**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive systematic approach to ensure effective monitoring to maintain acceptable parameters of nutritional status for 5 of 5 sampled Residents (23, 43, 51, 58, and 673) when: 1. Resident 23 experienced a severe unplanned weight loss of 16 lbs. (pounds- a measurement of weight), 8.04% from the weights obtained on 11/5/24 to 2/26/25. Weights were obtained but a weight loss change of condition was not completed, the resident was not placed on weekly weights, the Registered Dietitian (RD) did not reassess the resident to determine appropriate interventions, weight loss was not communicated to the Physician, the IDT (IDT- an interdisciplinary team comprised of professionals from various disciplines who work in collaboration to address a Resident with multiple physical and psychological needs) did not address the severe unplanned weight loss, and the care plan did not reflect the severe unplanned weight loss for the interventions to be implemented. Resident 23 was diagnosed with uncontrolled diabetes mellitus (condition in which the body has trouble controlling blood sugar). 2. Resident 43 experienced a severe unplanned weight loss of 14 lbs. or 11.67% from the weights obtained on 11/5/24 to 2/7/25. Weights were obtained but a weight loss change of condition was not completed, the resident was not placed on weekly weights, the RD did not reassess the resident to determine appropriate weight loss interventions, weight loss was not communicated to the Physician, the IDT did not address the severe unplanned weight loss, and the care plan did not reflect the severe unplanned weight loss for the interventions to be implemented. Resident 43 was diagnosed with hyperlipidemia (elevated blood fat levels) and a body mass index (BMI) of 16.5 (less than 18 is underweight). 3. Resident 51 experienced a severe unplanned weight gain of 16 lbs., 10.26% from the weights obtained on 11/5/24 to 2/7/25. Weights were obtained but the resident was not placed on weekly weights, the weight loss was not addressed by the Physician, the IDT did not address the severe unplanned weight loss, and the care plan did not reflect the severe unplanned weight loss for the interventions to be implemented. Resident 51 was diagnosed with chronic kidney disease (CKD) (when the kidneys cannot filter waste). 4. Resident 58 experienced a severe unplanned weight loss of 23 lbs., 12.3% from the weights obtained on 12/24/24 to 2/20/25. Weights were obtained but the resident was not reassessed by the RD to determine appropriate interventions, and the IDT did not follow up with the Physician to address the severe unplanned weight loss to ensure appropriate interventions were implemented. Resident 58 was diagnosed with hypothyroidism (condition which the thyroid gland does not produce enough thyroid hormone). 5. Resident 673 experienced a severe unplanned weight loss of 8.6 lbs., 5.78% from the weights obtained on 11/5/24 to 2/6/25. Weights were obtained but a change of condition for severe unplanned weight loss was not completed, the Physician or the RD did not address the severe weight loss with the IDT to determine effective interventions to prevent further weight loss, and the care plan did not reflect goals to address the severe unplanned weight loss. Resident 673 was diagnosed with dysphagia (difficulty swallowing) and hemiplegia (paralysis of one side of the body). As a result of these failures, these five (5) residents compromised nutritional status was not addressed which could have resulted in further medical complications including but not limited to dehydration, loss of muscle mass with decreased mobility and negatively affect the diagnoses for each resident, which could include death. Because of the severe unplanned weight losses for Residents 23, 43, 51, 58, and 673 and the facility lacking a comprehensive systematic approach to ensure effective monitoring to maintain acceptable parameters of nutritional status, an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) situation was called on 2/27/25 at 7:45 PM, under Code of Federal Regulations (CFR) §483.25 Nutrition/Hydration Status Maintenance (F692) with the Administrator (ADM), Director of Nursing (DON), and Dietary Services Manager/Registered Dietitian (DSM-RD) in attendance. The IJ template was provided to the ADM. The facility submitted an acceptable IJ Removal Plan (Version 3) on 2/28/25, at 4:53 PM. The IJ Removal Plan included but was not limited to the following: 1) Notify the Physicians for Residents 23, 43, 51, 58, and 673 of significant and severe weight change. 2) Re-weigh all five residents and place on weekly weights for four weeks. 3) Review labs (clinical blood tests), weights, physician visits, PO (eating by mouth) intake, and therapy orders for the five identified weight loss residents 23, 43, 51, 58, and 673. 4) The RD will re-assess and re-evaluate Residents 23, 43, 51, 58, and 673 nutrition status. 5) Immediate training for Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) on monitoring and recording meal intake percentages and supplement orders. 6) The RD will monitor the weekly weights and residents with significant weight loss of 5% /5# (pounds) x 30 days, 7.5% x 90 days, 10% x 180 days, and 3# or more for residents who are under 100# x 30 days were reevaluated by the Senior (Sr.) Regional Registered Dietitian and followed up by the Facility RD, as well as the Weight Variance and Nutrition Condition Interdisciplinary team (IDT) weekly for 4 weeks, then, bi-monthly for 2 months. 7) IDT will monitor for sustainable compliance to determine weight variances/significant weight losses and accuracy of assessments to meet weight loss resident's nutritional needs and goals of care such as improved PO intake or weight goals are met. Identified concerns will be addressed immediately and reported to the DON and Administrator for follow-up as warranted. 8) Senior Regional Registered Dietitian provided one to one (1:1) re-education to the Registered Dietitian on Evaluation of Weight & Nutritional Status Policy and Procedures and an RD competency with current facility's RD. 9) Regional Quality Management Compliance (RQMC) and Senior RD completed education on Evaluation of Weight and Nutritional Status policy with IDT members. 10) the Medical Director was notified by the Administrator and Director of Nursing (DON) of the concerns related to Weight Loss and Nutritional Assessments and presented and discussed the immediate action plan for implementation. 