**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review and facility policy review, the facility failed to notify the physician for a significant change in condition for two (2) of six (6) residents sampled for nutrition Resident #20 and Resident #13 as evidenced by: 1) failed to recognize, evaluate, communicate, and address a resident's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. Resident #13. The facility's failure to notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, or possible death. 2) failed to identify, communicate, and address a resident at risk for malnutrition due to prolonged nausea and vomiting, and failure to identify a decrease in food intake due to pain and nausea resulted in an unintended significant weight loss of 40.5 pounds in six (6) months. Resident #20. The facility's failure to notify the attending physician of a significant change in condition, and address the residents' prolonged symptoms of nausea and vomiting, and decreased food intake placed the resident and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, or possible death. The facility's failure also resulted in a functional decline for Resident #20, which potentially resulted in the resident's admission to hospice services on 2/14/24. The State Agency (SA) identified an Immediate Jeopardy (IJ) that began on 11/02/23 when the facility failed to recognize, evaluate, and address Resident #13's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. The IJ existed at: 42 CFR §483.10(g)(14) Notification of Changes - F580 - Scope/Severity J The facility Administrator was notified of the IJ on 2/13/24 at 4:30 PM and provided the IJ Template. The facility provided an acceptable Removal Plan on 2/14/24, in which they alleged all corrective actions to remove the IJ were completed on 2/13/24 and the IJ removed on 2/14/24. The SA validated the Removal Plan on 2/20/24 and determined the IJ was removed. Therefore, the scope and severity for 42 CFR §483.10(g)(14) Notification of Changes - F580, was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the facility policy titled Change in a Resident's Condition or Status with a review date of 7/24/23 revealed, Policy Statement: Our facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .Policy interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): . c. adverse reaction to a medication; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; . i. specific instruction to notify the physician of changes in the resident's condition . Resident #20 Cross reference F600, F692 On 2/11/24 at 3:19 PM, an observation and interview with Resident #20 revealed her lying in a fetal position at the foot of the bed. The room was dark upon entrance and the door to her room was closed, and a garbage can was located on the floor beside the resident and she stated she was sick to her stomach. She had a washcloth in her hand and was wiping her face which was observed as pale, lips were dry, and she was thin in appearance. On 2/12/24 at 8:29 AM, an observation of Resident #20 revealed her lying on her right side in bed with a garbage can located on the floor, close by the resident. The breakfast tray was located on the bedside table untouched. CNA #2 entered the resident's room, and stated the resident refused to eat or drink due to nausea. CNA #2 removed the tray cover, and the resident began to retch and vomited a small amount of clear substance. The resident was weak and pale, and her lips were dry. On 2/12/24 at 8:35 AM, in an interview with CNA #2 revealed she had worked at the facility for three (3) weeks and Resident #20 had refused to eat or drink everyday that she had been here since then. She explained that the resident had been nauseated, dry heaving, and vomiting for the past three (3) weeks, since she had been employed at the facility. She confirmed that she had reported the symptoms to the medication nurse every day that she worked. Record review of Resident #20's Progress Notes from 11/01/23 through 2/11/24, revealed there was not any documentation that the resident had nausea and vomiting or that she refused meals. Record review of the Occupational Therapy Progress Notes dated 2/01/24 revealed, Patient refused: pt (patient) is refusing to eat and has poor appetite. pt (patient) c/o (complains of) nausea almost every day, but is not eating even with max encouragement and assist from therapist. Also revealed under, Assessment and Summary of Skilled Services: . therapist encouraging pt (patient) daily to eat and providing assist, but pt (patient) refuses to eat and c/o (complains of) nausea . Record review of the Order Summary Report for Resident #20 revealed an order dated 2/11/24 at 1827 (6:27 PM), Ondansetron HCL (Hydrochloride) Tablet 4 (four) MG (milligrams) Give 1 (one) tablet by mouth every 6 (six) hours as needed for Nausea and Vomiting . Record review of Resident #20's January and February 2024 Medication admission Record (MAR) revealed, there was not a physician's order for nausea/vomiting medication before the new order for Zofran started on 2/11/24, which indicated the resident's symptoms of prolonged nausea and vomiting were left untreated. Record review of the Meal Intake Documentation Report completed by the Certified Nurse Aides (CNAs) revealed, Resident #20 refused eighteen (18) meals from 12/18/23 through 12/31/23. She refused thirty-one (31) meals in the month of January 2024, with a total of thirty-nine (39) meals consumed at 0-25% (percent), and she refused sixteen (16) meals from 2/01/24 through 2/11/24, with a total of fourteen (14) meals consumed at 0-25% (percent). Record review of Resident #20's weights revealed a significant weight loss of 13.9% (percent) in one (1) month, 21.6% (percent) in three (3) months, and 26.2% (percent) in six (6) months. Record review of the Order Summary Report for Resident #20 revealed an order dated 1/04/24, Regular diet Regular texture, Regular consistency . Also revealed an order dated 1/04/24, Med Pass 2.0 two times a day for supplement. On 2/11/24 at 3:55 PM, during an interview with the Director of Nursing (DON) revealed Resident #20's condition had declined over the past couple of months related to her diagnosis of dementia. She explained that the resident had a significant decline after she fell in December 2023, and received a fracture of the T-12 vertebrae and had to be placed on strong pain medications. She stated, to her knowledge, the resident had not experienced any nausea and vomiting until yesterday when the Survey Agency brought it to her attention. She stated none of the staff had reported it to her and that she should be aware of what was happening with the resident if something like that was going on. She revealed she was aware that the resident was not eating or drinking and had been refusing meals and stated she had made the physician aware of the resident's decline, and the significant weight loss. Record review of the Consultant Registered Dietician (RD) Note dated 12/27/23, for Resident #20 revealed the RD (Registered Dietician) recommended, Med Pass 2 oz (ounces) BID (twice daily), weekly weights x (times) 4 (four) weeks, and add Fortified Pudding BID (twice daily) at lunch and dinner . Record review of the Consultant Registered Dietician (RD) Note dated 1/5/24, for Resident #20 revealed, Resident w/(with) significant wt (weight) loss x (times) 1 (one) mo (month) (-9%) and x (times) 6 (six) mo (months) (-13.7%) (percent). Po (by mouth) intake likely not meeting nutritional needs. Resident is at risk for skin breakdown and wt (weight) loss d/t (due to) decreased appetite . NO N/V/c/D (nausea, vomiting, complaints of diarrhea) documented. Also revealed under REC (recommendations): Resident may benefit from an appetite stimulant, please document % (percentage) of supplement consumed daily, add fortified pudding BID (twice daily) at lunch and dinner, weekly weights x (times) 4 (four) weeks to assure stable weight . Record review of the Consultant Registered Dietician (RD) Note) dated 2/10/24, for Resident #20 revealed, Resident w/(with) significant wt (weight) loss x times 1 (one) mo (month), x (times) 3 (three) mo (months) and x (times) 6 (six) mo (months) . consuming <25% w/(with) refusals of meals . Po (by mouth) intake likely not meeting nutritional needs . NO N/V/c/D (nausea, vomiting, complaints of diarrhea) documented. Also revealed under REC (recommendations): Resident may benefit from an appetite stimulant, please document % of supplement consumed daily, weekly weights x 4 weeks to assure stable weight, if po (by mouth) intake and wt (weight) status does not improve, resident may benefit from an alternate means of nutrition support. Record review of the Order Summary Report for Resident #20 revealed there was not a physician's order for fortified pudding at lunch and supper or a medication to stimulate appetite per Registered Dietician (RD) recommendations. On 2/11/24 at 4:20 PM, an interview with Licensed Practical Nurse (LPN) #3 revealed Resident #20 had a decline over the past several weeks. She explained that the resident would not eat or drink, including the med pass supplement. She stated that usually they cannot get her to take her medications and that the resident would eat crushed ice chips, but that was about it. LPN #3 explained that she noticed a change after the resident fell and hurt her back and she was in a lot of pain and she confirmed that she had not notified the resident's physician of the change in the resident's condition. On 2/12/24 at 6:05 PM, a telephone interview with Medical Director revealed the staff had contacted him last night regarding Resident #20 having nausea and vomiting, and he had ordered Zofran as needed. He confirmed that the staff had not contacted him or made him aware of the residents' decline in condition or her refusal to eat or drink. He stated that he was not notified of her significant weight loss (40.5 pounds in 6 months) or the Registered Dietician (RD) recommendations. He confirmed Resident #20's current condition was serious and stated What you have relayed screams neglect. Record review of Resident #20's Physician Nursing Home Visit dated 1/26/24 revealed, No concerns reported by the nursing staff The physician progress note did not identify any documentation to support the resident's nausea and vomiting or weight loss. On 2/13/24 at 8:13 AM, an interview with the Dietary Manager (DM) revealed Resident #20 did not have a physician's order for fortified pudding, and to her knowledge, had never been started on an appetite stimulate. She explained that the facility had trouble getting the RD recommendations and that she just realized last week on Friday 2/9/24 that they were going to her spam email. She confirmed that lack of implementation of the RD recommendations could cause the resident to have weight loss and malnourishment. On 2/13/24 at 10:38 AM, an interview with the Director of Nursing (DON) confirmed after reviewing Resident #20's progress notes, she observed there was no documentation to support a decline and there was no documentation to show the Medical Director had been notified. She revealed before the fall the resident was ambulatory, rarely in bed, and she took herself to the bathroom. She stated she would sit up in a chair in her room and after the fall the resident required more help with her Activities of Daily Living (ADLs), stayed in bed, became incontinent, had more falls, and required the staff to assist with eating. She confirmed that the facility should have notified the physician immediately when the decline came about, and verbalized that was a failure on their part. The DON stated that the facility did not reach out to the physician to inquire about drawing labs or starting any intravenous fluids throughout these months of the resident refusing to eat or drink. She stated that she did report the weight loss to the physician while he was inside the facility and stated, I do not recall the date or month I notified him. She confirmed that she did not have documentation to support her notification. On 2/13/24 at 2:10 PM, an interview with the Administrator (ADM) revealed Resident #20's weight loss had been discussed in January 2024 during a PAR (patients at risk) meeting. The ADM confirmed that the Dietary Recommendations for Resident #20 had not been implemented and that the facility failed to document the significant changes that occurred in the resident's condition. She stated, I know the documentations not there. She revealed that she was told the DON had reached out to the physician and stated, It looks bad on our part. Record review of the Progress Notes for Resident #20 dated 2/14/24, Proper Name Hospice consulted per MD (medical doctor) order and family request . for declining condition related to Alzheimer's disease . Record review of the Transfer/Discharge Report revealed the facility admitted Resident #20 on 1/24/22 with medical diagnoses that included Alzheimer's disease, Rheumatoid Arthritis, and Wedge compression fracture of T 11-T 12 vertebra, subsequent encounter for fracture with delayed healing. