**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interviews and records review, the facility failed to ensure a safe environment for one of three sampled residents (Resident 1) when the facility staff were aware that Resident 1 attempted to leave the facility a few hours after his admission and did not develop and implement interventions to prevent Resident 1 from leaving the facility unsupervised. This failure resulted to Resident 1 leaving the facility unnoticed few hours after midnight and ended at the hospital with Hypothermia (a medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature) and Traumatic (relating to or denoting physical injury) hematoma (occurs when a blood vessel ruptures and blood collects in the area) of left elbow. Findings: During a telephone interview with Family Member A on 11/17/23 a 2:38 p.m., Family Member A stated he received a call from the facility on Sunday 11/12/23 at 3 a.m. to inform him that Resident 1 was missing. Family Member A stated the nurse told him that Resident 1 managed to leave the building through an unlocked back door outside of Resident 1's room. Family Member A stated Resident 1 was missing for seven hours until a concerned citizen found him on some street corner and called for an ambulance. Family Member A stated Resident 1 was admitted to the ICU (Intensive Care Unit - unit in a hospital providing intensive care given to patients who are acutely unwell and require critical medical care) for Hypothermia and cuts and bruises on his legs and his left elbow. During a review of the Face Sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnosis including but not limited to Diabetes Mellitus (disease that result in too much sugar in the blood); Psychosis (severe mental disorder); and Epilepsy (a disorder of the brain characterized by repeated seizures [alteration of behavior due to a temporary change in the electrical functioning of the brain.]). During a review of the Progress Notes for Resident 1 titled admission Summary dated 11/11/23 at 4:48 p.m. indicated, Resident 1 arrived at the facility after discharge from a hospital at approximately 4:40 p.m. The Progress Note indicated Resident 1 was alert and oriented with intermittent confusion. The progress note indicated, at the end of PM (evening) shift, [Resident 1] attempted to leave facility but staff was able to reorient him to room. The Progress Note indicated Resident 1 calmed down after talking to Family Member A. The Progress Note indicated, Report given, and patient's care was endorsed to charge nurse on duty. During a review of the Progress Notes for Resident 1 titled Nurse ' s Note dated 11/12/23 at 4:13 a.m. indicated, Resident 1 was alert and oriented with intermittent confusion. The Progress Note indicated Licensed Staff B saw Resident 1 during her room rounds (a process of checking on residents) at approximately 12:45 a.m. and a CNA (Certified Nursing Assistant) saw Resident 1 at approximately 1:00 a.m. The Progress Note indicated staff noted Resident 1 was missing from his bed at 3 a.m. and staff attempted to search the facility grounds and adjoining streets for Resident 1. The Progress Note indicated the hospital emergency department was called at 3:23 a.m. to inquire if Resident 1 was admitted back to the hospital, however, there was no record of Resident 1 being admitted back to the hospital. The Progress Note indicated Resident 1's roommate saw Resident 1 leave through the back door at approximately 2:00 a.m. During a review of the hospital document titled Emergency Department (ED) History and Physical dated 11/12/23 at 8:41 a.m., indicated an ambulance brought Resident 1 to the Emergency Department on 11/12/23 at 8:20 a.m. The document indicated a bystander found Resident 1 on the corner of the street with multiple abrasions and altered mentation (disruption in how your brain works that causes a change in behavior). The document indicated Resident 1 presented to the ED with Hypothermia due to cold environment and traumatic hematoma of left elbow. During an interview and concurrent record review with the DON (Director of Nursing) on 11/20/23 at 2:19 p.m., when the DON was asked if she was aware that Resident 1 attempted to leave the facility few hours after his admission to the facility, the DON stated she was not informed of the above incident. After review of the Progress Note dated 11/11/23 at 4:48 p.m. with the DON, the DON verified there was a nurse's note indicating Resident 1 attempted to leave the facility at the end of PM shift on 11/11/23. When the DON was asked what interventions were put in place to ensure Resident 1 did not leave the facility unsupervised, the DON stated a wanderguard (bracelet that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time) was not necessary at that time because Resident 1 calmed down after talking to Family Member A and Resident 1 did not appear he was adamant to leave the facility. The DON stated staff did their routine check, however, she stated there was no set time for staff to check the resident. When the DON was asked how Resident 1 managed to leave the facility unnoticed, the DON stated Resident 1's room was at the far back of the nurse's station and Resident 1 exited through the back door. When the DON was asked how staff would know if a resident left the facility unsupervised through the back door, she stated the door was equipped with an alarm system triggered by a wanderguard. The DON stated if a resident did not have a wanderguard, there was no way for staff to know if a resident left the back door. The DON stated that a room change (closer to a nurse's station) was not considered for Resident 1 after his first attempt to leave the facility because Resident 1 calmed down and was not adamant to leave. During a review of the facility document titled Elopement (A situation in which a resident leaves the premises or a safe area without the facility ' s knowledge and supervision) Risk Observation/ Assessment for Resident 1 dated 11/11/23 at 4:49 p.m., with the DON on 11/20/23 at 2:29 p.m. indicated, If the total score is 10 or greater, the Resident would be considered At Risk for Elopement. Interventions would be implemented as determined by the facility. The document indicated Resident 1 was able to propel self/some assist (2 points); Resident 1 had mood-altering medication (2 points) and Resident 1 had any type of cognitive impairment (2 points) giving Resident 1 a total elopement risk score of six (6). The document did not show checkmarks for the following items: is disoriented and/or confused with no wandering (2 points); and has made 1 or more attempts in the last year (10 points); however, the DON verified that the Progress Note dated 11/11/23 at 4:48 p.m. indicated Resident 1 had intermittent confusion and had attempted to leave the facility. The DON stated the assessment was completed prior to Resident 1's attempt of leaving the facility and concurred that the assessment