11) Pharmacy medication regimen review completed for the five (5) identified weight loss residents 23, 43, 51, 58, and 673 for review of weight change related medications. The components of the IJ Plan of Removal were validated through observations, interviews, and record review and the IJ was removed on 3/3/25 at 12:50 PM with the ADM and DON in attendance. Findings: According to a 2002 American Academy of Family Physicians Journal article, Involuntary weight loss can lead to muscle wasting, decreased immunocompetence, (the ability for the body to develop an immune response) depression and an increased rate of disease complications. Research has shown institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year. (www.aafp.org/afp) According to a literature review of the Academy of Nutrition & Dietetics, Nutrition Care Manual, dated 2022, .Unintended weight loss is linked to increased mortality (death) among older adults . residents in long-term-care facilities who continue losing weight have a higher mortality rate compared with those who stop losing weight. Weight loss of 5% or more within 30 days is associated with a tenfold increase in the likelihood of death . https://www.nutritioncaremanual.org/ 1. A record review of Resident 23's Facility admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), diabetes mellitus, hypertension (elevated blood pressure levels), gastro-esophageal reflux disease-GERD (a condition where stomach contents flow back up into the esophagus, causing irritation) and hyperlipidemia (abnormally high levels of fat in the blood). Record review of Resident 23's minimum data set (MDS- a standardized comprehensive assessment of residents' health conditions, functional abilities, and care needs) report dated 1/8/25 indicated the resident's brief interview of mental status-BIMS (a short cognitive screening test) score was 6, whereby a score of 0-7 refers to severe impairment. Review of Resident 23's Weights and Vitals Summary report on 2/28/25 indicated: 8/06/24 - 198 lbs. 9/03/24 - 200 lbs. 10/2/24 - 198 lbs. 11/5/24 - 199 lbs. 12/5/24 - 197 lbs. 01/6/25 - 203 lbs. 02/7/25 - 185 lbs. 2/26/25 - 183 lbs. Resident 23 experienced a 16-pound, 8.04% severe weight loss in ninety days or 3 months, from 11/5/24 to 2/26/25. Review of Resident 23's eInteract Change in Condition (COC) Evaluation dated 1/30/25 completed by Licensed Vocational Nurse (LVN) 7 indicated the .Signs and symptoms . Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) and Functional decline (worsening mobility). Weight loss was not checked. Review of Resident 23's physician's diet order dated 2/10/25 indicated NAS (no added salt) CCHO (consistent carbohydrate) diet, Mechanical Soft texture, Regular/Thin consistency and supplement order dated 2/8/25 indicated 4 ounce (oz.) House Supplement/Milk Shake three times a day for Malnutrition risk with meals. On 2/28/25 at 12:40 PM, a joint observation and interview of resident 23's lunch meal intake was conducted in the resident's room. Resident 23's lunch meal tray was on his bedside table. Certified Nursing Assistant (CNA) 2 and CNA 5 were feeding the resident his lunch meal which was beef goulash with spaghetti noodles, bite-sized coin carrots, and a parsley garnish on the plate. The resident drank thickened milk in 8-ounce cup with his meal. The CNA 5 stated the resident generally eats 50%-100% of his meals, depending on the meal. Review of Resident 23's January 2025 - February 2025 Meal Intake percentage (%) report indicated the resident consumed an average of 25% to 100% of meals, 25% of his house supplements. The facility's Diet Manual indicated the CCHO diet provided 2200 calories and 70-90 grams of protein per day, which led to Resident 23 consuming up to 550 fewer calories and 20 fewer grams of protein per day required to meet his estimated daily nutrition needs. Review of Resident 23's Nutrition Risk assessment dated [DATE] completed by the DSM-RD, indicated the resident's usual body weight was 206 lbs., estimated daily nutrition needs were 1800-2250 kcal (calories) and 90-108 grams of protein. Nutrition Goal: 1) stable wt. (weight) (fluct.- fluctuation) < 5%/month) within goal weight range: 195-205 lbs. through review date. 2) Maintain adequate nutrition & hydration status as evidenced by no new signs and symptoms of malnutrition, skin breakdown or dehydration. 3) Tolerate diet; average PO meets 75%-100% est. (estimated) needs. During a concurrent interview and record review with the Dietary Services Manager- Registered Dietitian (DSM-RD) on 2/27/25 at 3:06 PM, the DSM-RD stated resident 23's weight loss interventions should have been reassessed to address his continual weight loss. The DSM-RD further stated the resident should have remained on weekly weights and the change of condition form should have indicated weight loss as a sign and symptom so the IDT could have evaluated the resident's weight changes with the physician to avoid further loss. 2. A review of Resident 43's Facility admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease-COPD (a condition involving restricted airflow in the lungs and difficulty breathing), hypertension (elevated blood pressure levels) and hyperlipidemia (abnormally high levels of fat in the blood). Record review of Resident 43's MDS report dated 12/28/24 indicated the BIMS score was 11, whereby a score of 8-12 refers to moderate impairment. Review of Resident 43's Weights and Vitals Summary report on 2/28/25 indicated: 11/05/24- 120 lbs. 12/05/24 -117 lbs. 01/07/25 -105 lbs. 02/07/25 -106 lbs. Resident 43 experienced a 14-pound, 11.67% severe weight loss in ninety days or 3 months, from 11/5/24 to 2/7/25. Review of Resident 43's eInteract Change in Condition (COC) Evaluation dated 11/26/24 completed by LVN 1 indicated the signs and symptoms was 31. Other Change in Conditions . Low Hemoglobin 3.2 g/dL (normal range 12.1 g/dL to 15.1 g/dL). Weight loss was not checked. Review of Resident 43's physician's diet order dated 11/29/23 indicated Fortified (addition of calories to meals to reduce weight loss) Diet, Regular texture diet, Regular thin consistency; supplement order: 4 oz House Supplement/Milk Shake two times a day for Malnutrition risk w/ Lunch and dinner dated 1/8/25, 8 oz High Protein Nourishment two times a day dated 11/30/24, and Prostat (protein rich item) one time a day for Supplement for