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/10/24 revealed a Brief Interview for Mental Status (BIMS) of 03 which indicated the resident had severe cognitive impairment. Prior MDS's dated 09/18/23 revealed a BIMS of 11, MDS dated [DATE] revealed a BIMS of 9. Resident #13 Cross reference F600, F692 On 2/13/24 at 11:05 AM, during an observation and interview Resident #13, lying in bed, stated she had lost weight while in the facility. She revealed there were times she did not eat well and she was not on supplements. On 2/14/24 at 11:40 AM, during an interview the DON confirmed Resident #13 had a significant weight loss which was not reported to the physician, therefore, no interventions to prevent and treat the nutritional status concerns were ordered and her weight continued to decrease. She confirmed the facility's failure to notify Resident #13's physician led to a 6.92% weight loss during her first month at the facility and to a 17.52% weight loss during her first four months at the facility. On 2/15/24 at 8:45 AM, an interview with the facility's Regional Nurse Consultant confirmed the facility neglected to identify a nutritional concern and to notify the physician of a significant weight loss, therefore, no interventions to prevent adverse consequences were ordered and the resident's weight continued to decline. Record review of Resident #13's admission Record revealed she was admitted to the facility on [DATE]. Diagnoses included Stevens-Johnson Syndrome, Non-pressure ulcers, Anxiety Disorder, Major Depressive Disorder. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/12/23 revealed a BIMS score of 12 which indicated the resident had a moderate cognitive impairment. The facility submitted the following removal plan: On 02/13/2024 at 4:30 PM the Mississippi State Department of Health (MSDH) state survey team notified the Administrator of an Immediate Jeopardy for failing to ensure processes were in place to review and implement Registered Dietician (RD) recommendations, notify the physician of weight loss, and implement interventions to address weight loss for Resident #20, who had lost 40.5lbs in the last six months. Resident #20 also had nausea and vomiting and was not eating or drinking adequately for the last three weeks and the facility had failed to notify the physician of the significant change. The facility failed to follow care plan interventions to identify weight loss and address weight loss for Resident #20. The facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) meeting to ensure all recommendations from the Registered Dietician were addressed in a prompt manner. Review of facility processes revealed that the recommendations from the registered dietician was being sent to the Dietary Manager via email and the emails were not received and not presented to the interdisciplinary team and reviewed by the provider and implemented. Interview with staff indicates that resident has had poor appetite since January, and it was not documented in the medical record. On 02/11/2024 at 6:27 PM, the facility nurse notified the provider and obtained orders for anti-emetic. On 2/12/2024 at 9:27 am, the facility attempted to transfer resident to the emergency room for evaluation and treatment as indicated. The Responsible Party refused for resident to be sent to the emergency room on this date. The facility obtained a physician's order for hospice services. On 02/13/2024 5:00 PM, In-services began on Abuse and Neglect for all staff by the Assistant Director of Nursing. All staff will be trained prior to returning to work. In-services began by Assistant Director of Nursing on Documentation, Provider Notification, and Change of Condition. All staff will be trained prior to returning to work. On 02/13/2024 at 5:15 PM, Social Services and Medical Records Nurse interviewed all residents regarding Nausea and Vomiting to ensure all significant changes of conditions were reported to the providers. It was noted upon interview that nine (9) residents reported recent complaints of nausea and vomiting, one (1) resident noted to have yellow discharge from mouth and nose, 1 resident was unable to recall when nausea or vomiting occurred with no staff being knowledgeable of nausea or vomiting, two (2) residents reported nausea or vomiting after eating, 2 residents reported not having appetite or eating, 1 resident reported nausea but did not report to nurse, 2 residents reported nausea and medications received. On 02/13/2024 at 5:30 PM, all residents were audited for weight loss by the Director of Nursing, Regional Nurse Consultant, and Minimum Data Set Nurse. Results of weight loss audit were reviewed by the medical director (15 unplanned weight losses, 1 planned) and new orders and diagnoses were provided by the medical director. All nutrition care plans audited by Minimum Data Set Nurse on 02/13/2024 with 5 residents whose registered dieticians' recommendations were not on care plans, dietary recommendations reviewed with providers and orders received per providers. On 02/13/2024 at 6:05 PM, the Director of Nursing notified the physician of all 9 residents, notified the Institutional Specialized Needs Plan (ISNP) nurse practitioner of all residents (4) and hospice of all residents (1) with Nausea and Vomiting with new orders received from provider. 1 resident reviewed with new orders for chest x-ray due to cough, congestion, and yellow discharge from mouth and nose, 2 residents were ordered medications for reflux, 1 resident noted to be receiving antibiotics and has orders in place for anti-emetic medications, 1 resident reported abdominal pain and MD was notified and seen resident on 02/12/2024 with new orders for stool softener, 1 resident noted to have diarrhea and has been antibiotics new orders received for Zofran and anti-diarrheal, 1 resident noted to have weight loss and nausea and vomiting new orders received on 2/11/2024 to start Zofran and start peri-actin the family was not agreeable to start peri-actin and wanted to wait to speak to hospice on 02/14/2024, 2 residents did not report nausea to nurses at time of occurrence. On 02/13/2024 at 6:59 PM, Social Services and Medical Records nurse interviewed residents with BIMS 10 or higher to ensure feeling of safe and are free of health concerns, no health or safety concern during interviews. On 02/13/2024 at 8:30 PM, all Registered Dietician recommendations for last 90 days audited by Dietary Manager and Minimum Data Set Nurse with 5 residents whose registered dietician recommendations were not addressed. All Dietary recommendations reviewed with the Medical Director (5) and subsequent providers as appropriate Hospice (2 residents who have been on hospice services prior to survey entrance) and Institutional Special Needs Program nurse practitioner (1), new orders received from providers as appropriate. On 02/13/2024 at 8:40 PM, All nutrition care plans audited by Minimum Data Set Nurse with 5 residents whose registered dieticians' recommendations were not on care plans, dietary recommendations reviewed with providers and orders received per providers and care plans updated. On 02/13/2024 at 9:00 PM, all residents noted with weight loss were reviewed with the Medical Director, the Medical Director performed medication review on all residents with weight loss. Ad Hoc QAPI was held on 02/13/2024 at 10:15 PM with the Medical Director via phone, Administrator, Director of Nursing, Social Services, Minimum Data Set Nurse, Life Connections Coordinator, Regional Nurse Consultant, Regional Director of Operations, Assistant Director of Nursing, Registered Nurse Supervisor, Dietary Manager, and Medical Records Nurse. The Minimum Data Set Nurse has been designated as the Quality Assurance Nurse with responsibility reviewing all audits, Performance Improvement Plans, Quality Measures, and actively participating in the Quality Assurance and Performance Improvement meetings. All areas of deficiencies were reviewed in Ad-Hoc Quality Assurance and Performance Improvement meeting. Medical Records nurse or Assistant Director of Nursing will be responsible for receiving Registered Dietician recommendations, reviewing with providers, entering orders, and progress notes. New processes for Medical Director to review facility weight losses each week on visit, Registered Dietitian recommendations to be reviewed weekly with the Interdisciplinary Team and the Medical Director by Friday, in the event Registered Dietician recommendations are not received, the medical director will be notified. The Dietary Manager will review the weight and vital sign exception report and present findings in the clinical meeting. The Director of Nursing will review weights and registered dietician recommendations. The Director of Nursing will review progress notes daily. The administrator will review the audit findings weekly. All results will be reviewed in Quality Assurance and Performance Improvement meetings. On 02/13/2024 at 10:00 PM, One-on-one Inservice conducted with Administrator by the Regional Director of Operations for weights, care plans, Quality Assurance and Performance Improvement, Notifying Physicians, Registered Dietician Recommendations, Documentation, and Administration Processes. The Regional Nurse Consultant conducted one-on-one in-services with the Director of Nursing, Dietary Manager, Assistant Director of Nursing, Medical Records Nurse, and Minimum Data Set Nurse regarding weights, care plans, Quality Assurance and Performance Improvement, Notifying Physicians, Registered Dietician Recommendations, Documentation and Administration Processes. One-on-one in-service conducted with the Dietary Manager by the Administrator regarding Communication of Dietary Recommendations, Review of Recommendations, and reporting any identified areas of concerns with Dietary Recommendations. All nurses who provided care to resident #20 for the previous 3 weeks were provided One-on-one in-services regarding reporting changes of condition to provider, documentation, and following plan of care then were provided with a post-test to confirm understanding of one-on-one in-services. As of 02/14/2024, the facility alleges compliance. All corrective action completed on 02/13/2024. The Survey Agency (SA) validated the facility's Corrective Actions on 2/20/24: The SA validated through record review that Resident #20 was ordered an anti-emetic for nausea/vomiting. The SA validated through interview and record review that in-services were conducted for Abuse and neglect, documentation, provider notification, and change of condition. No staff can return to work until they have received in-services. The SA validated through record review that all residents were interviewed and screened for symptoms of nausea and vomiting and the physician was notified of the findings with physician orders if appropriate. The SA validated through record review and staff interview that all residents were audited for weight loss and the Medical Director was updated. All nutrition care plans were audited and updated with dietary recommendations. The SA validated through record review that all residents with a Brief Interview for Mental Status (BIM's) of 10 or higher were interviewed to ensure feeling safe in their environment and free from health concerns. The SA validated through record review that all Registered Dietician (RD) recommendations were audited and addressed with the provider as appropriate. The SA validated the Medical Director reviewed the resident with weight loss and performed medication review. The SA validated through staff interview and record review on 2/20/24 that an Emergency Quality Assurance and Performance Improvement (QAPI) meeting was conducted on 2/13/24 with all members in attendance. The SA validated through record review and staff interview that one-on-one in-services were conducted on weights, care plans, Quality Assurance and Performance Improvement (QAPI), notifying physicians, reporting changes, Registered Dietician Recommendations, Documentation, and Administrative Processes. No staff can return to work until they have received in-services. The SA validated on 02/20/24 that all corrective actions were completed on 2/13/24 and the IJ (Immediate Jeopardy) was removed as of 2/14/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #15 Record review of the Care Plan, undated, for Resident #15 revealed, I have an ADL self-care performance deficit . Interventions: .BED MOBILITY: The resident uses half rails x (times) 2 (two) to improve bed mobility . On 2/12/24 at 2:30 PM, an observation of Resident #15 revealed the resident lying in bed with her eyes open. She was alert/verbal and confused. Three -quarter (¾) side rails were up on both sides. Record review of the Quarterly Evaluation for Resident #15 dated 9/05/23 revealed, Summary Findings . 