should have been updated after the incident to reflect an accurate elopement risk score of Resident 1 which could have triggered him as high elopement risk. During an observation, and concurrent interview with the DON on 11/20/23 at 2:36 p.m., the DON stated Resident 1's room was located in the west wing of the building which was observed to be at the far back of the nurse's station. Beside Resident 1's room there was a glass exit door going to the parking lot. The DON stated the doors were locked from the outside during the night to restrict people from outside going in, however, people inside the facility could open the door to go outside. During an interview with Licensed Staff D on 11/20/23 at 2:53 p.m., when asked about the facility policy when a resident was observed attempting to leave the facility unsupervised, Licensed Staff D stated she would notify the doctor and obtain an order for wanderguard or could also use one-to-one supervision (intervention aimed to keep residents safe through observation by staff) as needed. During an interview with Licensed Staff E on 11/20/23 at 2:57 p.m., when asked about the facility policy when a resident was observed leaving the facility unsupervised, Licensed Staff E stated the resident would be listed on the elopement binder and obtain an order from the doctor for wanderguard immediately. Licensed Staff E stated the exit doors (including the glass exit door on west wing) were equipped with alarm systems triggered by a wanderguard to alert the staff of resident's attempt to leave the facility unsupervised. When asked how staff were notified if a resident with no wanderguard left the facility without notice during the night, Licensed Staff E stated the staff would not know unless the resident was observed leaving. Review of the Facility policy and procedure titled Elopements (revised December 2007) with the DON on 11/20/23 at 4:13 p.m., the DON verified the policy did not address how the facility would assess, identify, monitor, and manage residents at risk for elopement. The DON stated the facility did not have other policies and procedure related to elopement other than what was reviewed. During a telephone interview with Licensed Staff B on 11/21/23 at 4:12 a.m., Licensed Staff B stated Unlicensed Staff C informed her that Resident 1 was missing at around 3:00 a.m. on 11/12/23. Licensed Staff B stated Resident 1 ' s roommate said Resident 1 left the facility around 2:00 a.m. using the back door. Licensed Staff B stated staff looked for Resident 1 in and out of the facility. Licensed Staff B stated they did not find Resident 1 during their search. She stated she called the hospital to check if Resident 1 was brought to the hospital but there was no report that Resident 1 was at the hospital. When Licensed Staff B was asked if she received a report from the PM shift nurse that Resident 1 attempted to leave the facility during PM shift, she stated, yes. When Licensed Staff B was asked how she made sure that Resident 1 did not leave the facility again without supervision, Licensed Staff B stated there was only one attempt on PM shift of Resident 1 leaving the facility. Licensed Staff B stated no interventions were put in place to ensure a resident did not leave the facility other than doing her routine room checks every two hours for all residents. Licensed Staff B stated applying a wanderguard to Resident 1 was not necessary because Resident 1 was calm until he was found missing. During a telephone interview with Unlicensed Staff C on 11/21/23 at 4:18 a.m., Unlicensed Staff C stated he looked for Resident 1 all over the facility when he noticed Resident 1 was not in his room before he reported to Licensed Staff B. Unlicensed Staff C stated he and another CNA drove around the area to look for Resident 1, however, they did not find Resident 1. Unlicensed Staff C stated he was aware that Resident 1 had already attempted to leave the facility from the previous shift and stated, that is why I was checking the resident every two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 3 sampled resident's (Resident 1) maintained adequate hydration (fluid status in the body) and nutrition (food intake) during his approximate 3.5 week stay at the facility. Resident 1 was transferred to the facility from Hospital 1 (approximately 90 miles North of the facility) after having his right toe amputated (removed) and his plan of care included post-surgical (after surgery) rehabilitation at the facility, with an ultimate goal of returning home to his wife. Upon admission to the facility, Resident 1 required the assistance of staff for eating and drinking and nursing staff documented he was at risk for dehydration and malnutrition. Although Resident 1 was a Full Code (directs a patient's medical care regarding life-sustaining interventions; full support): 1) Nursing staff and the Registered Dietitian (RD) did not notify Resident 1's physician (Physician F), Nurse Practitioner (NP G), or family when he had a 30.8 (31) pound weight loss 18 days after admission; 2) Nursing staff and the RD did not identify Resident 1's consuming too little fluid, dating back to his admission; 3) Resident 1's severe weight loss was not presented and discussed during the Weight Committee (also known as the Nutritionally at Risk [NAR] Committee; RD and nursing staff monitor/intervene in patient care as it relates to weight loss and weight gain) nor during an IDT meeting (interdisciplinary team of healthcare professionals including nursing, social workers, pharmacy, and dietary staff); 4) Nursing staff did not implement a Change of Condition (COC; clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) in response to Resident 1's severe weight loss and failed to document it in his medical record; and, 5) Certified nursing assistants (CNA's) did not consistently and accurately document Resident 1's oral fluid intake in his medical record. These failures: 1) Caused Resident 1 to lose approximately 30.8 pounds during his first 18 days at the facility; 2) Contributed to Resident 1 ' s approximate 44-pound weight loss (an approximate 27% weight loss) between hospital discharge (on 5/24/23) and hospital ED re-admission [DATE]), Resident 1 ' s approximate 3.5 week stay at the facility; 3) Caused Resident 1 to become severely dehydrated and severely malnourished, 4) Prevented Physician F and NP G from being aware of Resident 1's decline and therefore, prevented them from evaluating and treating his severe weight loss; 5) Caused Resident 1's family, after observing his condition during a visit, to remove him from the facility AMA (Against Medical Advice) and drive him to Hospital 1; 6) Caused Resident 1 to be admitted into Hospital 1's Intensive Care Unit (hospital department in which dangerously ill patients are under constant observation); 7) Prevented Resident 1's family from being aware of his decline, thereby denying them the opportunity to support and comfort