Wound Healing 30 ml PO, started 11/27/23. On 3/3/25 at 7:49 AM, an observation of resident 43's breakfast meal intake was conducted. Resident 43 received a Banana, Toast, Cereal, Bacon, and chocolate health shake. The resident did not have assistance and fed herself. Resident 43's January 2025 - February 2025 Meal Intake percentage (%) reports were requested by Surveyors on 2/28/25 and 3/3/25 but were not provided by the facility. Review of Resident 43's Nutrition Risk assessment dated [DATE] completed by the DSM-RD, indicated the resident's weight was 103 lbs., height 5 feet 7.5 inches tall, BMI (body mass index) 16.5 (below 18 is underweight), No labs indicated, PI (Pressure Injury) sacrum (large bone at bottom of spine) stage 2 pressure wound, estimated daily nutrition needs 1410-1645 kcal and 47-57 grams of protein.Nutrition Risk Related To: The resident has risk for unplanned/unexpected weight loss and risk for malnutrition r/t chronic conditions: COPD (chronic obstructive pulmonary disease), HTN (hypertension), HLD (hyperlipidemia), Muscle weakness; increased protein/calorie needs for wound healing; variable food intake with low BMI =16.5. Nutrition Goal: The resident will consume 75% two of three meals/day to maintain weight within goal range: 103-113# (pounds). The resident will consume >75% of nutrition supplements ordered. The resident will maintain adequate hydration status. Nutritional Intervention: Continue all supplements for wound healing and monitor prn (as needed) . Review of Resident 43's Lab's Results Report dated 11/26/24 indicated the resident's Albumin (a protein in blood that transport nutrients and maintains fluid balance) = 3.2 g/dL (grams/deciliter) was low, where 3.5 g/dL to 5.7 g/dL is the normal range. During a concurrent interview and record review on 2/27/25 at 3:06 PM about resident 43's lab results on 11/26/24 with the DSM-RD, the DSM-RD stated the resident's albumin was borderline low and recent weight loss was unintentional. The DSM-RD further acknowledged the resident's nutritional needs should have been addressed by completing a reassessment of the resident's nutrition interventions and change of condition for the weight loss when it was identified. The DSM-RD also stated modifying the resident's nutrition interventions may have prevented further weight loss. 3. A review of Resident 51's Facility admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), hypertension (elevated blood pressure levels), hyperlipidemia (abnormally high levels of fat in the blood), rhabdomyolysis (breakdown of muscle tissue), and chronic kidney failure (the kidneys cannot filter waste). Review of Resident 51's minimum data set (MDS) report dated 11/22/24 indicated the resident's brief interview of mental status-BIMS (a short cognitive screening test) score was 14, where a score of 11-15 refers to intact cognition. Review of Resident 51's Weights and Vitals Summary report on 2/28/2025 indicated: 8/19/24 - 177 lbs. 9/03/24 - 167 lbs. 10/1/24 - 160 lbs. 11/5/24 - 156 lbs. 12/5/24 - 149 lbs. 01/7/25 - 148 lbs. 02/7/25 - 140 lbs. Resident 51 experienced a 16-pound, 10.26% severe weight loss in ninety days or 3 months, from 11/5/24 to 2/7/25, and a 20.9% severe loss in 180 days or 6 months from 8/19/24 to 2/7/25. Review of Resident 51's eInteract Change in Condition (COC) Evaluation dated 12/6/24 completed by LN 4 indicated the .Signs and symptoms .30. Weight loss . was checked. The COC also stated Resident noted with 7 lbs. weight loss x 30 days & 18 lbs. weight loss x 90 days .no s/s (signs and symptoms) of dehydration noted. Communicated with RD & MD (medical doctor), no new orders/ recommendations at this time. Review of Resident 51's physician's diet order dated 9/5/24 indicated CCHO - Standard Portion diet Regular texture, Regular Thin liquid consistency, fortify meals; Supplement order: 4 oz House Supplement/Milk Shake three times a day for Malnutrition risk with meals. Review of Resident 51's December 2024 - February 2025 Meal Intake percentage (%) report indicated the resident consumed 51% to 100% of meals. Resident 51's Nutrition Assessment completed in 2024 by the Registered Dietitian was requested by Surveyors but not provided by the facility. Review of Resident 51's IDT Progress Notes dated 11/8/24 completed by the DSM-RD indicated .Note Text: IDT Reviewed d/t: significant wt loss WT/BMI: 156#/23.7 kg/m2 WT TREND: -21#/-11.9% x 90 days; DIET: CCHO - Standard Portion diet, Regular texture, Regular/Thin consistency SNACK/SUPPLEMENT: Pro-stat, Vit C, Zinc, Vit D3 MEAL PO: Mostly 76-100%, 51-75% at times. EVAL: At risk for malnutrition d/t: spinal stenosis, sepsis, enterocolitis d.t c diff, AKF, BPH, HLD Weight loss likely r/t poor PO intake at times and compromised skin integrity. Resident currently has a L- posterior knee . Supplements for wound healing in place. Goal weight 155-165#. No new recommendations at this time. RECS: 1) Continue POC (plan of care) . During a concurrent interview and record review on 2/27/25 at 3:06 PM with the DSM-RD about resident 51's weight loss, the DSM-RD acknowledged a nutrition assessment was not completed for resident 51 when weight loss was identified at thirty and sixty days in 2024. The DSM-RD further stated the IDT progress notes were completed in September and November 2024 that mentioned resident 51's weight loss but the recommendations should have been modified with weekly weights and other interventions to avoid further weight loss. 4. A record review of Resident 58's Facility admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included GERD (gastro-esophageal reflux disease), hypertension, and hyperlipidemia, type 2 diabetes with hyperglycemia, and hypothyroidism (condition which the thyroid gland does not produce enough thyroid hormone). Review of Resident 58's minimum data set (MDS) report dated 12/27/24 indicated the resident's brief interview of mental status- BIMS (a short cognitive screening test) score was 11, whereby a score of 8-12 refers to moderate impairment. Review of Resident 58's Weights and Vitals Summary report on 2/28/25 indicated: 12/24/24 -187 lbs. 01/22/25- 176 lbs. 02/07/25 -163 lbs. 02/20/25 -164 lbs. Resident 58 experienced a 23 pound, 12.3%, severe weight loss in ninety days or 3 months from 12/24/24 to 2/20/25. Review of Resident 58's eInteract Change in Condition (COC) Evaluation dated 2/7/25 completed by LN 4 indicated .Signs and symptoms .30. Weight loss .Resident