2. Type of rail in use: Half rail 3. Rails in use: Bilateral . 5. Bed rails are indicated and serve as an enabler to promote independence: yes . On 2/12/24 at 2:50 PM, an interview and observation with the Director of Nursing (DON) , confirmed Resident #15 had three-quarter (3/4) rails. She stated she had no idea how long the rails had been on the bed. An interview with the Minimum Data Set (MDS) Nurse on 2/14/24 at 5:19 PM, revealed that the purpose of the Care Plan was for the staff to know how to care for a resident. She confirmed that Resident #15 did not have a care plan for the applied bed rails. Record review of the admission Record for Resident #15 revealed the facility admitted Resident #15 on 9/02/23 with diagnoses that included Unspecified dementia, Other seizures and Repeated falls. The facility submitted the following removal plan: On 02/13/2024 at 4:30 PM, the Mississippi State Department of Health (MSDH) state survey team notified the Administrator of an Immediate Jeopardy for failing to ensure processes were in place to review and implement Registered Dietician (RD) recommendations, notify the physician of weight loss, and implement interventions to address weight loss for Resident #20, who had lost 40.5 lbs in the last six months. Resident #20 also had nausea and vomiting and was not eating or drinking adequately for the last three weeks and the facility had failed to notify the physician of the significant change. The facility failed to follow care plan interventions to identify weight loss and address weight loss for Resident #20. The facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) meeting to ensure all recommendations from the Registered Dietician were addressed in a prompt manner. Review of facility processes revealed that the recommendations from the registered dietician was being sent to the Dietary Manager via email and the emails were not received and not presented to the interdisciplinary team and reviewed by the provider and implemented. Interview with staff indicates that resident has had poor appetite since January, and it was not documented in the medical record. On 02/11/2024 at 6:27 PM, the facility nurse notified the provider and obtained orders for anti-emetic. On 2/12/2024 at 9:27 am, the facility attempted to transfer resident to the emergency room for evaluation and treatment as indicated. The Responsible Party refused for resident to be sent to the emergency room on this date. The facility obtained a physician's order for hospice services. On 02/13/2024 5:00 PM, In-services began on Abuse and Neglect for all staff by the Assistant Director of Nursing. All staff will be trained prior to returning to work. In-services began by Assistant Director of Nursing on Documentation, Provider Notification, and Change of Condition. All staff will be trained prior to returning to work. On 02/13/2024 at 5:15 PM, Social Services and Medical Records Nurse interviewed all residents regarding Nausea and Vomiting to ensure all significant changes of conditions were reported to the providers. It was noted upon interview that nine (9) residents reported recent complaints of nausea and vomiting, one (1) resident noted to have yellow discharge from mouth and nose, 1 resident was unable to recall when nausea or vomiting occurred with no staff being knowledgeable of nausea or vomiting, two (2) residents reported nausea or vomiting after eating, 2 residents reported not having appetite or eating, 1 resident reported nausea but did not report to nurse, 2 residents reported nausea and medications received. On 02/13/2024 at 5:30 PM, all residents were audited for weight loss by the Director of Nursing, Regional Nurse Consultant, and Minimum Data Set Nurse. Results of weight loss audit were reviewed by the medical director (15 unplanned weight losses, 1 planned) and new orders and diagnoses were provided by the medical director. All nutrition care plans audited by Minimum Data Set Nurse on 02/13/2024 with 5 residents whose registered dieticians' recommendations were not on care plans, dietary recommendations reviewed with providers and orders received per providers. On 02/13/2024 at 6:05 PM, the Director of Nursing notified the physician of all 9 residents, notified the Institutional Specialized Needs Plan (ISNP) nurse practitioner of all residents (4) and hospice of all residents (1) with Nausea and Vomiting with new orders received from provider. 1 resident reviewed with new orders for chest x-ray due to cough, congestion, and yellow discharge from mouth and nose, 2 residents were ordered medications for reflux, 1 resident noted to be receiving antibiotics and has orders in place for anti-emetic medications, 1 resident reported abdominal pain and MD was notified and seen resident on 02/12/2024 with new orders for stool softener, 1 resident noted to have diarrhea and has been antibiotics new orders received for Zofran and anti-diarrheal, 1 resident noted to have weight loss and nausea and vomiting new orders received on 2/11/2024 to start Zofran and start peri-actin the family was not agreeable to start peri-actin and wanted to wait to speak to hospice on 02/14/2024, 2 residents did not report nausea to nurses at time of occurrence. On 02/13/2024 at 6:59 PM, Social Services and Medical Records nurse interviewed residents with BIMS 10 or higher to ensure feeling of safe and are free of health concerns, no health or safety concern during interviews. On 02/13/2024 at 8:30 PM, all Registered Dietician recommendations for last 90 days audited by Dietary Manager and Minimum Data Set Nurse with 5 residents whose registered dietician recommendations were not addressed. All Dietary recommendations reviewed with the Medical Director (5) and subsequent providers as appropriate Hospice (2 residents who have been on hospice services prior to survey entrance) and Institutional Special Needs Program nurse practitioner (1), new orders received from providers as appropriate. On 02/13/2024 at 8:40 PM, All nutrition care plans audited by Minimum Data Set Nurse with 5 residents whose registered dieticians' recommendations were not on care plans, dietary recommendations reviewed with providers and orders received per providers and care plans updated. On 02/13/2024 at 9:00 PM, all residents noted with weight loss were reviewed with the Medical Director, the Medical Director performed medication review on all residents with weight loss. Ad Hoc QAPI was held on 02/13/2024 at 10:15 PM with the Medical Director via phone, Administrator, Director of Nursing, Social Services, Minimum Data Set Nurse, Life Connections Coordinator, Regional Nurse Consultant, Regional Director of Operations, Assistant Director of Nursing, Registered Nurse Supervisor, Dietary Manager, and Medical Records Nurse. The Minimum Data Set Nurse has been designated as the Quality Assurance Nurse with responsibility reviewing all audits, Performance Improvement Plans, Quality Measures, and actively participating in the Quality Assurance and Performance Improvement meetings. All areas of deficiencies were reviewed in Ad-Hoc Quality Assurance and Performance Improvement meeting. Medical Records nurse or Assistant Director of Nursing will be responsible for receiving Registered Dietician recommendations, reviewing with providers, entering orders, and progress notes. New processes for Medical Director to review facility weight losses each week on visit, Registered Dietitian recommendations to be reviewed weekly with the Interdisciplinary Team and the Medical Director by Friday, in the event Registered Dietician recommendations are not received, the medical director will be notified. The Dietary Manager will review the weight and vital sign exception report and present findings in the clinical meeting. The Director of Nursing will review weights and registered dietician recommendations. The Director of Nursing will review progress notes daily. The administrator will review the audit findings weekly. All results will be reviewed in Quality Assurance and Performance Improvement meetings. On 02/13/2024 at 10:00 PM, One-on-one Inservice conducted with Administrator by the Regional Director of Operations for weights, care plans, Quality Assurance and Performance Improvement, Notifying Physicians, Registered Dietician Recommendations, Documentation, and Administration Processes. The Regional Nurse Consultant conducted one-on-one in-services with the Director of Nursing, Dietary Manager, Assistant Director of Nursing, Medical Records Nurse, and Minimum Data Set Nurse regarding weights, care plans, Quality Assurance and Performance Improvement, Notifying Physicians, Registered Dietician Recommendations, Documentation and Administration Processes. One-on-one in-service conducted with the Dietary Manager by the Administrator regarding Communication of Dietary Recommendations, Review of Recommendations, and reporting any identified areas of concerns with Dietary Recommendations. All nurses who provided care to resident #20 for the previous 3 weeks were provided One-on-one in-services regarding reporting changes of condition to provider, documentation, and following plan of care then were provided with a post-test to confirm understanding of one-on-one in-services. As of 02/14/2024, the facility alleges compliance and all corrective actions were completed on 02/13/2024. The Survey Agency (SA) validated the facility's Corrective Actions on 2/20/24: The SA validated through record review that Resident #20 was ordered an anti-emetic for nausea/vomiting. The SA validated through interview and record review that in-services were conducted for Abuse and neglect, documentation, provider notification, and change of condition. No staff can return to work until they have received in-services. The SA validated through record review that all residents were interviewed and screened for symptoms of nausea and vomiting and the physician was notified of the findings with physician orders if appropriate. The SA validated through record review and staff interview that all residents were audited for weight loss and the Medical Director was updated. All nutrition care plans were audited and updated with dietary recommendations. The SA validated through record review that all residents with a Brief Interview for Mental Status (BIM's) of 10 or higher were interviewed to ensure feeling safe in their environment and free from health concerns. The SA validated through record review that all Registered Dietician (RD) recommendations were audited and addressed with the provider as appropriate. The SA validated the Medical Director reviewed the resident with weight loss and performed medication review. The SA validated through staff interview and record review on 2/20/24 that an Emergency Quality Assurance and Performance Improvement (QAPI) meeting was conducted on 2/13/24 with all members in attendance. The SA validated through record review and staff interview that one-on-one in-services were conducted on weights, care plans, Quality Assurance and Performance Improvement (QAPI), notifying physicians, reporting changes, Registered Dietician Recommendations, Documentation, and Administrative Processes. No staff can return to work until they have received in-services. The SA validated that all corrective actions were completed on 2/13/24 and the IJ was removed as of 2/14/24. Resident #26 Record review revealed an ADL care plan in place for Resident #26 with a focus on ADL self-care performance deficit related to Parkinson's disease with an intervention under Bathing/showering to check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. During an observation and interview on 02/11/24 at 5:55 PM, Resident #26's fingernails on both hands were approximately one-half (1/2) inch long and jagged with a brown substance underneath the nails. Resident #26 revealed he would like his nails to be cut because they are too long. An interview with Licensed Practical Nurse (LPN) #2 on 02/12/24 at 2:55 PM, revealed Resident #26 is a diabetic and his nails must be cut by a registered nurse, the LPNs are not allowed to cut diabetic nails. She confirmed while reviewing Resident #26's care plan that Resident #26 did not have a care plan for his nails to be cut only by a registered nurse. During an interview on 02/12/24 at 3:10 PM, the DON revealed the registered nurses are responsible for doing diabetic nail care. She confirmed that Resident #26 did not have on his ADL or diabetic care plan for the registered nurses to cut his nails and revealed his care plan was not developed to specify the nail care for a diabetic. She confirmed he did not have an order for his fingernails to be cut by an RN and therefore it didn't show up on the Treatment Administration Record (TAR) for the registered nurse to cut his nails. Record review of Resident #26's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Parkinsonism, Chronic obstructive pulmonary disease, and Type 2 Diabetes Mellitus with hyperglycemia. Record review of Resident #26's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated the resident is severely cognitively impaired. Based on observation, resident and staff interview, record review and facility policy review, the facility failed to implement a comprehensive care plan for five (5) of eighteen sampled residents as evidenced by: Resident #13, #15, #20, #26, and #54 1) failed to implement the nutritional care plan for Resident #13 which resulted in a significant weight loss which placed the resident at risk for dehydration, malnutrition, skin breakdown and placed the resident and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. 