him; 8) Contributed to an exacerbation (make worse) of Resident 1's kidney injury; 9) Contributed to a urinary tract infection and aphasia (loss of ability to understand or express speech); and, 10) Potentially contributed to Resident 1 being placed on Hospice care (End of Life Care). Online review of the Mayo Clinic website revealed dehydration occurs when a person uses or loses more fluid than they take in; the body doesn't have enough water and other fluids to carry out its normal functions; if lost fluids are not replaced, dehydration occurs. One common cause is vomiting and older adults and people with chronic illnesses are most at risk. Severe dehydration requires immediate medical treatment. One complication of dehydration is kidney failure, a potentially life-threatening problem. (https://newsnetwork.mayoclinic.org/discussion/dehydration-can-lead-to-serious-complications/). Findings: Review of Resident 1's medical records from Hospital 1 (first admission, prior to his stay at the facility) indicated he was admitted on [DATE] and discharged to the facility on 5/24/2023 (six-day hospital stay). The physician Discharge Summary (physician documentation summarizing the hospital stay), dated 5/24/23, indicated, Hospital Course . male with history of . DM2 (diabetes type 2; chronic disease characterized by elevated levels of blood glucose [blood sugar]), CVA (stroke), and dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) who presents with generalized weakness .1. Right food diabetic ulcer (wound) .right fifth toe amputation (on 5/19/2023) . 2. Fever, positive for group B strep (bacteria) on admission . received ceftriaxone (antibiotic) .3. AKI (Acute kidney injury; an abrupt decrease in kidney function, which encompasses both injury [structural damage] and impairment [loss of function]) present on admission: Baseline serum creatinine (chemical waste product; indicates how well the kidney works; Creatinine is removed from the body entirely by the kidneys) approximately 0.9 mg/dL (milligrams per deciliter – unit of measure showing concentration of a substance), presented (on hospital admission) at 1.3 mg/dL, now (at discharge, 5/24/23) 1.1 mg/dL (normal). Likely . due to dehydration. Received maintenance fluids (intravenous fluids) with normalization of his creatinine . 5. Type 2 diabetes . 6. Physical deconditioning per the family, weak beyond his baseline in the setting of acute (new/current) illness . Discharge details indicated, Follow-Up Plans: Per SNF (skilled nursing facility) orders .Discharge Activity: Ambulates (walks) with Assist (assistance) Discharge Diet: Pureed diet (food with soft, pudding-like consistency; pureed diet continued at the facility) . Wound care: (physician name) from podiatry (medical specialty devoted to the study/diagnosis/treatment of foot and ankle disorders) has been consulting on this patient . Daily dressing changes by nursing at (facility name) . Review of Resident 1's medical records from Hospital 1 (second admission, after his 3.5 week stay in the facility), dated 6/18/2023 at 8:05 p.m., revealed documentation by Physician C titled, Emergency Department Reports, subtitled, History (History of Present Illness). Physician C documented, Family went to go visit Patient (Resident 1) today at (facility name) where the patient has been . since discharge (5/24/2023) to that facility from here (approximately twenty-five days/3.5 weeks). He was noted to be markedly more emaciated (abnormally thin or weak, especially because of illness or lack of food) and nonverbal than he was on their previous visit which was approximately 3 weeks ago. Family elected to sign him out of that facility and bring him here for evaluation. Patient does apparently have a history of being verbal and ambulatory (able to walk) and now is neither . by report, the patient has not been eating much at this post-acute facility for some time . Physician C documented his diagnosis to include acute (new onset) renal failure, dehydration, urinary tract infection, and encephalopathy. Physician C documented Resident 1 was, .clearly quite ill ., and in, critical condition. Physician C documented he was admitting Resident 1 into the Intensive Care Unit. Continued review of Resident 1's medical records from Hospital 1 (second admission), dated 6/18/2023 at 10:11 p.m., revealed documentation by Physician D (a nephrologist; specialist in kidney function) that indicated, Per (family member) at bedside, reports visiting (at the facility) with other family members today, (and) noticed significant weight loss, was non-verbal, unintelligible when (he, Resident 1) attempted to speak. (Family member) reports (the facility) mentioned that he (Resident 1) hasn't eaten or had water in days; even vomited a few times a few days ago . Physician C documented his impression (diagnosis) included, #AKI, oligoanuris (condition lying between anuria [no urine output] and oligouria [low urine output], when less than 100 cc (cubic centimeters) of urine is produced per day; normal urine output is [PHONE NUMBER] cc each day) . etiology (cause) suspect to be due to . severe volume depletion in the setting of significant caloric and water deprivation; as family mentions days without food/water and significant weight loss . Physician D documented a second impression to include, #Electrolytes (minerals in blood/body fluids that affect how the body functions in many ways including the amount of water in the body and the acidity of blood) . HyperNA (increased sodium concentration in the blood; causes lethargy/confusion/excessive thirst) HyperCl (excessive Chloride level in the blood; sign of dehydration, kidney disease, and too much acid in the blood), Hypo K (low potassium) . suspect related to lack of access to free water and poor nutritional intake . Continued review of Resident 1's medical records from Hospital 1 (second admission), dated 6/19/2023 at 10 minutes after midnight and 6/19/2023 at 4:56 a.m., indicated Physician E documented Resident 1's History and Physical assessment (documentation of physician's thorough medical history and physical exam). Physician E's history and physical indicated, . pt (patient) . admitted in May 2023 (first admission) for R fifth toe infection s/p (status post) amputation . who was discharged to (facility name) . who presents to the (Hospital 1 name) ED from the care home (facility) via private transportation [his family drove him] . They (family) visited him for Father's Day and found him to be in terrible condition: generalized weakness, dehydration, non-verbal, oral thrush (fungal infection of the mouth), and significant weight loss . They were concerned enough to remove him from the care home (facility) and drive him to (Hospital 1's) ED . His weight in the ED was 44 kg (kilograms), whereas upon hospital discharge on [DATE]th, it had been recorded as 64 kg, representing a 20 kg (44 lbs [pounds]) weight loss in just 3.5 weeks. Labs (laboratory