noted with 25 lbs. weight loss within 30 days. no s/s of dehydration noted. Offered fluids & snacks as tolerated. Notified MD, no new orders at this time, RD aware . Continue to monitor .resident Review of Resident 58's physician's diet order dated 12/23/24 indicated CCHO - Standard Portion diet, Regular texture, Regular/Thin consistency; Supplement order dated 2/9/25, 4 oz House Supplement/Milkshake one time a day for Malnutrition risk w/ Dinner . Review of Resident 58's December 2024 - February 2025 Meal Intake percentage (%) report indicated the resident consumed 51% to 100% of meals and 75% to 100% of liquids, not including supplements. The daily supplement percentage intake was requested by Surveyors but not provided by the facility. Resident 58's initial Nutrition Risk Assessment completed by the RD was requested but not provided. During a review of Resident 58's IDT Weight and Nutrition Condition progress notes dated 1/22/25 and signed by the DSM-RD, indicated Note Text: IDT Reviewed d/t:significant wt loss WT/BMI: 176#/27.6 kg/m2, WT TREND: -9#/-4.9% x 1 week. DIET: CCHO - Standard Portion diet, Regular texture, Regular/Thin consistency SNACK/SUPPLEMENT: Snack HS, MEAL PO: 76-100% poor PO x 2 days likely r/t high k+ (potassium) abnormal labs. EVAL:73 yo (year old) male at risk for malnutrition r/t (related to) a-fib (atrial fibrilation), DM2 (diabetes mellitus), ASHD (atherosclerotic heart disease- abnormal heart functioning), CKD (chronic kidney disease) .hypothyroidism, HLD (hyperlipidemia). Weight loss likely r/t COC for hyperkalemia sent out for immediate care returned same day 1/21/2024. RECS: 1) 4oz Health Shake QD w/ Dinner. IDT will continue to monitor. MD and Family made aware . During a joint interview and record review on 2/27/25 at 3:06 PM with the DSM-RD about Resident 58's weight loss, the DSM-RD stated resident 58's nutrition interventions should have been modified and follow up with the physician should have occurred to prevent further weight loss. 5. A record review of Resident 673's Facility admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypertension, and hyperlipidemia, dysphagia, depression, and hemiplegia and hemiparesis (paralysis or weakness on one side of the body). Review of Resident 673's minimum data set (MDS) report dated 11/30/24 indicated the resident's brief interview of mental status- BIMS (a short cognitive screening test) score was 7, whereby a score 0-7, severe cognitive impairment. Review of Resident 673's Weights and Vitals Summary report on 2/27/25 indicated: 8/26/24 - 150 lbs. 9/24/24 - 142 lbs. 10/5/24 - 138 lbs. 11/5/24 - 135 lbs. 12/05/24-121 lbs. 01/3/25 - 121 lbs. 02/6/25 - 123 lbs. Resident 673 experienced a 12-pound, 8.89% severe weight loss in ninety days or 3 months, from 11/5/24 through 2/6/25, and an 18% severe weight loss in 6 months from 8/26/24 to 2/6/25. Resident 673's eInteract Change in Condition (COC) Evaluation was requested by Surveyors but not provided by the facility. Review of Resident 673's physician's diet order dated 2/10/25 indicated NAS (no added salt) diet, Pureed texture, Thin liquids, Nectar thick consistency; Supplement order dated 12/07/24, 4 oz. House supplement/Milk shake three times a day for Malnutrition risk with all meals . Resident 673's December 2024 - February 2025 Meal Intake percentage (%) report was requested from Surveyors but not provided by the facility. On 2/28/25 at 12:30 PM, an observation and interview of resident 673' lunch meal was conducted in the resident's room. Resident 673 stated she did not like mashed potatoes, and they serve them 3 to 4 times a week, or almost every other day. The meal tray was placed on the resident's bedside table, and it had pureed beef goulash, pureed mashed potatoes, and pureed carrots. The tray also had a chilled 8 ounce thickened 2 % milkshake drink carton. Resident 673 ate 25% to 50% of her lunch meal and drank 0% of the milkshake drink. On 3/3/25 at 7:47 AM, an observation and interview of resident 673's breakfast meal intake was conducted in the resident's room. CNA 5 stated the resident consumed 50% of her meal and needed minimal assistance. CNA 5 further stated the resident did not like her meals and the food choices. CNA 5 stated the resident was offered alternate meals for lunch and dinner, and the charge nurse was notified each time. Review of Resident 673's Nutrition Risk Assessment completed by the DSM-RD dated 9/4/24, indicated the resident's usual weight was 145-150 lbs., goal weight: 140-150 pounds, labs: Albumin 2.5 g/dL (Low) dated 8/30/24, estimated daily calorie and protein intake to meet needs: 1600-1920 kcal and 80-96 grams of protein; Nutrition Intervention: hydration status a/e/b (as evidenced by) no new s/s of malnx (malnutrition), skin b/d (breakdown), or dehydration. 3) Tolerate diet; avg (average) PO meets 75-100% of est. needs through next review date. Nutrition Goal: 1) 4 oz Health Shake QD (once a day) with Dinner 2) Weekly weights x 4 then monthly when stable 3) Update food preference as needed. During a concurrent interview and record review on 2/27/25 at 3:06 PM with the DSM-RD about resident 673's weight loss, the DSM-RD acknowledged she completed a nutrition assessment on 9/6/24 and identified weight loss, and stated a change of condition for weight loss should have been completed to notify the physician and IDT. The DSM-RD stated she did not reevaluate or assess resident 673 to determine if the nutrition interventions were successful to prevent further weight loss. During an interview on 2/27/25 at 4:05 PM with the RD-C (Corporate Registered Dietitian), the RD-C stated her expectation is for the facility's Dietitian to reassess the resident's weight history, clinical conditions, person-centered care plans, a calculated goal weight, and lab values to make nutrition recommendations and set goals to prevent further weight loss. The RD-C stated this information should be documented in the resident's medical chart for members of the IDT to view what the resident's nutrition goals are to prevent weight loss. During an interview on 2/27/25 at 5:19 PM with the Director of Nursing (DON) about residents' weight loss, the DON stated residents with significant or severe weight loss should be addressed with appropriate interventions with the RD, physician, nursing and IDT according to the facility's policy. During an interview on 3/3/25 at 11:41 AM with the facility's medical physician (FMP), the