2) failed to implement a pain and nutritional care plan for Resident #20 which resulted in the resident experiencing prolonged nausea, vomiting, and an infrequent passage of stool (constipation), significant weight loss, with a potential outcome for fecal impaction, bowel obstruction (blockage), dehydration, malnutrition, skin breakdown and placed the resident and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. Findings that did not rise to the level of Immediate Jeopardy: 3) failed to implement a care plan for personal hygiene for Resident #26, and Resident #54 as evidenced by long nails with a brown/black substance underneath. 4) failed to implement a care plan for bedrails and oxygen for Resident #15. The State Agency (SA) identified an Immediate Jeopardy (IJ) that began on 11/02/23 when the facility failed to recognize, evaluate, and address Resident #13's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. The facility's failure to consult a Registered Dietician (RD), notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious negative outcomes. The IJ existed at: 42 CFR §483.21(b)(1) Comprehensive Care Plans - F656 - Scope/Severity J The facility Administrator was notified of the IJ on 2/13/24 at 4:30 PM and provided the IJ Template. The facility provided an acceptable Removal Plan on 2/14/24, in which they alleged all corrective actions to remove the IJ were completed on 2/13/24 and the IJ removed on 2/14/24. The SA validated the Removal Plan on 2/20/24 and determined the IJ was removed on 2/14/24. Therefore, the scope and severity for 42 CFR §483.21(b)(1) Comprehensive Care Plans - F656 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy titled Care Plan - Comprehensive undated, revealed, Policy Statement: It is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs .Procedure: 1. An interdisciplinary team, in coordination with the resident and his/her family or representative, develops and maintains a comprehensive care plan for each resident. 2. The comprehensive care plan had been designated to: a. Incorporate identified focus areas b. Incorporate risk factors associated with identified problems c. Build on the resident's strengths d. Reflect treatment goals and objectives in measurable outcomes that incorporate the resident's personal and cultural preferences and wishes e. Identify the professional services that are responsible for each element of care f. Enhance the optional functioning of the resident by focusing of rehabilitative programs and resources as needed . Resident #13 Cross reference F580, F600, F692 During an interview on 2/13/24 at 11:05 AM, Resident #13 stated she had lost weight while in the facility. She revealed there were times she did not eat well and she did not receive supplements. Record review of Resident #13's Comprehensive Care Plan dated 12/19/23 revealed a care plan for potential nutritional problems with interventions including, Observe/record/report to MD (medical doctor) PRN (as needed) signs/symptoms of malnutrition: emaciation (Cachexia), muscle wasting, significant weight loss - three (3) pounds in one week, greater than 5% in one month, and greater than 7.5% in 3 months. At 11:40 AM on 2/14/24, during an interview the Director of Nursing (DON) revealed Resident #13 had a significant weight loss which was not reported to the physician for interventions, therefore, her weight continued to decrease. This led to a 6.92% weight loss during her first month at the facility and to a 17.5% weight loss during her first four months at the facility. She confirmed the resident's care plan for nutritional problems included an intervention to report to the physician as needed any signs or symptoms of malnutrition or significant weight loss and this was not followed. She confirmed the facility failed to follow care plan. At 8:45 AM on 2/15/24, an interview with the facility's Regional Nurse Consultant , revealed the physician was not consulted concerning Resident #13 significant weight loss so therefore, no interventions were initiated and weight continued to decline. She confirmed the care plan informed staff to notify the physician for concerns with nutrition such as weight loss and this was not followed. An interview with the Minimum Data Set (MDS) Registered Nurse (RN) on I2/14/24 at 5:30 PM, revealed the purpose of the care plan was for the staff to know the resident's needs and preferences and how to care for the resident and this resident's care plan for nutritional needs was not followed. Record review of Resident #13's admission Record revealed she was admitted to the facility on [DATE]. Diagnoses included Stevens-Johnson Syndrome, Non-pressure Ulcers, Anxiety Disorder, Major Depressive Disorder. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/12/23 revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident was moderately cognitively impaired. Resident #20 Cross reference F580, F600, F684, F692 Record review of Resident #20's Pain Care Plan revealed under, Interventions/Tasks: . Observe/document for side effects of pain medication. Observe for constipation; . nausea; vomiting; . Report occurrences to the physician. Record review of Resident #20's Order Summary Report revealed an order dated 1/02/24, Norco Oral Tablet 7.5 -325 MG (milligrams) (Hydrocodone-Acetaminophen) Give 7.5 mg (milligrams) by mouth every 6 (six) hours related to Pain . Record review of Resident #20's Order Summary Report revealed an order dated 12/13/23, Tramadol HCL (Hydrochloride) Tablet 50 MG (milligrams) Give 1 tablet by mouth every 12 (twelve) hours as needed for pain. Also revealed an order dated 12/13/23, Tramadol HCL (Hydrochloride)Tablet 50 MG (milligrams) Give 2 (two) tablets by mouth every 12 (twelve) hours as needed for pain . At 3:19 PM on 2/11/24, an observation and interview with Resident #20, revealed her lying in a fetal position at the foot of the bed with small garbage can was located on the floor close beside the resident. She stated she was sick to her stomach and had a washcloth in her hand and was wiping her face. At 8:35 AM on 2/12/24, an interview with Certified Nurse Aide (CNA) #2 revealed Resident #20 had been nauseated, dry heaving, and vomiting for the three (3) weeks since she had been employed at the facility. She revealed that she had reported it to the medication nurse every day that she worked. At 5:36 PM on 2/13/24, an interview with the Director of Nursing, confirmed that the facility did not have a monitoring tool in place for Resident #20 to monitor for the common side effects of an opioid pain medication such as constipation, nausea, and vomiting. The DON confirmed that the resident's care plan was not being followed because the physician had not been notified of the nausea and vomiting. Record review of Resident #20's Nutritional Care Plan revealed, Focus: I have potential nutritional problem .Interventions/Tasks: 01/04/24 - discussed weight loss in idt (interdisciplinary) meeting, nsg (nursing) to notify md (Medical Doctor) of weight change and await instruction to poc (plan of care) . 01/05/24 - RD (Registered Dietician) consult . Resident may benefit from an appetite stimulant . Add fortified pudding BID (twice daily) at lunch and dinner . 02/10/24 - RD review . Resident may benefit from appetite stimulant . If po (by mouth) intake and wt (weight) status does not improve, Resident may benefit from an alternate means of nutrition support. Will continue to monitor po (by mouth) intake, wt (weight) trends, labs and skin . Record review of Resident #20's weights revealed a significant weight loss of 13.9% (percent) in one (1) month, 21.6% (percent) in three (3) months, and 26.2% (percent) in six (6) months. Record review of the Order Summary Report for Resident #20 revealed there was not a physician's order for fortified pudding at lunch and supper or a medication to stimulate appetite per Registered Dietician (RD) recommendations. An interview with the Minimum Data Set (MDS) Nurse on 2/14/24 at 5:23 PM revealed that she developed the Nutritional Care Plan for Resident #20 by reading the Registered Dietician (RD) progress notes in the Electronic Medical Record (EMR) and adding the recommendations to the Care Plan. She revealed that she was aware that the resident did not have a physician's order for the fortified pudding or an appetite stimulant, but she thought the RD recommendation should be listed on the care plan. She stated, I can't say if the nutritional care plan was being followed because the weight loss was being addressed, even though the RD recommendations were not implemented. She revealed the purpose of the care plan was to give staff a guide to follow to know how to care for a resident. Record review of the Transfer/Discharge Report revealed the facility admitted Resident #20 on 1/24/22 with medical diagnoses that included Alzheimer's disease, rheumatoid arthritis, primary open-angled glaucoma, and wedge compression fracture of T 11-T 12 vertebra, subsequent encounter for fracture with delayed healing. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/10/24 revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicated the resident had severe cognitive impairment. Prior MDS's dated 09/18/23 revealed a BIMS of 11, MDS dated [DATE] revealed a BIMS of 9. Findings that did not rise to the level of IJ: Resident #54 Record review of Resident #54's Comprehensive Care Plan revealed the resident had an Activities of Daily Living self-care performance deficit. One intervention listed was personal hygiene - partial moderate assist. An interview with and observation of Resident #54 on 02/12/24 at 9:30 AM, revealed his fingernails were noted to be approximately 1/2 inch from nail bed with dark brown/black substance noted under each nail. He stated he prefers his nails to be kept short and he would like for them to be trimmed today. An interview on 2/12/24 at 3:20 PM, the Assistant Director of Nursing (ADON) confirmed Resident #54 had multiple scratch marks on abdomen and arms and nails were long and dirty with a substance under nails that appeared to be old dried blood. She confirmed the resident's nails should be kept clean and trimmed to the length the resident preferred and since he preferred his nails short, the staff needed to assist him to ensure this was done. She confirmed the facility failed to provide the resident's Activities of Daily Living (ADL) care for his nail care needs. She confirmed that nail care was part of the resident's personal hygiene care plan and this was not followed. An interview with the Director of Nursing (DON) on 2/12/24 at 4:55 PM, revealed the facility failed to ensure adequate Activity of Daily Living (ADL) nail care for a dependent resident was done. She confirmed the care plan was to inform staff of the needs and preferences for each resident and this part of Resident #54's personal hygiene care plan was not followed. During an interview on I2/14/24 at 5:30 PM, the Minimum Data Set (MDS) Registered Nurse (RN) confirmed the purpose of the care plan was for the staff to know the resident's needs and preferences and how to take care of the resident and this resident's care plan for personal hygiene assistance was not followed. Record review of Resident #54's admission Record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Muscle Weakness and Lack of Coordination. Record review of Resident #54's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/5/24, Section GG revealed for personal hygiene, Resident #54 required partial/moderate assistance. Section C revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to maintain acceptable parameters of nutrition for two (2) of six (6) residents sampled for nutrition as evidence by: Resident #13 and Resident #20 1) failed to recognize, evaluate, and address a resident's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% in four (4) months. Resident #13. The facility's failure to consult a Registered Dietician (RD), notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. 