blood work) showed significant AKI, with a serum Cr (creatinine) of 6.2, whereas it had been 1.1 on May 23rd . UA (urinalysis) was positive for UTI (urinary tract infection). He was given 1 L NS (one liter [1000 cc's] normal saline [intravenous fluids]) as well as Rocephin (antibiotic) . He appeared gaunt and weak and was non-verbal. His tongue was white. His abd (abdomen) was scaphoid (abdominal wall is sunken; concave). Continued review of Physician E's History and Physical (dated 6/19/2023 at 10 minutes after midnight and 6/19/2023 at 4:56 a.m.) indicated Physician E's active diagnoses included, AKI. Due to severe dehydration . Severe dehydration. Probably due to significantly reduced oral intake, for whatever reason (not sure if dysphagia [difficulty or discomfort in swallowing] precluded oral intake, or if he was refusing, or if he was being neglected). Aggressive IVFs (aggressive intravenous fluid treatment) . Severe Acute Protein-Calorie Malnutrition; Unintentional Weight Loss . Aphasia. Could be due to TME (toxic-metabolic encephalopathy; encephalopathy caused by toxins (substances that are poisonous [toxic] to humans; can be produced inside the body), AKI, and hypernatremia (elevated blood sodium level) . Acute Encephalopathy on Chronic Dementia. Acute component most likely a TME due to dehydration . Oral thrush . UTI . S/P (status post) R (right) 5th toe amputation May 2023 . Physician E documented Resident 1's code status was, Code: Full and his disposition was, ICU. Expected stay 2 or greater midnights. Continued review of Resident 1's medical records from Hospital 1 (second admission), dated 6/25/23, indicated Nurse Practitioner K documented a Discharge Summary (summary of hospital stay) that indicated, . removed by family from (facility) . found to have (in the ED) acute renal failure . Thought related to severe dehydration. Also with significant malnutrition with weight loss of 20 kg (kilograms) in last month . 1. Acute kidney injury . likely secondary to severe dehydration . 3. Severe dehydration this is likely the result of very poor oral intake . 5. Severe acute protein calorie malnutrition . Discharge planning: Palliative care (comfort measures only) . Confirmed that patient will be receiving services from hospice . Review of Resident 1's facility electronic medical record (EMR; at the facility) Facesheet (a demographic) indicated he was admitted from Hospital 1, and into the facility on 5/24/2023. Resident 1's facility Facesheet indicated his diagnoses included sepsis (infection; treated at the hospital), aftercare following surgical amputation (his right toe), generalized weakness, difficulty walking, dementia, diabetes type 2, acute kidney failure, Cerebral infarction (history of stroke), blindness in one eye, and dysphagia (difficulty swallowing). Review of Resident 1's facility EMR revealed a nursing care plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes), dated 5/24/2023, that indicated, Nutrition: Resident at nutrition & hydration risk . Goals on the care plan indicated, Maintain po (oral) intake (greater than) 75% (for) most meals . maintain CBW (current body weight) 146# (146 pounds) +/- (plus or minus) 5# (5 pounds) . Adequate fluid intake . No sign/symptoms of dehydration . Nursing interventions included, Assess for signs/symptoms of dehydration . Assist with meals . Encourage adequate fluids as tolerated, monitor % of intake . RD evaluation as needed .Weight as ordered . A second nursing care plan, dated 5/24/2023, indicated, Dehydration: At risk for dehydration .Interventions .Encourage increase p.o. fluid .monitor for s/s (signs/symptoms) of dehydration . provide adequate fluids . A third nursing care plan, dated 6/5/2023 indicated, Resident is in facility for short term placement . Lives in (city name) w/ (with) his wife and support from his adult children . Wife plans for him to return home . Resident 1's facility EMR contained one provider (physician or nurse practitioner) progress note documented by NP G on 6/2/2023 at 1:49 p.m. (nine days after admission) that indicated, .Seen today for initial exam . Here for rehab (rehabilitation) following hospitalization for AKI, R (right ) diabetic foot ulcer s/p (status post) partial amputation of the R 5th (toe) . PMH (past medical history) DM II (diabetes type 2) Dementia . Glaucoma (increased pressure within the eyeball, causing gradual loss of sight) - R eye blind .CODE status: FULL . NP G documented her assessment and plan for Resident 1's stay was, Weakness/ambulatory impairment - PT/OT (physical therapy/occupational therapy) - Supportive care Dementia .(medication for treatment listed) .AKI - Resolving: CR (creatinine) 1.1 (normal level) at time of discharge (from hospital, 5/24/23) . DMII - controlled - R foot wound s/p R (sic) - Wound care per nursing - F/u (follow up with) podiatry . During a tour of the facility and concurrent interview on 8/16/2023 at 1:30 p.m., LN H was asked how staff handled residents with weight loss. LN H stated the RD came to the facility three times per week and made recommendations (for nutritional interventions) and the resident would be discussed at the Weight Committee. LN H stated staff monitored resident intake and output and RNA's (restorative nursing assistants; help residents perform tasks that restore/maintain physical function as directed by the established care plan) weighed residents. Review of Resident 1's medical record revealed one assessment from the RD (dated 5/31/2023 - one week after admission) that indicated, E Physical and Mental Functioning . e. Feeds Self . (MDS assessment indicated he required assistance of one staff to eat/drink). RD documented the following data regarding Resident 1: L. Fluid Intake . 1. Consumes 1,500 and over cc/day . M . 5a. Meal Intake % 76% . Under the category titled, S. Nutrition Goals/Monitoring and Evaluation, the RD documented, . Recommendations: Continue with current POC (plan of care) Goals: Maintain CBW (current body weight) 146# (pounds) +/- (plus or minus) 5# (pounds). Maintain po intake (greater than) 75% x (for) most meals. Maintain (+) [positive] hydration status. Eval (evaluation): Resident with dementia and currently tolerating puree texture diet . Will continue to monitor PRN (as necessary) . (Resident 1 ' s facility diet order was CCHO (consistent, constant, or controlled carbohydrate diet – secondary to DM), puree consistency, with thin liquids). During an interview and concurrent record review on 8/16/2023 at 2:20 p.m., the Registered Dietitian (RD) was asked how the facility handled resident weight loss and specifically, Resident 1's weight loss. RD stated residents who were newly admitted to the facility had their weights monitored weekly for four weeks. She stated weekly weights were discontinued until the resident's weight was stable, at which time the resident would be weighed monthly. RD stated interventions to address the weight loss included a root cause analysis (determining the potential causes) including assessing the resident's appetite/food preferences, determining if medications may be a contributing factor, and considering absorption [absorbing nutrients from the small and large intestines] issues. The RD stated additional interventions included discussing the weight loss at the Weight Committee (Registered Dietitian, DON and/or the Assistant DON, and the treatment nurse [nurse who treats wounds]) and calling/faxing the physician if necessary. The RD stated the physician was always faxed to notify him/her and to suggest interventions. During the same interview and concurrent record review on 8/16/2023 at 2:20 p.m., Resident 1's medical record titled, Weights and Vitals Summary indicated Resident 1 was weighed 5/25/23 (the day after admission) and his weight was 148 pounds; his weight on 5/31/23 was 146 pounds; and his weight on 6/12/23 was 117.2 pounds (a 30.8-pound weight loss in approximately eighteen days). The RD stated in addition to the three documented weights, Resident 1 had an undocumented weight obtained on 6/8/23 which was 119 pounds. During the same interview and concurrent record review on 8/16/2023 at 2:20 p.m., RD stated Resident 1's family took him out of the facility on 6/18/23 AMA. When asked why the family took Resident 1 out AMA, RD stated the family wanted to take him because he was declining. When asked if she thought Resident 1 had been declining, RD stated he had a vomiting issue. RD stated she did not remember the details but Resident 1 had been eating well but was vomiting. RD stated Resident 1 was eating everything until he began having nausea and vomiting. She stated Resident 1 stopped eating two days prior to his family taking him to the Emergency Department. During the same interview and concurrent record review on 8/16/2023 at 2:20 p.m., RD was asked about the interventions implemented to address Resident 1's weight loss and she stated there were, none. RD stated her normal process was to ask for a re-weight (to ensure the weight was accurate) and then document the re-weight. When asked why that was not done for Resident 1, RD stated she did not know. RD stated she had added additional items to his tray such as yogurt, but this was written in her binder and did not show up in the medical record. When asked if the CNAs or nursing staff informed her of Resident 1's weight loss, RD stated she tracked resident weights herself. When asked why Resident 1's medical record did not have an RD progress note (with one exception of the RD assessment on 5/31/2023), RD stated she normally wrote a note. RD stated she was not sure why (his weight loss) was not caught. RD stated the weight loss was missed. Review of a document titled, Weekly Weights 6/4/22 - (facility name), provided by the RD (weight loss tool; not located in Resident ' s EMR), indicated Resident 1 had an 18.49% weight loss. RD stated she assumed that number was incorrect. During the same interview and concurrent record review on 8/16/2023 at 2:20 p.m., RD stated the facility received a call from Adult Protective Services (APS) on 7/18/23 (after Resident 1 had left the facility) regarding Resident 1. RD stated APS was requesting Resident 1's medical progress notes. Review of facility policy titled, Weight Assessment and Intervention, subtitled, Weight Assessment (revised March 2022) indicated, .4. The threshold for significant unplanned and undesired weight loss will be based on the following . a. 1 month - 5% weight loss is significant; greater than 5% is severe . During a telephone interview on 9/11/2023 at 3:31 p.m., Adult Protective Services Social Worker (APS S.W.) stated (an anonymous complainant) had filed a complaint with her department (Adult Protective Services). APS S.W. stated the complaint indicated that Resident 1's family had gone to visit him at the facility and found him in a, bad situation. APS S.W. stated the family was very upset the facility had not communicated (with them) that he had declined (in health status). APS S.W. stated the family took Resident 1 (out of the facility) and brought him to Hospital 1. APS S.W. stated the family had not been able to visit Resident 1 at the facility for three weeks and when they saw him at the facility (on 6/18/2023), they took him straight to Hospital 1. Review of a nursing progress note from Resident 1's medical record (dated 6/18/2032 at 11:50 a.m.), documented by Licensed Nurse A (LN A), indicated, Approx (approximately) 0930 (9:30 a.m.) residents ' family .want the resident to be discharged AMA (against medical advice) . They (family members) said that they are very concerned that the resident seems to be declining and he has lost weight. They want to take him home so they can . take care of him better . During an interview and concurrent record review on 9/14/23 at 2:33 p.m., Certified nursing assistant B (CNA B) stated she had worked with Resident 1 once or twice in the past. When asked how she monitored a resident's intake (oral) and output (urine and stool), CNA B stated she looked at the meal tray and marked down how much they ate and drank. She stated if a resident only drank a little, she would tell (verbally) the nurse. During an interview on 9/14/23 at 2:55 p.m., LN A stated she had some recollection of Resident 1 and he had been her patient when she worked in the morning (morning shift). When asked what she recalled, LN A stated Resident 1's family took him out of the facility AMA. LN A stated she remembered they said, they could take care of him better (than the facility). During the same interview and concurrent record review on 9/14/23 at 2:55 p.m., LN A stated Resident 1 was a fall risk and therefore, his room was near the nurse's station. LN A stated, he's a feeder (unable to feed himself; requires staff assistance to eat). LN A reviewed the Weights and Vitals Summary (that indicated Resident 1 lost 30.8 pounds between 5/25/23 and 6/12/23) and stated it was a, significant weight loss. When asked if she was aware of Resident 1's weight loss, LN A stated she did not remember. When asked what she would have done if she had been aware, LN A stated she would have called the doctor, notified the RD, and documented a note (in the nurse progress notes). LN A confirmed Resident 1's EMR did not contain a nurses note indicating Resident 1's physician (Physician F) or family were notified of the significant weight loss. LN A confirmed Resident 1's medical record did not contain a Change of Condition (COC) or an SBAR (Situation-Background-Assessment-Recommendation; communication technique between health care team members regarding a patient's condition) nursing note identifying the significant weight loss. During the same interview and concurrent record review on 9/14/23 at 2:55 p.m., LN A confirmed a COC, dated 6/16/23 (four days after his documented significant weight loss), was located in Resident 1's medical record. LN A stated the form was completed due to Resident 1 experiencing nausea and vomiting. LN A stated Resident 1 had emesis (vomiting) three times in an eight-hour period and NP G had been notified. LN A confirmed NP G had ordered medication (Zofran) to treat Resident 1's nausea and vomiting after she was notified. LN A confirmed Resident 1's weight loss was not addressed in the COC dated 6/16/23. Review of facility policy titled, Change in a Resident's Condition or Status, subtitled, Policy Statement (revised February 2021) indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition . Under subtitle, Policy Interpretation and Implementation, the policy indicated, 1. the nurse will notify the resident's attending physician . when there has been a(an): .d. significant change in the resident's physical/emotional/mental condition . 