FMP stated it was important for residents to maintain a certain weight because they're an aging population who could lose lean body mass if the weight loss was not addressed. The FMP stated she was recently notified in February of Resident 43 and Resident 51's weight loss but had not spoken to the IDT about the reason for the weight loss. The FMP stated she knows Resident 43 had a low BMI (body mass index), does not like the facility's food and recently declined an appetite stimulant but did not know there was severe weight loss. The FMP also stated she expected to be notified when a significant or severe weight loss occurred for a resident so she could follow-up with a nutrition consult, request lab tests, and address the weight loss to prevent further problems. During an interview on 3/3/25 at 12:18 PM with the medical director (MDR), the MDR stated there should be a process for how weight losses of 2% to 3% are reported to the physician depending on the resident's underlying condition. The MDR stated they need to make sure there are no 15-pound weight losses experienced in one month and the policies and procedures be followed to prevent or avoid further weight loss. He stated physicians should be documenting how they address the resident's weight loss in the chart and to make sure the interventions are appropriate and the RDs need to be involved to address the weight loss. The MDR further stated weight is a very important component of a resident's medical and nutrition status because it helps them gain strength to fight off diseases. During an interview on 3/03/25 at 3:29 PM with the DSM-RD, the DSM-RD stated it was important for resident weight loss issues to be appropriately addressed to ensure the care of the resident. The DSM-RD further stated all tools should be used including fortified diets, supplements and shakes, additional portions and possible appetite medications to help improve a resident's food intake and nutrition status, and prevent more weight loss. Review of the facility's policy titled Change of Condition dated April 1, 2015, indicated .Procedure . III. A Licensed Nurse will notify the resident's Attending Physician and legal representative or an appropriate family member when there is an: .D. A change in weight of five pounds or more within a 30 day period unless a different stipulation has been stated in writing by the patient's physician . Review of the facility's policy titled Evaluation of Weight and Nutritional Status dated 2022 revised 1/30/25, indicated .1. The facility will maintain an acceptable nutritional status for residents per professional standards by a) Assessing the residents nutrition status and the factors that put the resident at risk of not maintaining acceptable parameters of nutritional status. b) Analyzing the assessment information to identify the medical conditions, causes and/or problems related to the resident's condition and needs. c) Implementing interventions for maintaining or improving nutrition status that are consistent with the resident's needs, preferences, goals, and professional standards of practice. d) Developing interventions involving the resident and/or resident representative to ensure the resident's needs .are accommodated. e) Monitoring and evaluating the resident's response .to interventions. PROCESS 1 .b. Weight Loss- Unplanned weight loss in a resident. Significant weight loss (5% &/or 5 lb. in one month, 7.5%in three months, or 10% in six months), .c. Insidious weight loss refers to gradual, unintended, progressive weight loss over a three (3) or twelve (12) month period. 2 .b. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days or 10% in 180 days, or is considered insidious weight loss, with be evaluated by the IDT to determine the cause of the weight loss .and the intervention(s) required. c. The resident's Attending Physician will be notified when there is a weight variance of 5 pounds in 1 month .d.Residents at risk who should be weighed weekly include (but are not limited to) the following: .2. Significant weight loss or gain identified .3. Residents demonstrating insidious weight loss; .5. Residents on dialysis .ii. Weekly weights will be discontinued when the resident's weight has been within stable range for a period of four (4) weeks . Review of the facility's policy titled Nutritional Status Evaluation dated May 19, 2022, indicated .I. A registered dietitian will complete a nutritional evaluation upon admission .readmission, annually, and upon a significant change of condition.The Dietitian will use information from the Resident's medical record to complete the nutritional evaluation .including but not limited to: .A. diagnosis, B. diet order .E. skin condition, F. Ability to chew and swallow . H. Meal intake percentage .K. pertinent medications, L. laboratory data, M. usual body weight, N. BMI, O. estimated nutrition needs range .IV.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility's policy and procedures were followed, for two of three sampled residents, Residents 1 and 2, who were identified as at risk for elopement (when a resident leaves a healthcare facility without permission or when they are unable to make safe decisions on their own), when: 1. The facility did not provide supervision for Resident 1 who had multiple prior attempts to elope; and 2. The facility did not ensure there was a system in place to monitor placement and functionality of the WanderGuard (bracelet worn by the resident that triggers alarms on doors to alert staff if a resident leaves a safe area) when Resident 2 was observed not wearing a WanderGuard bracelet as ordered by the physician. On November 18, 2024, at 7:20 p.m., The Administrator (ADM) and Director of Nursing (DON) were verbally notified of an Immediate Jeopardy (IJ- situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death to a resident), due to the facility ' s failure to implement a system for monitoring residents identified at risk for elopement. The facility failed to provide supervision to Resident 1, who was identified to be at risk for elopement and had multiple prior attempts to elope. This failure resulted in Resident 1 eloping from the facility on November 18, 2024, at approximately 2:00 a.m., placing Resident 1 at risk for serious injury while out in the cold environment with no access to needed healthcare. The facility failed to monitor the placement and functionality of the WanderGuard for Resident 