility failed to have a plan in place to ensure caloric intake would be maintained if the resident did not eat by mouth. This was true for one (1) of three (3) residents reviewed who receive nutrition via a G-tube. Resident #55. Facility Census: 57. Findings included: a) Resident #55 Resident #55 was admitted to the facility from the hospital on [DATE]. The resident had suffered a recent stroke and was admitted to the with a Gastrostomy tube (g-tube). The g-tube allowed the resident to receive nutrition directly through the stomach. b) Facility policy Facility policy titled, Procedure Weight and Heights effective date 06/01/01, with a revision date of 02/01/23 read as follows: 2. Significant weight Change Management: 2.1 Significant weight changes will be reviewed by the licensed nurse for assessment. 2.1.1.1 - 5% in one month 2.1.1.2 - 10% in six month 2.2 The licensed nurse will: 2.2.1 Notify the physician/APP and the Dietitian of significant weight changes: 2.2.2 Document notification of physician/APP and the Dietitian in the PCC (point click care) weight Change Progress Note. 2.3 The licensed nurse will notify the: 2.3.1 Physician/APP of the Dietitian recommendations: 2.3.2 Patient representative of the weight change and the Dietitian recommendations. During an interview, on 07/10/23 at 12:58 PM, Resident #55 wife/Medical Power of Attorney (MPOA) stated she was aware her husband had lost weight. She said the staff were trying to get him to eat by mouth so he could do without the feeding tube and go home. Record review on 07/10/23 at 2:15 PM, revealed the following weights: -07/09/23 - 162.2 Pounds (Lbs.) Mechanical Lift -07/02/23 - 168.4 Lbs. Mechanical Lift -06/25/23 -167.4 Lbs. Mechanical Lift -06/18/23 - 170.6 Lbs. Mechanical Lift -06/11/23 - 171.8 Lbs. Mechanical Lift -06/04/23 - 173.2 Lbs. Mechanical Lift -05/28/23 - 167.6 Lbs. Mechanical Lift -05/21/23 -171.4 Lbs. Mechanical Lift -05/14/23 - 170.2 Lbs. Mechanical Lift -05/07/23 - 177.2 Lbs. Mechanical Lift -05/02/23 - 178.0 Lbs. Standing On 06/04/23, the resident weighed 173.2 lbs. On 07/09/2023, the resident weighed 162.2 pounds which is a -6.35 % significant weight loss in one (1) month. On 05/02/23, the resident weighed 178 lbs. On 07/09/2023, the resident weighed 162.2 pounds which is a -8.88 % significant weight loss in two (2) months. Review of the Speech therapists (ST)' notes found the ST recommended holding the resident's feedings to attempt to get the resident to eat by mouth. Further record review revealed a physician order dated 07/06/23, to hold the feedings to help stimulate PO (by mouth) appetite. Further record review revealed a Medication Administration Record (MAR) for the month of July (typed as written) Enteral Feed Order, one time a day Jevity 1.5 CAL (calorie) Administer continuous via Pump 88 ML(milliliters) per hour. Until total nutrient delivered of 968 ml. (milliliters) Start at rate of 50 ml/hr (milliliters per hour) titrating up to 25mls/hr every 4 hours until goal of 88ml/hr is reached. Start Date 06/06/23. This order was placed on hold from 07/06/23 through 07/09/23. A second order directed: Enteral Feed Order, two times a day Jevity 1.5 CAL administer bolus via gravity 237 ml 2 times a day per day Start Date 06/03/23. This order was placed on hold from 7/06/23 through 07/08/23. Further Record Review revealed Resident #55 PO (by mouth) meal consummation percentage for the days the feedings were held is as follows: -07/06/23 1:19 PM 0 percent (%) -07/06/23 6:37 PM 25% -07/07/23 was void of any documentation -07/08/23 8:18 AM void of any documentation -07/08/23 12:28 PM 0% -07/08/23 5:54 PM 0% -07/09/23 10:52 AM 0% -07/09/23 12:00 PM 0% -07/09/23 6:06 PM 0% In a three (3) day time period the resident only received 25% of a meal via oral intake on 07/06/23 at 6:37. The resident was not weighed directly before and after the feedings were held. The weights indicate the resident was weighed on 07/02/23 and his weight was 168.4 lbs. On 07/09/23 the Residents weight was 162.2 lbs., which