2. A significant change of condition is a major decline . in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard . interventions . c. requires interdisciplinary review and/or revision to the care plan . 3. Prior to notifying the physician . the nurse will make detailed observations and gather relevant and pertinent information . 4 . a nurse will notify the resident's representative when: .b. there is a significant change in the resident's physical, mental .status .5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition . During an interview and concurrent record review on 9/14/23 at 3:57 p.m., the Social Worker (SW) stated her memory of Resident 1 was that he lived in a nearby city with his wife, he was at the facility for therapy and nursing care, and the plan for him was to return home with his wife (after discharge from the facility). Review of an IDT progress note (dated 6/12/2023 at 4:46 p.m. - after Resident 1's weight loss was documented in his medical record) indicated the following: Note Text: Psychoactive Medication Review. The IDT note indicated the DON, LN H and the SW were the members present at the meeting. SW reviewed the IDT note and confirmed the meeting was, just (a) psychoactive (medication) review and did not address his weight loss. When asked if she had been aware of Resident 1's significant weight loss, the SW stated she was, not aware at that point. SW stated she had called Resident 1's family member two days after he left the facility AMA and his family member informed SW that Resident 1 was in the Hospital 1's Intensive Care Unit. During an interview and concurrent record review on 9/14/2023 at 4:29 p.m., the DON was asked if she had had any interaction with Resident 1 during his approximately three and a half-week stay at the facility and she stated, no, just rounding (proactive, systematic, nurse-driven, evidence-based intervention that helps anticipate and address patient needs). The DON stated she had not spoken to his family, either. The DON reviewed the Weights and Vitals Summary, documenting weights from 5/25/23, 5/31/23 and 6/12/23, (indicating Resident 1's 30.8-pound significant weight loss) and stated it was a huge weight loss. When asked what staff should have done with this information, the DON stated normally staff would recheck the weight to ensure accuracy, notify the RD for her review and recommendations, notify the DON or ADON (assistant DON), call (notify) the provider (physician or nurse practitioner), notify the family and/or responsible party, document (interventions and actions taken), and write a COC note to document and monitor the issue. When asked if any of these interventions had been taken for Resident 1, the DON stated, Unfortunately, I do not remember and further stated she did not remember if she was notified. The DON confirmed the EMR did not contain evidence Resident 1's weight had been rechecked or that the DON, RD, or ADON had been notified of the weight loss. During the same interview and concurrent record review on 9/14/2023 at 4:29 p.m., the DON confirmed the RD had provided a nutritional evaluation for Resident 1 on 5/31/23 but the medical record did not contain documentation by the RD of Resident 1's significant weight loss. During a concurrent interview and review of Resident 1's medical record on 9/14/23 at 4:45 p.m., the Director of Staff Development (DSD) and the DON reviewed the documents titled, Documentation Survey Report v2 (report generated when the CNA's charted resident's intake/output). The documents indicated that from 5/24/23 (admission) until 6/18/23 (leaving AMA), the CNA's documentation of Resident 1's fluid consumption was both incomplete and reflected he had a low fluid intake; the DSD and DON confirmed this information. The report indicated on 5/25/23, CNA's documented Resident 1 consumed a total of 360 cc of fluid (the RD's assessment indicated he consumed 1500 cc/day) but his fluid intake at night was left blank; on 5/26/23, the CNA's documented he consumed a total of 580 cc. During Resident's stay at the facility, the CNA's failed to document his fluid intake on approximately seven occasions (Day shift: 6:30 a.m. to 2:30 p.m. - on 6/3/2023; Night shift: 10:30 p.m. to 6:30 a.m. - on 5/24/2023, 5/25/23, 5/29/23, 6/1/23, 6/3/23, 6/14/23); the DSD and DON confirmed this trend. During his stay at the facility, the documents indicated Resident 1 consumed between 100 cc - 1110cc of fluid per day. The documentation indicated Resident 1 consumed less than 500cc in twenty-four hours on approximately eight occasions (5/25/23, 5/27/23, 5/29/23, 5/31/23, 6/3/23, 6/9/23, 6/14/23, 6/15/23 and 6/17/2023). The DSD and DON confirmed nursing staff did not document Resident 1's low oral intake trend on their daily nursing notes titled, Nursing - Daily Skilled Charting Form - V 3.0 or on the MAR (Medication Administration Report) from 5/24/23 through 6/18/23. During a telephone interview on 9/18/2023 at 2:17 p.m., Physician F (Resident 1's doctor and the facility's Medical Director at the time of Resident 1's admission) stated Nurse Practitioner G (NP G, Resident 1's NP during his stay) worked under him (he supervised her work). Physician F was asked about Resident 1's weight loss, poor fluid intake, lack of nurse monitoring of intake, and lack of RD and nurse response to his severe weight loss. When asked if he had been notified Resident 1's weight loss, Physician F stated he did not recall being notified. Physician F stated if a resident who was a Full Code (like Resident 1) had a thirty-one-pound weight loss, he and/or the NP would act on the information. He stated they would recheck the weight for accuracy, assess any medical trends with the resident, call and notify the family, have a Care Conference to discuss the issue, get a written nutritional evaluation, possibly order an appetite stimulant, possibly order intravenous fluids, and order stat (immediate) labs (laboratory tests such as albumin (a simple form of protein that is found in blood serum). Physician F stated if he had known about Resident 1's decline, he would have intervened. When asked if he thought the facility's failure to