2, who was observed not wearing a WanderGuard bracelet as ordered by the physician. This failure resulted in the potential for Resident 2 to elope from the facility placing her at serious risk for injury and no access to needed healthcare. On November 19, 2024, at 3:30 p.m., the ADM presented an acceptable plan of action which included the following: On November 18, and 19, 2024: a. Resident 1 was located by law enforcement and taken to the hospital for evaluation. b. The DON/Designee reviewed and audited residents with multiple attempts to leave the facility. Resident 2 was identified and placed under one-on-one supervision for safety. c. The Maintenance Supervisor inspected all exit doors and the WanderGuard system to ensure the alarms were working. All alarms and systems were functioning properly. d. New orders to monitor WanderGuard placement and function were added to the medication administration records for the five residents who were at risk. All wander guards were in place as ordered. IDT ((interdisciplinary team - a group of healthcare professionals from different disciplines who work together to provide care for a resident), and care plans were updated based on elopement risk assessments. e. The Administrator and DON provided in-service training to facility staff on the facility's wandering and elopement, policies, focusing on interventions for residents attempting to leave the facility and monitoring the WanderGuard system. The Administrator initiated an in-service with facility staff regarding Adequate Supervision and providing the appropriate level of oversight for all residents based on their needs. f. The Administrator conducted an in-service to licensed nurses on using the transmitter tester for WanderGuard, including proper usage, storage, extra supplies, and battery changes. g. The elopement binder (book with information on the residents identified as an elopement risk) was updated, and residents are being monitored and supervised according to their care plans. h. Starting on 11/19/24, the licensed nurses will conduct room rounds every 2 hours during their assigned shifts to ensure all residents are accounted for and safe. i. DON/Designee checked that all resident identified as risk for elopement had orange arm bands. On November 19, 2024, at 7:43 p.m., the Immediate Jeopardy was removed in the presence of the ADM, DON, Regional Quality Management Consultant and ADM Consultant, upon onsite verification of implementation of the plan of action. Noncompliance for F689 remained at the lower scope and severity of D no actual harm with potential for more than minimal harm. Findings: On November 15, 18, and 19, 2024, unannounced visits were conducted at the facility to investigate complaint allegations. 1. On November 18, 2024, at 12:00 p.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he received notice that Resident 1 eloped from the facility on November 18, 2024, during the night (11:00 p.m. to 7:00 a.m.) shift and had not returned yet. LVN 1 stated according to the information he received Resident 1 opened the front door of the facility at 2:00 a.m. A certified nursing assistant (CNA) tried to stop him, but he started running. LVN 1 stated the CNA tried to follow Resident 1 for 30 minutes outside the facility, but it got too dark, and the CNA returned to the facility. LVN 1 stated Resident 1 had an ankle monitor due to being on probation, and a WanderGuard as well. LVN 1 stated Resident 1 had a history of leaving the facility and staff had been able to bring him back to the facility. LVN 1 stated the facility placed an extra lock to the front door and there are alarms on all the doors of the facility. LVN 1 stated residents are assessed for risk for elopement upon admission, after each incident of elopement and quarterly. LVN 1 stated when a resident is identified as at risk for elopement, they get an order for WanderGuard from the physician, place the resident ' s information in the elopement binder, initiate a care plan and notify the staff as well. LVN 1 stated a resident at risk for eloping may also be placed on close monitoring like a 1:1 (a medical intervention where a resident is constantly observed by a staff member). LVN 1 stated a 1:1 is initiated after a resident tries to elope from the facility and if the resident is at high risk for elopement. LVN 1 stated the 1:1 ends depending on how the resident is doing. A concurrent review of Resident 1 ' s medical record was conducted with LVN 1. The record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (loss of cognitive functioning, such as thinking, remembering, and reasoning, that interferes with daily life). A review of Resident 1 ' s Elopement Assessment dated August 23, 2024, indicated Resident 1 was identified as at risk for elopement. A review of Resident 1 ' s care plan indicated Resident 1 had multiple attempts to leave the facility on August 19 and 23, September 4 and 19, October 27, and November 2 and 15, 2024. LVN 1 stated Resident 1 should have been placed on a 1:1 and frequent visual checks. On November 18, 2024, at 2:10 p.m., during an interview with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 1. CNA 1 stated Resident 1 was independent to most activities of daily living (ADL) and had a WanderGuard on. She stated on November 15, 2024, as they were passing out breakfast trays, she heard that Code Pink was announced and that meant that a resident eloped. CNA 1 stated she knew that it was Resident 1. CNA 1 stated LVN 3 followed Resident 1 up to the gasoline station and Resident 1 was brought back to the facility. CNA 1 stated Resident 1 was not placed on a 1:1. They just kept a closer eye on Resident 1, and all staff checked the doors. CNA 1 stated Resident 1 did not have any further attempts to elope during that shift. On November 18, 2024, at 3:29 p.m., during an interview with LVN 2, LVN 2 stated residents identified as at risk for elopement were frequently checked visually, the facility has alarms installed on all exit doors and provides WanderGuard to these residents. LVN 2 stated she was the charge nurse for the night shift (11:00 p.m. to 7:00 a.m.) when Resident 1 eloped on November 18, 2024, at around 2:00 a.m. LVN 2 stated Resident 1 had frequently eloped from the facility, and they conducted visual checks on him every 30 minutes. LVN 2 stated Resident 1 was pacing throughout the hallways, she gave him Ativan (a medication that treats anxiety-a