was a 6.2 pound weight loss in 7 (seven) days. During an interview on 07/12/23 at 11:18 AM, the Director of Nursing (DoN) stated, We notify the physician when residents looses 5% in a month. This surveyor asked, What if they are weight weekly and have a six (6) pound weight loss in a week?. The DoN stated, It depends if they are requesting to lose weight, have Congestive heart failure, or take diuretics. This surveyor asked, What if a resident has a G-tube and loses weight? The DoN stated,Yes definitely the physician needs to be notified of a weight loss like that. The issue of Resident #55's weight loss was discussed with the DoN. The DoN said it was the speech therapist's idea to stop the feedings for three (3) days to attempt to get the resident to eat by mouth. The DON was asked to provide information as to how the facility addressed the situation when the resident only consumed 25% of one oral meal in a three-day time period and provide documentation of notification to the physician and the registered dietician when the Resident ate only 25% of one of the nine meals that should have been served. She was asked what the plan was if the resident did not eat by mouth? On 07/12/23 at 1:05 PM, the DoN provided a weight change progress note written by LPN #19, dated 07/11/23. The note documented the Interdisciplinary care plan (IDCP) team, dietician and provider monitoring weekly weights related to residents transitioning from tube feeding to PO (by mouth) intake. Current weight was 162.2 lbs. and last week weight was 168.4. Resident weight decreased 6.2 lbs. The resident's tube feeding was placed on hold from 07/06/23 to 07/09/23. Resident bolus and nightly feeding resumed on 07/09/23. Resident trial of holding feeding to stimulate appetite was not successful. Resident PO (by mouth) appetite was poor on 07/06/23, 07/07/23 and 07/08/23. Resident continued to consume 25% or less of meals. Resident declined for staff to assist him with meals. Resident was able to feed self with left upper extremity (LUE) without difficulty. Wife aware of resident weight loss and poor PO (by mouth) appetite. Appetite stimulant discussed with wife (wife's name) requested to think about it and call her tomorrow. Name of family nurse practioner (FNP) and dietician aware. Will follow up with (wife's name) on 07/12/23. The note dated 7/12/23, was the first note written in the resident's medical record after the facility held the g-tube feedings. The DON was unable to provide any documentation the facility addressed the fact the resident only consumed 25% of one meal on 07/06/23, and nothing was eaten by mouth on 07/07/23 or 07/08/23. The DoN was unable to reach the speech therapist for comment due to a family emergency. The DON was unable to provide documentation the speech therapist (ST) addressed the situation in the ST notes. During an interview on 07/12/23 at 2:06 PM, Registered Dietitian (RD) #81 stated he worked with Speech, and they wanted Resident #55 PO (by mouth) intake to increase. Resident #55 was on Argiment AT powder, but the facility could no longer get it, so the RD switched him to Juven. The RD said, I do a nutritional assessment weekly on him, but I have been out for two weeks due to an illness. It looks like (Name of Resident #55's) weight loss was from the feeding being on hold and not eating anything PO (by mouth.) Because last time I was here and completed a nutritional assessment his weight had plateaued, and I adjusted it to accommodate his caloric and protein intake. The Surveyor asked the RD # 81 Should someone have made you aware of the significant weight loss and no nutritional intake? LPN #19 was present during this interview with the RD and LPN #19 stated, The nursing staff should have notified RD #81. LPN #19 also stated, We offer Resident #55 trays, and he keeps refusing them every time. The Surveyor asked the RD #81, how many calories should Resident #55 should consume daily. The RD #81 stated Resident #81 received his calories and protein from the Jevity