monitor and intervene in Resident 1's fluid status and weight loss contributed to his diagnosis in Hospital 1 (kidney injury, severe dehydration, severe malnutrition, etc.), P[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to develop and implement interventions to assure a resident with dementia received person centered care for activities of daily living for one of 26 sampled residents (Resident (R) 98), selected for review. As a result of this deficient practice, R98's dementia care needs were not addressed resulting in the inability to achieve the highest level of psychosocial and mental well-being. This deficient practice had the potential to affect the other 28 residents identified by the facility with a diagnosis of dementia, out of a total census of 119. Findings include: Review of the admission Record located in the front of R98's paper medical record, indicated he was admitted to the facility on [DATE] with diagnosis including dementia with behavioral disturbances. Review of the 30 day Minimum Data Set (MDS), an assessment tool completed by the facility staff to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end point of the evaluation period, of 07/09/19, located under the MDS tab in the electronic medical record (EMR), Section C: Cognitive Patterns, a Brief Interview of Mental Status (BIMS) score of 3 of 15, indicating severely impaired cognitive abilities; Section E: Behaviors, rejection of care was not present; Section H: Bladder and Bowel, the resident was always incontinent of bowel and bladder. The Care Plan dated 06/27/19, located under the Care Plan tab of the EMR, documented a focus area of refusing therapy services. The goal documented, he would be comfortable and have his needs met, with approaches of encouraging the resident to attend therapy, monitor for ill effects of his refusals, monitoring his vital signs each shift, and notifying his physician of his refusals. The Care Plan dated 06/27/19, located under the Care Plan section of R98's paper medical record, indicated a focus area for Activities of Daily Living (ADL). The focus area indicated the resident required assistance for bathing, with the Goal, the resident would be well-groomed and free of odor, and the Intervention, the resident should be provided or assisted with a shower or bed bath as scheduled. The Care Plan dated 07/23/19, located under the Care Plan tab of R98's EMR indicated the resident was incontinent of bowel and bladder, and was on a check and change program. Review of 98's EMR failed to reflect the diagnosis of dementia with behavioral disturbance was incorporated in the care plan and failed to reflect individualized person centered interventions were implemented in the plan of care. Observation on 08/06/19 at 11:40 AM, identified R98 was lying in bed on his back, wearing a hospital gown. He was not visibly soiled, and there was no odor in the room. The resident was leaning slightly to his left with the head of his bed elevated to approximately 30 degrees. There was an overbed table to the resident's left which contained a water mug approximately half full of water. There were no snacks or other food items visible in the room. The resident stated he was hungry and wanted something to eat. At 11:42 AM, Certified Nurse Aide (CNA) 1 entered the room and offered the resident a bed bath. The resident stated he did not want a bath but wanted something to eat. CNA1 responded by stating, I have to change you. The resident became agitated and stated, No you don't Goddammit. You try to do that every damn day. I don't need to change clothes that much, I'll exchange [the bath] for something to eat. As CNA1 turned to leave the room, the resident again asked for something to eat. CNA1 left the room without responding. Observation identified that at 11:58 AM, CNA1 returned with CNA3. No other staff were observed to enter the resident's room after CNA1 left the room. CNA3 approached R98's bed as CNA1 went into the bathroom and filled a basin with soapy water. CNA3 told R98 they were there to clean him. R98 stated, No, I'm clean enough. I'm not going to do this every day. I don't want that water here either [referring to the basin of soapy water]. The resident stated he fought in World War II in Japan and knew when he was dirty. CNA3 asked some questions about the food the resident ate in Japan while she and CNA1 attempted to reposition the resident in bed. CNA1 and CNA3 did not inform the resident they were going to reposition him. As they moved the resident's right arm, he yelled out, Ow, stop it. Stop it. I feel like a damn piece of sandpaper. CNA1 stated, I'm being gentle. CNA1 then used a washcloth to wash the resident's face. He was agitated and yelled, Ow, ow, ow, you're rubbing too hard. You're rubbing too Goddamned hard, Stop. CNA1 stated, I'm not rubbing, I'm patting, and continued the task. The resident stated in a loud tone of voice, Lady will you stop that. Both of you. I'm hungry. CNA1 and CNA3 continued to bathe the resident's neck and arms, with the hospital gown in place. CNA3 told the resident it was almost lunchtime. The resident stated, That don't mean a Goddamn thing. I'm hungry now. That's f***ing hot water. I hurt. I'm going to find somewhere else to live. Continued observation identified, CNA3 and CNA1 began to remove R98's hospital gown, so the observation continued from the hallway. The privacy curtain around the resident's bed was drawn, but the door to the room was open. From the hallway outside the room, the resident could be heard calling out, Ow, ow, ow, I'm hungry, that hurts, and You two knock it off repeatedly. At 12:07 PM, the resident yelled, Quit touching my Goddamn ass. At 12:09 PM, the resident began to call out, Ow, let go of my Goddamn legs At 12:10 PM, CNA3 left the room. CNA1 remained in the room and stated, It's almost lunchtime. Now you can have your lunch. R98 began to call out that he needed to urinate. CNA1 told him she would get him another blanket. The resident stated loudly, Blanket, hell I've got to pee. CNA1 went into the bathroom, emptied the basin of water into the sink, and said that she would bring the resident another blanket. CNA1 gathered the soiled towels used for the bed bath and left the room. R98, alone now in the room, began calling out loudly, Please help me, where's my food, I've got to pee. At 12:14 PM, CNA1 returned to the room with a blanket. R98 stated, I'm hungry. Can I get some food? I'll take anything. CNA1 stated she would get some ice cream, left the room, and returned a minute later with a pudding cup. She assisted the resident to eat the pudding without speaking to him, then left the room. No staff entered the room until 12:40 PM. Observation continued at 12:22 PM, the surveyor approached the resident in his room. He was lying in bed, dressed again in a hospital gown, leaning slightly towards the left, with the head of his bed elevated to approximately 30 degrees. The resident stated, I'm hungry