2) failed to identify and address a resident at risk for malnutrition due to prolonged nausea and vomiting, and failure to identify a decrease in food intake due to pain and nausea resulted in an unintended significant weight loss of 40.5 pounds in six (6) months. Resident #20. The facility's failure to implement a Registered Dietician (RD) recommendation, notify the attending physician of a significant change in condition, and address the residents' prolonged symptoms of nausea and vomiting, and decreased food intake placed the resident and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. The facility's neglect also resulted in a functional decline for Resident #20, which possibly resulted in the resident's admission to hospice services on 2/14/24. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 11/02/23 when the facility failed to recognize, evaluate, and address Resident #13's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. The facility's failure to consult a Registered Dietician (RD), notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious negative outcomes. The IJ and SQC existed at: CFR §483.25(g)(1) Nutrition/Hydration Status Maintenance - F692- Scope /Severity J The facility administrator was notified of the IJ and SQC on 2/13/24 at 4:30 PM and provided the IJ Template. The facility provided an acceptable Removal Plan on 2/14/24, in which they alleged all corrective actions to remove the IJ were completed on 2/13/24 and the IJ removed on 2/14/24. The SA validated the Removal Plan on 2/20/24 and determined the IJ was removed on 2/14/24. Therefore, the scope and severity for 42 CFR §483.25(g)(1) Nutrition/Hydration Status Maintenance - F692, was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy titled Weight Assessment and Intervention with a review date of 8/2003 revealed, Policy Statement: Resident weights are monitored for undesirable or unintended weight loss or gain Weight Assessment: 1. Residents are weighed upon admission and at intervals weekly or monthly or as ordered by the physician 3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietician in writing. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria . a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months- 10% weight loss is significant; greater than 10% is severe Under, Evaluation: . 2. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Review of the facility policy titled Nutritional Assessment with a review date of 7/24/23 revealed, Policy Statement: As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident .Policy interpretation and Implementation: 1. The dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change that places the resident at risk for impaired nutrition. 4. The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, the following situations that place the resident at increased risk for impaired nutrition. d. Medication changes - includes changes resulting in loss of appetite, nausea, constipation, lethargy, decreased absorption, swallowing difficulties., etc h. Fluid and nutrient loss-prolonged fluid and nutrient loss secondary to diarrhea and/or vomiting that may increase nutritional requirements . Resident #20 Cross reference F580, F692, F656 An observation and interview with Resident #20 on 2/11/24 at 3:19 PM, revealed her lying in a fetal position at the foot of the bed with a garbage can located on the floor beside the resident. The resident stated she was sick to her stomach and had a washcloth in her hand and was wiping her face. The resident's color was pale, lips were dry, and she was thin in appearance. An observation and interview with Resident #20 on 2/11/24 at 6:07 PM, revealed her lying on her right side in bed. The resident stated she was nauseated and could not eat dinner. She stated, I'm just sick. An interview on 2/11/24 at 6:12 PM, with Certified Nurse Aide (CNA) #7 revealed Resident #20 refused her dinner tray due to nausea and vomiting. She stated she was unsure how long the resident had been sick. An observation of Resident #20 on 2/12/24 at 8:29 AM, revealed her lying on her right side in bed. The garbage can was located on the floor, close by the resident. The breakfast tray was located on the bedside table untouched. CNA #2 entered the resident's room, and stated the resident refused to eat or drink due to nausea. CNA #2 removed the tray cover, and the resident began to retch and vomited a small amount of clear substance. The resident was weak, pale, and her lips were dry. An interview with CNA #2 on 2/12/24 at 8:35 AM, revealed she had worked at the facility for three (3) weeks and Resident #20 had refused to eat or drink since then. She explained that the resident had been nauseated, dry heaving, and vomiting for the past three (3) weeks since she had been employed at the facility. CNA #2 confirmed that she had reported the symptoms to the medication nurse every day that she worked. An interview with CNA #1 on 2/15/24 at 8:35 AM, revealed Resident #20 refused breakfast due to nausea. She stated that she had notified the nurse each time that she witnessed the resident with nausea and vomiting or refusing to eat and drink. Record review of Resident #20's Progress Notes from 11/01/23 through 2/11/24, revealed there was not any documentation that the resident had nausea and vomiting or that she refused meals. Record review of the Occupational Therapy Progress Notes dated 2/01/24 revealed, Patient refused: pt (patient) is refusing to eat and has poor appetite. pt (patient) c/o (complains of) nausea almost every day, but is not eating even with max encouragement and assist from therapist. Also revealed under, Assessment and Summary of Skilled Services: . therapist encouraging pt (patient) daily to eat and providing assist, but pt (patient) refuses to eat and c/o (complains of) nausea. Record review of the Order Summary Report for Resident #20 revealed an order dated 2/11/24 at 1827 (6:27 PM), Ondansetron HCL (Hydrochloride) Tablet 4 (four) MG (milligrams) Give 1 (one) tablet by mouth every 6 (six) hours as needed for Nausea and Vomiting . Record review of Resident #20's January and February Medication admission Record (MAR) revealed, there was not a physician's order for nausea/vomiting medication before the new order for Ondansetron HCL started on 2/11/24, which indicated the resident's symptoms of prolonged nausea and vomiting were left untreated. Record review of the Meal Intake Documentation Report completed by the Certified Nurse Aides (CNAs) revealed, Resident #20 refused eighteen (18) meals from 12/18/23 through 12/31/23. She refused thirty-one (31) meals in the month of January 2024, with a total of thirty-nine (39) meals consumed at 0-25% (percent), and she refused sixteen (16) meals from 2/01/24 through 2/11/24, with a total of fourteen (14) meals consumed at 0-25% (percent). Record review of Resident #20's Order Summary Report revealed an order dated 1/08/24, Weekly weights x (times) 4 (four) weeks one time a day every 7 day(s) . Record review of Resident #20's Weight Summary revealed the following weights: 8/03/23 - 154.5 pounds 9/07/23 - 152.2 pounds 10/5/23 - 147.6 pounds 11/01/23 - 145.4 pounds 12/04/23 - 145 pounds 1/03/24 - 132.4 pounds 1/10/24 - 129.6 pounds 1/16/24 - 124 pounds 1/23/24 - 133.2 pounds 1/30/24 - 122.8 pounds 2/06/24 - 114 pounds 02/15/24 - 110 pounds Record review of Resident #20's weights revealed a significant weight loss of 13.9% (percent) in one (1) month, 21.6% (percent) in three (3) months, and 26.2% (percent) in six (6) months. Record review of the Order Summary Report for Resident #20 revealed an order dated 1/04/24, Regular diet Regular texture, Regular consistency . Also revealed an order dated 1/04/24, Med Pass 2.0 two times a day for supplement. An interview with the Director of Nursing (DON) on 2/11/24 at 3:55 PM, revealed Resident #20's condition had declined over the past couple of months related to her diagnosis of dementia. She explained that the resident had a significant decline after she fell in December 2023, and received a fracture of the T-12 vertebrae and had to be placed on strong pain medications. She stated, to her knowledge, the resident had not experienced any nausea and vomiting until yesterday when the Survey Agency brought it to her attention. She stated none of the staff had reported it to her and confirmed that she should be aware of what was happening with the resident. She revealed she was aware that the resident was not eating or drinking and had been refusing meals. The DON stated she had made the physician aware of the resident's decline, and the significant weight loss, and the Registered Dietician (RD) had evaluated her. An interview with Licensed Practical Nurse (LPN) #3 on 2/11/24 at 4:20 PM, revealed Resident #20 had a decline over the past several weeks. She explained that the resident would not eat or drink anything, including the med pass supplement. She stated that usually they cannot get her to take her medications and that the resident would eat crushed ice chips, but that's about it. LPN #3 explained that she noticed a change after the resident fell and hurt her back and was in a lot of pain. She confirmed that she had not notified the resident's physician of the change in condition. A telephone interview with Medical Director on 2/12/24 at 6:05 PM, revealed the staff had contacted him last night regarding Resident #20 having nausea and vomiting, and he had ordered Zofran (Ondansetron) as needed. He confirmed that the staff had not contacted him or made him aware of the resident's decline in condition or her refusal to eat or drink. He stated that he was not notified of her significant weight loss (40.5 pounds in 6 months) or the Registered Dietician (RD) recommendations. He confirmed Resident #20's current condition was serious and stated what you have relayed to me screams neglect. Record review of the emergency room (ER) Report dated 12/17/23, revealed Resident #20 was transported to the ER after suffering an unwitnessed fall at the facility with complaints of back pain. Findings of the CT (Cat Scan) of the Spine Lumbar without contrast dated 12/17/23 revealed, There is a T-12 vertebral fracture involving both the superior and inferior endplates as well as the posterior cortex. Record review of Resident #20's Order Summary Report revealed an order dated 1/08/24, RD (Registered Dietician) consult . Record review of the Consultant Registered Dietician (RD) Note dated 12/27/23, for Resident #20 revealed the RD (Registered Dietician) recommended, Med Pass 2 oz (ounces) BID (twice daily), weekly weights x (times) 4 (four) weeks, and add Fortified Pudding BID (twice daily) at lunch and dinner . Record review of the Consultant Registered Dietician (RD) Note dated 1/5/24, for Resident #20 revealed, Resident w/(with) significant wt (weight) loss x (times) 1 (one) mo (month) (-9%) and x (times) 6 (six) mo (months) (13.7%) (percent). Po (by mouth) intake likely not meeting nutritional needs. Resident is at risk for skin breakdown and wt (weight) loss d/t (due to) decreased appetite . NO N/V/c/D (nausea, vomiting, complaints of diarrhea) documented. Also revealed under REC (recommendations): Resident may benefit from an appetite stimulant, please document % (percentage) of supplement consumed daily, add fortified pudding BID (twice daily) at lunch and dinner, weekly weights x (times) 4 (four) weeks to assure stable weight . Record review of the Consultant Registered Dietician (RD) Note) dated 2/10/24, for Resident #20 revealed, Resident w/(with) significant wt (weight) loss x times 1 (one) mo (month), x (times) 3 (three) mo (months) and x (times) 6 (six) mo (months) . consuming <25% w/(with) refusals of meals . Po (by mouth) intake likely not meeting nutritional needs . NO N/V/c/D (nausea, vomiting, complaints of diarrhea) documented. Also revealed under REC (recommendations): Resident may benefit from an appetite stimulant, please document % of supplement consumed daily, weekly weights x 4 weeks to assure stable weight, if po (by mouth) intake and wt (weight) status does not improve, resident may benefit from an alternate means of nutrition support. Record review of the Order Summary Report for Resident #20 revealed there was not a physician's order for fortified pudding at lunch and supper or a medication to stimulate appetite per Registered Dietician (RD) recommendations. Record review of Resident #20's Physician Nursing Home Visit dated 1/26/24 revealed, No concerns