mental illness) and approximately 15 minutes after giving Resident 1 Ativan, a CNA saw Resident 1 leave through the emergency exit door. The CNA followed Resident 1 but was not able to bring him back to the facility. The CNA returned to the facility and took her car to continue searching for the resident but Resident 1 could not be located. LVN 2 stated Resident 1 was not on a 1:1 at the beginning of the shift, and he continued to pace around the facility. LVN 2 stated there were no other interventions initiated for Resident 1. LVN 2 stated when Resident 1 was pacing around the facility a 1:1 was indicated, and she would have placed Resident 1 on 1:1 if there was enough staff. A review of Resident 1 ' s medical record was conducted on November 18, 2024. Resident 1's History and Physical dated May 6, 2024, indicated Resident 1 can make needs known but cannot make medical decisions. A review of Resident 1's Elopement Evaluation dated August 23, 2024, on PointClickCare (PCC - an electronic health record) indicated he was at risk for elopement. A review of the care plan titled, The resident has a behavior problem attempted to leave the facility, initiated on July 9, 2024, and revised on November 18, 2024, indicated Resident 1 had an actual attempt to leave the facility on August 19, 2024, and he eloped on November 18, 2024. The care plan had interventions initiated on July 9, 2024, which included .Administer medications as ordered. Monitor/document for side effects and effectiveness .Anticipate and meet The (sic) resident ' s needs .Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately . The care plan also had interventions inititated on August 20, 2024, which included .Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes .Provide a program of activities that is of interest and accommodates residents (sic) status . A review of the care plan titled, Risk for Wandering / Elopement Identified with an initiated date of August 19, 2024, indicated Resident 1 had an episode of elopement on September 4, 2024, and three episodes of elopement on August 19, 2024. The care plan had interventions initiated on September 4, 2024, which included, .Clearly identify Resident ' s room & bathroom .Engage Resident in purposeful activity .Identify if there is a certain time of day wandering / elopement attempts occur .Implement scheduled hydration, if not contraindicated .schedule time for regular walks / appropriate activity . A review of the care plan titled, Resident had an episode of non-compliance and attempted to leave the facility on 10/27/2024 .11/2/2024 . initiated on October 27, 2024 and revised on November 18, 2024, had interventions initiated on October 27, 2024, which included .Anticipate and meet needs .Apply wanderguard (sic) for increase safety, resident refused wanderguard (sic) .For monitoring of behavior per protocol .IDT with parole officer for safe discharge .Psychiatric evaluation . The care plan had interventions initiated on October 28, 2024, which included .Redirect resident as necessary . The care plan also had interventions initiated on November 2, 2024, which included .Lorazepam (Ativan) Tablet 0.5 mg Give 1 tablet by mouth every 8 hours as needed for restlessness for 14 Days and re-assess .Notify family per protocol .Notify MD (medical doctor) for recommendations . A review of Resident 1 ' s Physician Note titled Psychiatry dated October 29, 2024, indicated Resident 1 .presents significant risk to self due to impaired judgment and attempts to leave facility without safety awareness. Requires close supervision . A review of Resident 1's Behavior Note dated November 15, 2024, indicated .Resident 1 eloped this morning using emergency side door and staff were able to walk the resident back to the facility . A review of Resident 1 ' s Progress Notes indicated the following: a. On November 15, 2024, Resident 1 eloped from the facility in the morning using emergency side door. Resident 1 was brought back to the facility by staff. The ADM, Resident 1 ' s doctor and family were made aware. b. On November 18, 2024, at 2:13 a.m., staff heard a door alarm and ran to the doors. CNA 1 chased Resident 1 but was unable to redirect back to the facility. Staff drove around the perimeter of the facility but was unable to locate the resident. The ADM and Police Department were notified. Resident 1 ' s doctor and family were notified. There was no documented revision on Resident 1 ' s care plans or post elopement IDT meetings from November 15 to November 18, 2024, to address why Resident 1 continued to make elopement attempts or interventions implemented to reduce his risk for elopement. On November 19, 2024, at 11:59 a.m., during an interview with Registered Nurse (RN) 1, RN 1 stated residents who are at risk for elopement and exhibit exit seeking behaviors are provided with a WanderGuard and a 1:1. RN 1 further stated a 1:1 is also recommended for a patient who had eloped. RN 1 stated incidents of elopement were discussed during their stand-up meeting, and sometimes they do not document that. RN 1 further stated it was usually the Social Service Director who documents IDT meetings. A review of Resident 1 ' s care plan was conducted with RN 1. RN 1 stated there were no updates on Resident 1 ' s elopement care plans after November 2, 2024. RN 1 stated the care plans were ineffective because Resident 1 successfully eloped on November 18, 2024. On November 19, 2024, at 2:27 p.m., during an interview with the DON, the DON stated Resident 1 had multiple attempts to elope, was always redirected back to the facility by staff, was provided with frequent visual checks, every 30-minute monitoring, had a psychiatry evaluation with (name of psychiatrist), and the family, doctors and parole officers were notified. The DON further stated the facility was not the proper place for Resident 1 and he needed a locked unit. The DON stated it was not appropriate for Resident 1 to stay at the facility. The DON stated every time Resident 1 eloped, they contacted the police; on August 19, 2024 after he attempted to elope, he was transferred to the hospital for evaluation and returned to the facility the same day, they contacted the crisis team interventions multiple times and sought a 5150 hold (a legal procedure that allows involuntary detention of an adult for up to 72 hours for psychiatric evaluation and treatment), but none were able to assist. A record review of the Social Services