and I have to pee. When asked about the pudding cup, the resident stated, I ate it. It wasn't very good. I want some f***ing food. They keep saying they'll bring it and then they never do. I'm going to pee my pants, I'm hungry, and I f***ing hurt. Staff did not enter R98's room until 12:40 PM, though he continued to call out that he was hungry and had to urinate. At 12:40 PM, LVN1 entered the room and asked R98 if he was in pain. The resident responded, Yes, hunger pains. LVN1 offered R98 ice cream, and he stated he would like vanilla. LVN1 left the room and returned a minute later with a small Styrofoam container of strawberry ice cream. She removed the lid, began to set the container down on the resident's overbed table, then stopped herself and stated, Oh, it's too frozen. We'll have to wait for it to thaw. As she placed the lid back on the container, R98 shouted, No please I'm hungry, I can eat it, just leave it please. LVN1 told R98 again that the ice cream was too frozen and he would have to wait. At 12:44 PM as LVN1 turned to leave the room with the ice cream, CNA1 brought the resident's lunch tray and began to cut up his food. The resident asked her to hurry, and cut it into big bites damn it, I'm hungry. Interview on 08/06/19 at 12:50 PM, LVN1 stated CNA3 informed her after R98 had been bathed that he was complaining of pain, so she went into the room to assess his pain level. LVN1 stated R98 ate breakfast that morning, and had a snack mid-morning, so it was acceptable for the CNA's to bathe him before his lunch was served, even though he was complaining of hunger. LVN1 stated she brought ice cream in response to the resident's statements that he had hunger pains, but the ice cream was too frozen for the resident to eat so she planned to let it thaw for a few minutes once she removed the lid. LVN1 stated she was planning to keep the ice cream on her medication cart until it was thawed enough to eat, since the resident needed assistance to eat. LVN1 stated she knew the resident wanted her to leave the ice cream, but she also knew his lunch would be delivered shortly so felt it was acceptable to take the ice cream. Interview on 08/06/19 at 1:55 PM, CNA3 stated she did not normally take care of R98, but CNA1 asked for assistance to give him a bed bath on 08/06/19. CNA3 acknowledged R98 was complaining of hunger and pain throughout the bath. CNA3 stated, He was not my resident, but if he was, I would have stopped when he said no. CNA3 stated she thought CNA1 just wanted to hurry through it. CNA3 stated, I had the authority to stop CNA1, but I didn't. He was her resident, not mine. Interview on 08/07/19 at 08:48 AM, R98's physician, who is the facility's Medical Director (MD) stated the resident frequently complained of hunger, and frequently refused cares. The MD stated if staff were forcing R98 to bathe, especially when voicing complaints of other physical discomforts, the facility needed to review its approaches. The MD stated in general, the resident had the right to refuse cares, but there is a line if the resident lacks the capacity to understand the social consequence of his decision, then staff have to proceed. The MD stated the parameters defining at what point staff should halt or proceed with cares during resident refusals should be identified in the resident care plan, but for R98 he would consider odor to be a reason to proceed with a bath against the resident's objections, and weight gain to be a reason to not provide food when the resident complained of hunger. Interview on 08/07/19 at 9:00 AM, the Master Social Worker (MSW)1 stated she would typically be informed of continued resident refusals of care, so there could be further evaluation of the root cause and a care plan could be developed. MSW1 stated she was not informed R98 was resistive during care. MSW1 reviewed R98's care plan and confirmed the care plan did not include a focus area for dementia and dementia care interventions were not implemented for R98. Interview on 08/07/19 at 9:36 AM, the Director of Nursing (DON) said she agreed the CNA's should have listened to the resident, even though he had a diagnosis of dementia, and informed the nurse of his concerns before proceeding with the bath. Interview on 08/07/19 at 12:26 PM, CNA1 stated she was often assigned to care for R98, and when assigned to care for him she often gives him a bed bath. When questioned about the observation on 08/06/19, CNA1 said, I know I didn't do a thorough job. I wanted to wash his hair, but it's hard because he's always in pain when we move him, and he's really confused. I always ask him if I can change him, and he usually says yes even though he always tells me he is clean or just changed himself. If he says no, I leave and come back, but if he still says no, we just have to go ahead and do it [provide care]. Regarding the resident's statements that he was hungry, CNA1 stated, He's so confused, he thought he hadn't eaten yet, even though he ate breakfast that morning. I knew he was hungry again, because it was almost lunchtime, which is why I wanted to hurry. I told him I would get him some ice cream. He has the right to refuse, but if he is dirty, we have to just go ahead and clean him. He's just so confused. On 08/07/19 at 1:00 PM, LVN5 in interview stated, she has been one of R98's regular nurses since he had moved to his current room several weeks ago, and it would be her expectation that CNA's stop performing cares when a resident refused, so long as the resident was covered and safe, and inform the nurse. Interview on 08/08/19 at 9:00 AM, the Staff Development Coordinator (SDC) stated she was responsible for training staff to provide care to residents with dementia. The SDC stated it would be her expectation that CNA's would stop providing care when a resident refused and inform the nurse for further evaluation. The SDC stated the CNA's should listen to the needs expressed by a resident, no matter how confused, and respond to those needs. Regarding the 08/06/19 observation, the SDC stated the CNA's should have stopped the bath, provided the resident with something to eat, and informed the nurse of his complaints of pain. Interview on 08/08/19 at 10:27 AM, the administrator stated the CNA's should have stopped the bath and reported the resident's concerns to the charge nurse. The administrator said he would make sure all staff received re-education on this matter. The facility policy titled Requesting, Refusing and/or Discontinuing Care or Treatment Policy Statement, revised May 2017 and provided by the Administrator on 08/08/19 at 4:09 PM documented, The resident is not forced to accept any medical care or treatment and may refuse or discontinue care or treatment at any time. This includes care or treatment prescribed by a physician, care or treatment that has been administered previously and/or care or treatment that the resident has previously agreed to but has not yet been administered.