reported by the nursing staff The physician progress note did not identify any documentation to support the resident's nausea and vomiting or weight loss. An interview with Licensed Practical Nurse (LPN) #2 on 2/13/24 at 7:45 AM, revealed Resident #20 was not drinking the med pass supplement, and was refusing meals. She stated that the resident had been refusing meals for several weeks. She revealed that the resident's family was highly involved with her care, and the resident would report nausea to them, and they would come and notify her. An interview with the Dietary Manager (DM) on 2/13/24 at 8:13 AM, revealed that she was new to the role and had been in the position since June 2023. She revealed that the facility had weekly PAR (Patients at Risk) meetings where the weights were discussed. She stated all the Department Heads attend the meetings. The DM revealed, if a resident should need a RD (Registered Dietician) consult, she would notify the RD after the weekly PAR meeting by texting or calling. She stated that the RD would usually text her back to let her know she had the resident down on her list. She revealed that the RD did not come to the facility and did all her consultations remotely. She explained that the RD was consulted on Resident #20 in January 2024, but confirmed that she had not seen any RD recommendations. She stated that the resident had never received fortified pudding, and to her knowledge, had never started on an appetite stimulate. She explained that the facility had trouble getting the RD recommendations. The DM stated she just realized last week on Friday 2/9/24 that the RD recommendations were going to her spam email. She revealed that she tried to open the email and the email read it was quarantined. She revealed that she told the Director of Nursing (DON) that she was not receiving anything from the RD, and she thought the DON had texted her. She revealed that the Administrator had been going into all the residents 'progress notes and printing out the recommendations to make sure they were being implemented. She confirmed that lack of implementation of the RD recommendations could cause the resident to have weight loss and malnourishment. A telephone interview with the Registered Dietician (RD) on 2/13/24 at 9:56 AM, revealed that she worked remotely and tried to be onsite every 60-90 days. She revealed that her last visit to the facility was December 16, 2023. The RD explained that she had access to the Electronic Medical Record (EMR) and was able to chart under the residents' Progress Notes or under the Miscellaneous tab. She revealed that she was usually notified by the Director of Nursing (DON) or the Dietary Manager (DM) when a resident needed a dietary consultation. The RD stated she was notified in late December that Resident #20 needed to be seen due to a significant change. She revealed that she recommended med pass 2 ounces twice daily as a supplement, weekly weights and fortified pudding added with lunch and dinner. She revealed that she also did a consultation on Resident #20 on 1/5/24 and 2/10/24 and recommended that the resident would benefit from an appetite stimulant. She explained that she emailed all her recommendations to the Administrator (ADM), Director of Nursing (DON), Dietary Manager (DM), and the Regional Nursing Consultant (RNC). She explained that she marked on the recommendations if the physician needed to be contacted for a physician order. She confirmed that Resident #20's recommendation was marked to contact the physician for an appetite stimulant and adding the fortified pudding. She stated that she was unable to contact the doctor or write orders because she did not have the authority with her contract with the facility. She stated that she had not been contacted by anyone from the facility reporting that they had not received Resident #20's dietary recommendations. An interview with the Director of Nursing (DON) on 2/13/24 at 10:38 AM, revealed Resident #20 functional status had declined since her fall and after reviewing the progress notes, she observed there was no documentation to support a decline, nausea, and vomiting or food refusal. She revealed before the fall the resident was ambulatory, rarely in bed, and she took herself to the bathroom. She revealed that she would sit up in a chair in her room. She stated after the fall the resident required more help with her Activities of Daily Living (ADLs), stayed in bed, became incontinent, had more falls, and required the staff to assist with eating. She confirmed that the facility should have notified the physician immediately when the decline came about, and verbalized that was a failure on their part. She explained that the facility had spoken with the son about placing the resident on hospice today, and he had agreed. She explained that she knew it looked bad that they had consulted hospice, but she stated we had talked to the son before, and he thought she might recover. The DON stated that the facility did not reach out to the physician to inquire about drawing labs or any intravenous fluids throughout these months of the resident refusing to eat or drink. She stated that she did report the weight loss to the physician while he was inside the facility. She stated, I do not recall the date or month I notified him. She confirmed that she did not have documentation to support her notification. She stated that the facility was not receiving any of the dietary recommendations, and the Dietary Manager (DM) determined that the emails were going to her junk folder. She explained that the Administrator was going into the resident notes and printing them out to ensure they were all implemented. The DON stated that the RD would also add her notes to the Electronic Medical Record (EMR) and would not tell anyone. She revealed that she had texted the RD to tell her that the recommendations were not received, and the RD would reply that she would resend them. The DON revealed that she had never received any emails from the RD, and confirmed that she had not gone into her junk email to search and see if they came to her that way. The DON stated, I have over 700 junk emails and I do not have time to do that. An interview with the Administrator (ADM) on 2/13/24 at 2:10 PM, revealed the Registered Dietician (RD) worked remotely, and she had seen her in the facility twice. She explained that they were in the process of trying to find a RD onsite. She revealed that the facility usually communicates with the current RD through email or text messages and the last RD recommendation she had received by email was in August 2023. She stated that the Dietary Manager (DM) had received some, but they went to her spam folder encrypted. She explained that she had not reached out to the RD herself to follow up and that the facility had not started an audit and stated they tried to go over the recommendations in the High-Risk meetings. She stated that Resident #20 had been discussed in January 2024 during a PAR (patients at risk) meeting. The ADM confirmed that the Dietary Recommendations for Resident #20 had not been implemented and that the facility failed to document the significant changes that occurred in the resident's condition. She stated, I know the documentations not there. She revealed that she was told the Director of Nursing (DON) had reached out to the physician and stated, It looks bad on our part. An interview with Social Services (SS) on 2/13/24 at 3:00 PM, revealed she had reached out to the family of Resident #20 about the functional decline on 1/10/24. She revealed that the son did not want to do hospice at that time and was hoping the resident would perk up. She explained that since then, she followed up with the family and explained that the resident continued to decline and asked them to reconsider hospice services again. Record review of the Progress Notes for Resident #20 dated 2/14/24, Proper Name Hospice consulted per md order and family request . for declining condition related to Alzheimer's disease . An interview with the Minimum Data Set (MDS) Nurse on 2/14/24 at 5:23 PM, revealed that she did a significant change MDS after Resident #20 fell in December 2023, and after it was identified in the facility's clinical meeting that the resident had a significant weight loss in January 2024. She revealed that after the fall, the resident declined in her ability to get out of bed, and she was no longer able to sit in a chair, which was what the resident liked to do. She explained that the resident experienced increased pain, worsening incontinence and was required to wear a back brace when she was out of the bed. She stated that staff had identified the weight loss, and, in her opinion, it was being addressed. She confirmed that the documentation was absent to support a decline in the residents' condition, and stated she went off what was discussed in the High-Risk meetings. She revealed that she was aware that the resident did not have a physician order for the fortified pudding or an appetite stimulant that was recommended by the Registered Dietician (RD). Record review of the Transfer/Discharge Report revealed the facility admitted Resident #20 on 1/24/22 with medical diagnoses that included Alzheimer's disease, Rheumatoid Arthritis, Primary Open-angled Glaucoma, and Wedge Compression Fracture of T 11-T 12 vertebra, subsequent encounter for fracture with delayed healing. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/10/24 revealed a Brief Interview for Mental Status (BIMS) of 03 which indicated the resident had severe cognitive impairment. Prior MDSs dated 09/18/23 revealed a BIMS of 11, MDS dated [DATE] revealed a BIMS of 9. Resident #13 Cross reference F580, F600, F656 During an observation and interview on 2/13/24 at 11:05 AM, Resident #13 appeared comfortable lying in bed and stated she had lost weight while in the facility. She revealed there were times she did not eat well and she was not on supplements. During an interview on 2/14/24 at 11:40 AM, the Director of Nursing (DON) revealed Resident #13 had a significant weight loss which was not reported to the physician for interventions, therefore, her weight continued to decrease. She stated the Registered Dietician (RD) had not been consulted concerning the significant weight loss. She confirmed that due to the physician and the RD not being notified, the resident had a weight loss that could have possibly been avoided if interventions had been put in place for the resident's nutritional well-being. She confirmed the facility neglected to recognize, evaluate, and address the resident's weights, failed to notify the physician of the weight decline, and failed to consult the RD, therefore, appropriate evaluations and interventions were not ordered or initiated which put the resident at risk for a continued weight loss. She confirmed these failures led to a significant weight loss of 6.92% during Resident #13's first month at the facility and to a 17.52% weight loss during her first four months at the facility. An interview with the facility's Regional Nurse Consultant on 2/15/24 at 8:45 AM, revealed the physician nor the nurse practitioner were notified of Resident #13's significant weight loss and therefore, no interventions were initiated and weight continued to decline. She stated the initial consult with the Registered Dietician (RD) was on admission due to her wounds and once her weight was trending down, no additional consults were made. She confirmed the facility neglected to identify, evaluate, and intervene for nutritional concerns and, therefore, an avoidable weight loss occurred due to the facility's failure to appropriately manage the resident's nutritional needs. During an interview on 2/15/24 at 12:00 PM, the Dietary Manager confirmed she was unaware of Resident #13's significant weight loss and failed to ensure the Registered Dietician was notified of the weight loss concern. Record review of Weights and Vitals Summary revealed Resident #13's weight on 10/3/23 of 166.1 pounds and a weight on 11/2/23 of 154.6 pounds which listed a comparison weight of an 11.5 pound decrease and a 6.9% weight loss. Resident #13's weight on 2/5/24 was 137 pounds and compared to the admission weight 4 months previously of 166.1 pounds on 10/3/23 listed a comparison weight of a 29.1 pound decrease and a 17.5% weight loss. Record review of Resident #13's admission Record revealed she was admitted to the facility on [DATE]. Diagnoses included Stevens-Johnson Syndrome, Non-pressure Ulcers, Anxiety Disorder, Major Depressive Disorder. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/12/23 revealed a Brief Interview for Mental Status (BIMS) of 12 which indicated the resident had a moderate cognitive impairment. The facility submitted the following removal plan: On 02/13/2024 at 4:30 PM, the Mississippi State Department of Health (MSDH) state survey team notified the Administrator of an Immediate Jeopardy for failing to ensure processes were in place to review and implement Registered Dietician (RD) recommendations, notify the physician of weight loss, and implement interventions to address weight loss for Resident #20, who had lost 40.5 lbs in the last six months. Resident #20 also had nausea and vomiting and was not eating or drinking adequately for the last three weeks and the facility had failed to notify the physician of the significant change. The facility failed to follow care plan interventions to identify weight loss and address weight loss for Resident #20. The facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) meeting to ensure all recommendations from the Registered Dietician were addressed in a prompt manner. Review of facility processes revealed that the recommendations from the registered dietician was being sent to the Dietary Manager via email and the emails were not received and not presented to the interdisciplinary team and reviewed by the provider and implemented. Interview with staff indicates that resident has had poor appetite since January, and it was not documented in the medical record. On 02/11/2024 at 6:27 PM, the facility nurse notified the provider and obtained orders for anti-emetic. On 2/12/2024 at 9:27 am, the facility attempted to transfer resident to the emergency room for evaluation and treatment as indicated. The Responsible Party refused for resident to be sent to the emergency room on this date. The facility obtained a physician's order for hospice services. On 02/13/2024 5:00 PM, In-services began on Abuse and Neglect for all staff by the Assistant Director of Nursing. All staff will be trained prior to returning to work. In-services began by Assistant Director of Nursing on Documentation, Provider Notification, and Change of Condition. All staff will be trained prior to returning to work. On 02/13/2024 at 5:15 PM, Social Services and Medical Records Nurse interviewed all residents regarding Nausea and Vomiting to ensure all significant changes of conditions were reported to the providers. It was noted upon interview that nine (9) residents reported recent complaints of nausea and vomiting, one (1) resident noted to have yellow discharge from mouth and nose, 1 resident was unable to recall when nausea or vomiting occurred with no staff being knowledgeable of nausea or vomiting, two (2) residents reported nausea or vomiting after eating, 2 residents reported not having appetite or eating, 1 resident reported nausea but did not report to nurse, 2 residents reported nausea and medications received. On 02/13/2024 at 5:30 PM, all residents were audited for weight loss by the Director of Nursing, Regional Nurse Consultant, and Minimum Data Set Nurse. Results of weight loss audit were reviewed by the medical director (15 unplanned weight losses, 1 planned) and new orders and diagnoses were provided by the medical director. All nutrition care plans audited by Minimum Data Set Nurse on 02/13/2024 with 5 residents whose registered dieticians' recommendations were not on care plans, dietary recommendations reviewed with providers and orders received per providers. On 02/13/2024 at 6:05 PM, the Director of Nursing notified the physician of all 9 residents, notified the Institutional Specialized Needs Plan (ISNP) nurse practitioner of all residents (4) and hospice of all residents (1) with Nausea and Vomiting with new orders received from provider. 1 resident reviewed with new orders for chest x-ray due to cough, congestion, and yellow discharge from mouth and nose, 2 residents were ordered medications for reflux, 1 resident noted to be receiving antibiotics and has orders in place for anti-emetic medications, 1 resident reported abdominal pain and MD w[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review, the facility failed maintain an effective Quality Assurance and Performance Improvement (QAPI) program to identify, analyze, and address residents with weight loss for two (2) of six (6) residents reviewed for nutrition. Resident #13 and Resident #20. The facility's Quality Assurance and Performance Improvement (QAPI) review indicated the facility's failure resulted in a lack of action to identify and address weight loss, which placed Resident #13 and Resident #20, and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. The State Agency (SA) identified an Immediate Jeopardy (IJ) that began on 11/02/23 when the facility failed to recognize, evaluate, and address Resident #13's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. The facility's failure to consult a Registered Dietician (RD), notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious negative outcomes. The IJ existed at: 42 CFR §483.75(a) Quality Assurance and Performance Improvement (QAPI) Program - F865 - Scope/Severity J The facility Administrator was notified of the IJ on 2/13/24 at 4:30 PM and provided the IJ Template. The facility provided an acceptable Removal Plan on 2/14/24, in which they alleged all corrective actions to remove the IJ were completed on 2/13/24 and the IJ removed on 2/14/24. The SA validated the Removal Plan on 2/20/24 and determined the IJ was removed on 2/20/24. Therefore, the scope and severity for 42 CFR §483.75(a) Quality Assurance and Performance Improvement (QAPI) Program was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled Quality Assessment and Performance Improvement undated, revealed, Overview: The Quality Assurance and Performance Improvement (QAPI) committee will implement a process that is ongoing, multi level, and facility wide that encompasses managerial, administrative, clinical, ancillary, and environmental services as well as contracted services and suppliers. The program should address all systems of care and management practices while emphasizing safety, quality of life, and resident choice. The primary purpose of the committee is to identify and analyze actual or potential quality issues, develop and implement appropriate plans to improve performance, to address identified quality issues, and monitor the effectiveness of implemented changes. The committee will make any needed revisions to performance improvement plans. Other purpose of the QAPI committee are to maintain satisfactory, consistent functioning of systems, to prevent deviations from care processes (to the extent possible), to discern issues and concerns with facility systems, and to correct said systems as needed. The committee will ensure that information about the QAPI committee activity is provided to consultants or others who are not members of the committee but have responsibility of the Governing Body oversight. Governance And Leadership: The committee will consist of the facility administrator, the Director of Nursing, the Medical Director, the Infection Preventionist and at least 3 other designated key staff members. The facility administrator will be responsible for the effective functioning of the QAPI program but may designate one or more persons to be accountable for QAPI. The minutes of the monthly QAPI meeting will be reviewed with the Medical Director for input. The methodology utilized by the facility to identify quality concerns incorporates the following: Establishment of critical items .Data gathering and trending including input from staff, residents, and families regarding quality problems and opportunities for improvement .Establishment of benchmarks for critical items utilizing the best available evidence to define goals . Utilization of root cause analysis Resident #20 Record review of Resident #20's weights revealed a significant weight loss of 13.9% (percent) in one (1) month, 21.6% (percent) in three (3) months, and 26.2% (percent) in six (6) months. The Dietary Manager (DM) interview on 2/13/24 at 8:13 AM, revealed she was new to the role and had been in the position since June 2023. She revealed the facility had weekly PAR (Patients at Risk) meetings where the weights were discussed. She stated all the department heads attend the meetings but that the Registered Dietician (RD) does not attend PAR or Quality Assurance and Performance Improvement (QAPI) meetings. The RD sends her recommendations and we are suppose to review them at the quarterly meetings. The Registered Dietician (RD) revealed during a telephone interview with on 2/13/24 at 9:56 AM, she worked remotely and tried to be onsite every 60-90 days. She revealed that her last visit to the facility was December 16, 2023. The RD explained she had access to the Electronic Medical Record (EMR) and was able to chart under the residents' Progress Notes or under the Miscellaneous tab. She revealed she did not attend the Quality Assurance and Performance Improvement (QAPI) meetings. The Director of Nursing (DON) interview on 2/13/24 at 10:38 AM, revealed she had been in the position since October 2023 and she had been to one (1) Quality Assurance (QA) meeting since she started and could not recall if weights were even discussed. The DON stated she had not conducted any tracking/trending on the facility's weight loss, and confirmed that she should have. She stated the Registered Dietician (RD) did not attend Quality Assurance and Performance Improvement (QAPI) meetings or the weekly PAR meetings. The Administrator (ADM) interview on 2/13/24 at 2:10 PM, revealed the last Quality Assurance and Performance Improvement (QAPI) meeting conducted on weight loss was February 7, 2024, and included audits conducted by the DON on weights, physician orders, and Dietary Consults. She revealed no other QAPI's had been conducted pertaining to weight loss, and she was unsure what the Director of Nursing (DON) had completed in her tracking and trending and she confirmed that the Medical Director was not in attendance for the last meeting and stated she went over everything by phone. The Regional Nursing Consultant (RNC) interview on 2/14/24 at 5:40 PM, revealed the facility did not have a great QAPI (Quality Assurance Performance Improvement) system in place for identifying, tracking, and trending weight loss. The Administrator interview on 2/14/24 at 4:36 PM, , revealed she was the contact person for Quality Assurance and Performance Improvement (QAPI). She revealed we have a meeting monthly which includes the Director of nursing (DON), Assistant Director of Nursing (ADON), Dietary, Maintenance, Social Services and all personnel that were required. An interview with the Chief Clinical Officer (CCO) on 2/15/24 at 11:00 AM, revealed the facility has struggled with getting a Director of Nursing (DON). She stated they have had 4 DON's since the previous survey in 2022. She confirmed the facility did not have a great Quality Assurance and Performance Improvement (QAPI) program and revealed the corporate office was in the process of revamping the QAPI program so each facility will have a uniformed template to use. Record review of the QA (Quality Assurance) meeting minutes dated 1/9/24 for the month review of December 2023 revealed, . Director of Nursing -weights, auditing orders, and making rounds. No documentation was provided to indicate tracking and trending resident weight loss or to address what actions were put in place. The specific residents who had significant weight loss were not mentioned. Record review of the QA (Quality Assurance) meeting minutes dated 2/7/24 for the month review of January 2024 revealed, . Director of Nursing -weights, auditing orders, and making rounds. No documentation was provided to indicate tracking and trending resident weight loss or to address what actions were put in place. The specific residents who had significant weight loss were not mentioned. Record review of the Transfer/Discharge Report revealed the facility admitted Resident #20 on 1/24/22 with medical diagnoses that included Alzheimer's disease, Rheumatoid Arthritis, and Wedge compression fracture of T 11-T 12 vertebra, subsequent encounter for fracture with delayed healing. Resident #13 Record review of Weights and Vitals Summary revealed Resident #13's weight on 10/3/23 was 166.1 pounds and a weight on 11/2/23 was 154.6 pounds which listed a comparison weight of an 11.5 pound decrease and a 6.9% weight loss. Resident #13's weight on 2/5/24 was 137 pounds and compared to the admission weight 4 months previously of 166.1 pounds on 10/3/23 listed a comparison weight of a 29.1 pound decrease and a 17.5% weight loss. Record review of Resident #13's admission Record revealed she was admitted to the facility on [DATE]. Diagnoses included Stevens-Johnson Syndrome, Non-pressure Ulcers, Anxiety Disorder, Major Depressive Disorder. The facility submitted the following removal plan: On 02/13/2024 at 4:30 PM, the