Progress Note dated November 5, 2024, indicated .Crisis team in this afternoon, no changes per team the resident is safe, and in safe environment . On November 19, 2024, at 6:30 p.m., during a concurrent interview and record review with the DON, Resident 1 ' s care plans and progress notes for the period of November 15 to 18, 2024 were reviewed. The DON stated there were no revisions on the care plans titled The resident has a behavior problem attempted to leave the facility, initiated on July 9, 2024, and revised on November 18, 2024, Risk for Wandering / Elopement Identified with an initiated date of August 19, 2024, and Resident had an episode of non-compliance and attempted to leave the facility on 10/27/2024 .11/2/2024 . initiated on October 27, 2024 and revised on November 18, 2024, and there was no IDT meeting conducted on November 15 to 18, 2024. On November 19, 2024, at 7:08 p.m., during an interview with the ADM, The ADM stated the expectation for staff and the IDT was to find other interventions to prevent Resident 1 from eloping from the facility, but it was challenging. The ADM stated the facility tried to manage Resident 1 the best they could. On November 20, 2024, at 11:30 a.m., during an interview with Resident 1 at the general acute hospital (GACH), Resident 1 stated he left the facility because his wife and cousins were waiting for him. A review of Resident 1 ' s GACH records titled, ED (Emergency Department) Note - Physician dated November 19, 2024, indicated Resident 1 was admitted to the GACH on November 18, 2024, at approximately 8:50 p.m., and was placed on a 5150 hold (a legal process for the involuntary detainment of an adult in a psychiatric hospital up to 72 hours). The police found Resident 1 wandering in a stranger ' s backyard covered in feces (poo) and was disoriented. On November 29, 2024, at 2:09 p.m., during a telephone interview with the DON, the DON stated prior to Resident 1 eloping on November 18th, he was being monitored for elopement every shift. The DON stated he was not placed on every 30-minute monitoring because his elopement attempts was considered as his behavior. A review of the facility ' s policy and procedure titled, ' Wandering and Elopement dated February 10, 2023 indicated .The resident ' s risk for elopement and preventative interventions will be documented in the resident ' s medical records and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly and upon change in condition .The IDT will develop a plan of care considering the individual risk factors of the resident .upon return the Licensed Nurse will implement immediate interventions to prevent further elopement of the resident and update the plan of care .The Interdisciplinary Team as part of the investigation will conduct a post elopement meeting to determine if alternative prevention measures can be put in place (activities, rehab, etc.) . A review of the facility ' s policy and procedure titled, Resident Safety dated April 15, 2021, indicated .During the comprehensive assessment period the interdisciplinary team (IDT) members will assess the Resident ' s safety risk (e.g.wandering, elopement .) as well as any other Resident specific safety risks . After a risk evaluation is completed, a Resident-centered care plan will be developed to mitigate safety risk factors . 2. On November 18, 2024, a review of Resident 2 ' s electronic health information on PointClickCare (PCC) indicated the following: -Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia and was identified at risk for elopement. -The Minimum Data Set (MDS - an assessment tool) dated August 17, 2024, indicated Resident 2 had moderate cognitive (ability to think and reason) impairment. -The physician ' s order indicated Resident 2 had an order for .Wander Guard to left wrist for safety/elopement . dated August 15, 2024. -The care plan titled Risk for Wandering /Elopement Identified dated August 13, 2024, and was revised on September 6, 2024, indicated Resident 2 left the faciity on August 23, 2024, and Resident 2 attempted to elopement on September 6, 2024. On November 18, 2024, at 3:29 p.m., during an interview with LVN 2, LVN 2 stated she was not sure who monitors if the WanderGuards were functioning. On November 18, 2024, at 4:20 p.m., during an interview with LVN 3, LVN 3 stated Resident 2 had an order for a WanderGuard. On November 18, 2024, at 4:28 p.m., a concurrent interview and observation with Resident 2 was conducted with LVN 3. Resident 2 was in bed, alert, awake, and watching television. A suitcase was observed on top of a chair opposite her bed. Resident 2 stated she did not have any type of bracelet monitors on her. LVN 3 stated he did not know what happened to Resident 2 ' s WanderGuard. LVN 3 stated he did not know how to check if WanderGuards were working or how to connect it to the WanderGuard alarm system. LVN 3 stated that when a resident with a WanderGuard goes near the doors, the alarm will go off. On November 18, 2024, at 6:19 p.m., during a follow up observation of Resident 2 in her room, Resident 2 was not wearing a WanderGuard bracelet. On November 18, 2024, at 6:20 p.m., CNA 2 was asked to check if Resident 1 was wearing a WanderGuard. CNA 2 stated Resident 2 did not have a WanderGuard, CNA 2 further stated Resident 2 should have a WanderGuard on because she packed her things and has said she wanted to leave the facility in the past. On November 19, 2024, at 2:27 p.m., during an interview with the Director of Nursing (DON), the DON stated Resident 2 should have the WanderGuard on because there was a physician ' s order. On November 25, 2024, at 11:29 a.m., during a telephone interview with the DON, the DON stated it was the licensed nurses ' responsibility to check for the placement and functionality of the WanderGuard. A review of the facility ' s policy and procedure titled .Signaling Device dated October 26, 2023, indicated .A Signaling device is an intervention that can be utilized as part of a Resident ' s plan of care when they have been identified as being at risk for elopement .The need for the use of a signaling device will be based on the Resident ' s Elopement Assessment . A Physician ' s order must be obtained for the use of signaling device .The placement will be verified every shift .Functionality of the signaling device should be verified daily .The licensed nurse will document the placement and functionality in the Resident ' s medical record .