from G tube feedings and bolus feedings, he also receives Juven for calories and protein. RD #81 said, The orders to hold the feedings should have been written that if he accepted nothing or little by mouth then the feeding should have been altered and the physician notified. The RD was unable to provide documentation to validate this happened. The order directed to only hold the feedings. This surveyor asked the RD #81 When were you notified of Resident #55 significant weight loss from 07/09/23? The RD #81 stated, I did not know anything until I arrived in the facility today, I have been off for two weeks with Shingles. This surveyor referenced the weight change progress note mentioned above to LPN # 19 and asked, When did you write this note dated 07/11/23?. LPN #19 stated, I did put the note in today (07/12/23) I did not notify the RD, the note is wrong, I should not have written that note until I notified the RD and the medical director, I falsified the medical records. During an interview on 07/12/23 at 3:30 PM, the DON was made aware of LPN #19 not contacting the RD or the medical director when Resident #55's significant weight loss occurred and the fact that LPN #19's said she falsified the medical record. A further review of medical records on 07/12/23 at 4:30 PM revealed nutritional assessment by the Registered Dietician, dated 07/12/23, Section B titled Diet Order, Nutrients provided by enteral feeding: Calories 2163 Protein 92 Intake observation (typed as written) Working with ST (speech therapist). per nursing doc. (documentation) ST (speech therapist) requested for feeding to be held from 07/06-07/09 with goal of stimulating appetite. Per nursing notes FNP (family nurse practioner) aware and approved. Meal intakes 0-25% of meals with multiple refusal per activities of daily living (adls) on 14 day review (typed as written) 07/12/23 body weight of 163.6 lbs (pounds) (74.4kgs kilograms) used to calculate needs 25-30 kcals (kilocalories) /kg (kilogram). 1860-2232 kcals (kilocalories) /day 1.3-1.5 gms (grams)/pro (protein) /kg (kilogram) r/t (related to) wound healing 97-112 gms (grams) /pr (per) /day 1mL (milliliter) fluid kcal (kilocalorie) consumed or 30 ml (milliliter) /fluid/kg. (kilogram). 2232 ml (Milliliters) fluid/day (typed as written) Bolus feeding providing 711 kcals (kilocalories), 30 gms (grams) /pro per 360 mL(milliliter) /free water per day Continue feed providing 1452 kcals (kilocalories), 62 gms (grams) /pro 736 mL (milliliters) /free water Juven bid 160 kcals (kilocalories), 5 gms. (grams) /pro per day. Total intake feedings/supps (supplements) 2323 kcal (kilocalories), 97 gms. (grams) /pro.,1096 mL (milliliters) /free water per day. A further record review revealed a nutritional assessment by the RD, dated 06/13/23 reads as follows: Section B titled Diet Order, Nutrients provided by enteral feeding: Calories 2163 Protein 92 (typed as written) 06/13/23 body weight of 173 lbs (pounds) (78.6kgs -kilograms) used to calculate needs 25-30 kcals (kilocalories)/kg. (kilograms) 1965-2358 kcals (kilocalories/day 1.3-1.5gms (grams) /pro/kg (kilogram) r/t (related to) wound healing 102-118 gms (grams) /pr/day 1mL (milliliter) fluid kcal (kilocalories) consumed or 30 ml (milliliter) /fluid/kg. (kilogram) 2358 ml (milliliters) fluid/day (typed as written) Tube feed providing 2160 kcals 92 gms/pro per day + Argiment AT bid (twice a day) providing 240 and 20 gms./pro=2400 kcals (kilocalories) and 112 gms. (grams) /pro per day. Resident meeting estimated needs with supplementation and tube feed alone not including varied po (by mouth) meal intakes. During an interview on 7/12/23 at 5:30 PM the Administrator stated the speech therapist assisted Resident #55 with his meals and the speech therapist tells the Nurse Aides what percentage of meal consumption to document in the Residents medical records. Neither the Administrator nor the DoN was able to contact the Speech Therapist for an interview or to provide more information before the close of the survey.