Mississippi State Department of Health (MSDH) state survey team notified the Administrator of an Immediate Jeopardy for failing to ensure processes were in place to review and implement Registered Dietician (RD)recommendations, notify the physician of weight loss, and implement interventions to address weight loss for Resident #20, who had lost 40.5 lbs in the last six months. Resident #20 also had nausea and vomiting and was not eating or drinking adequately for the last three weeks and the facility had failed to notify the physician of the significant change. The facility failed to follow care plan interventions to identify weight loss and address weight loss for Resident #20. The facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) meeting to ensure all recommendations from the Registered Dietician were addressed in a prompt manner. Review of facility processes revealed that the recommendations from the registered dietician was being sent to the Dietary Manager via email and the emails were not received and not presented to the interdisciplinary team and reviewed by the provider and implemented. Interview with staff indicates that resident has had poor appetite since January, and it was not documented in the medical record. On 02/11/2024 at 6:27 PM, the facility nurse notified the provider and obtained orders for anti-emetic. On 2/12/2024 at 9:27 am, the facility attempted to transfer resident to the emergency room for evaluation and treatment as indicated. The Responsible Party refused for resident to be sent to the emergency room on this date. The facility obtained a physician's order for hospice services. On 02/13/2024 5:00 PM, In-services began on Abuse and Neglect for all staff by the Assistant Director of Nursing. All staff will be trained prior to returning to work. In-services began by Assistant Director of Nursing on Documentation, Provider Notification, and Change of Condition. All staff will be trained prior to returning to work. On 02/13/2024 at 5:15 PM, Social Services and Medical Records Nurse interviewed all residents regarding Nausea and Vomiting to ensure all significant changes of conditions were reported to the providers. It was noted upon interview that nine (9) residents reported recent complaints of nausea and vomiting, one (1) resident noted to have yellow discharge from mouth and nose, 1 resident was unable to recall when nausea or vomiting occurred with no staff being knowledgeable of nausea or vomiting, two (2) residents reported nausea or vomiting after eating, 2 residents reported not having appetite or eating, 1 resident reported nausea but did not report to nurse, 2 residents reported nausea and medications received. On 02/13/2024 at 5:30 PM, all residents were audited for weight loss by the Director of Nursing, Regional Nurse Consultant, and Minimum Data Set Nurse. Results of weight loss audit were reviewed by the medical director (15 unplanned weight losses, 1 planned) and new orders and diagnoses were provided by the medical director. All nutrition care plans audited by Minimum Data Set Nurse on 02/13/2024 with 5 residents whose registered dieticians' recommendations were not on care plans, dietary recommendations reviewed with providers and orders received per providers. On 02/13/2024 at 6:05 PM, the Director of Nursing notified the physician of all 9 residents, notified the Institutional Specialized Needs Plan (ISNP) nurse practitioner of all residents (4) and hospice of all residents (1) with Nausea and Vomiting with new orders received from provider. 1 resident reviewed with new orders for chest x-ray due to cough, congestion, and yellow discharge from mouth and nose, 2 residents were ordered medications for reflux, 1 resident noted to be receiving antibiotics and has orders in place for anti-emetic medications, 1 resident reported abdominal pain and MD was notified and seen resident on 02/12/2024 with new orders for stool softener, 1 resident noted to have diarrhea and has been antibiotics new orders received for Zofran and anti-diarrheal, 1 resident noted to have weight loss and nausea and vomiting new orders received on 2/11/2024 to start Zofran and start peri-actin the family was not agreeable to start peri-actin and wanted to wait to speak to hospice on 02/14/2024, 2 residents did not report nausea to nurses at time of occurrence. On 02/13/2024 at 6:59 PM, Social Services and Medical Records nurse interviewed residents with BIMS 10 or higher to ensure feeling of safe and are free of health concerns, no health or safety concern during interviews. On 02/13/2024 at 8:30 PM, all Registered Dietician recommendations for last 90 days audited by Dietary Manager and Minimum Data Set Nurse with 5 residents whose registered dietician recommendations were not addressed. All Dietary recommendations reviewed with the Medical Director (5) and subsequent providers as appropriate Hospice (2 residents who have been on hospice services prior to survey entrance) and Institutional Special Needs Program nurse practitioner (1), new orders received from providers as appropriate. On 02/13/2024 at 8:40 PM, All nutrition care plans audited by Minimum Data Set Nurse with 5 residents whose registered dieticians' recommendations were not on care plans, dietary recommendations reviewed with providers and orders received per providers and care plans updated. On 02/13/2024 at 9:00 PM, all residents noted with weight loss were reviewed with the Medical Director, the Medical Director performed medication review on all residents with weight loss. Ad Hoc QAPI was held on 02/13/2024 at 10:15 PM with the Medical Director via phone, Administrator, Director of Nursing, Social Services, Minimum Data Set Nurse, Life Connections Coordinator, Regional Nurse Consultant, Regional Director of Operations, Assistant Director of Nursing, Registered Nurse Supervisor, Dietary Manager, and Medical Records Nurse. The Minimum Data Set Nurse has been designated as the Quality Assurance Nurse with responsibility reviewing all audits, Performance Improvement Plans, Quality Measures, and actively participating in the Quality Assurance and Performance Improvement meetings. All areas of deficiencies were reviewed in Ad-Hoc Quality Assurance and Performance Improvement meeting. Medical Records nurse or Assistant Director of Nursing will be responsible for receiving Registered Dietician recommendations, reviewing with providers, entering orders, and progress notes. New processes for Medical Director to review facility weight losses each week on visit, Registered Dietitian recommendations to be reviewed weekly with the Interdisciplinary Team and the Medical Director by Friday, in the event Registered Dietician recommendations are not received, the medical director will be notified. The Dietary Manager will review the weight and vital sign exception report and present findings in the clinical meeting. The Director of Nursing will review weights and registered dietician recommendations. The Director of Nursing will review progress notes daily. The administrator will review the audit findings weekly. All results will be reviewed in Quality Assurance and Performance Improvement meetings. On 02/13/2024 at 10:00 PM, One-on-one Inservice conducted with Administrator by the Regional Director of Operations for weights, care plans, Quality Assurance and Performance Improvement, Notifying Physicians, Registered Dietician Recommendations, Documentation, and Administration Processes. The Regional Nurse Consultant conducted one-on-one in-services with the Director of Nursing, Dietary Manager, Assistant Director of Nursing, Medical Records Nurse, and Minimum Data Set Nurse regarding weights, care plans, Quality Assurance and Performance Improvement, Notifying Physicians, Registered Dietician Recommendations, Documentation and Administration Processes. One-on-one in-service conducted with the Dietary Manager by the Administrator regarding Communication of Dietary Recommendations, Review of Recommendations, and reporting any identified areas of concerns with Dietary Recommendations. All nurses who provided care to resident #20 for the previous 3 weeks were provided One-on-one in-services regarding reporting changes of condition to provider, documentation, and following plan of care then were provided with a post-test to confirm understanding of one-on-one in-services. As of 02/14/2024, the facility alleges compliance and all corrective action completed on 02/13/2024. The Survey Agency (SA) validated the facility's Corrective Actions on 2/20/24: The SA validated through record review that Resident #20 was ordered an anti-emetic for nausea/vomiting. The SA validated through interview and record review that in-services were conducted for Abuse and neglect, documentation, provider notification, and change of condition. No staff can return to work until they have received in-services. The SA validated through record review that all residents were interviewed and screened for symptoms of nausea and vomiting and the physician was notified of the findings with physician orders if appropriate. The SA validated through record review and staff interview that all residents were audited for weight loss and the Medical Director was updated. All nutrition care plans were audited and updated with dietary recommendations. The SA validated through record review that all residents with a Brief Interview for Mental Status (BIM's) of 10 or higher were interviewed to ensure feeling safe in their environment and free from health concerns. The SA validated through record review that all Registered Dietician (RD) recommendations were audited and addressed with the provider as appropriate. The SA validated the Medical Director reviewed the resident with weight loss and performed medication review. The SA validated through staff interview and record review on 2/20/24 that an Emergency Quality Assurance and Performance Improvement (QAPI) meeting was conducted on 2/13/24 with all members in attendance. The SA validated through record review and staff interview that one-on-one in-services were conducted on weights, care plans, Quality Assurance and Performance Improvement (QAPI), notifying physicians, reporting changes, Registered Dietician Recommendations, Documentation, and Administrative Processes. No staff can return to work until they have received in-services. The SA validated that all corrective actions were completed on 2/13/24 and the IJ was removed as of 2/14/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to protect a residents right to be free from neglect for two (2) of three (3) residents sampled for abuse, Resident #13 and Resident #20 as evidence by: 1) neglected to recognize, communicate, evaluate, and address a resident's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. Resident #13. The facility's failure to consult a Registered Dietician (RD), notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious serious harm, serious injury, serious impairment, or possibly death. 2) neglected to identify, communicate, and address a resident at risk for malnutrition due to prolonged nausea and vomiting, and failure to identify a decrease in food intake due to pain and nausea resulted in an unintended significant weight loss of 40.5 pounds in six (6) months. Resident #20. The facility's failure to implement a Registered Dietician (RD) recommendation, notify the attending physician of a significant change in condition, and address the residents' prolonged symptoms of nausea and vomiting, and decreased food intake placed the resident and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, or possibly death. The facility's neglect also resulted in a functional decline for Resident #20, which potentially resulted in the resident's admission to hospice services on 2/14/24. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 11/02/23 when the facility failed to recognize, evaluate, and address Resident #13's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. The facility's failure to consult a Registered Dietician (RD), notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious negative outcomes. The IJ and SQC existed at: 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation - F600 - Scope/Severity J The facility Administrator was notified of the IJ and SQC on 2/13/24 at 4:30 PM and provided the IJ Template. The facility provided an acceptable Removal Plan on 2/14/24, in which they alleged all corrective actions to remove the IJ were completed on 2/13/24 and the IJ removed on 2/14/24. The SA validated the Removal Plan on 2/20/24 and determined the IJ was removed on 2/14/24. Therefore, the scope and severity for 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation - F600, was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date of 10/22 revealed, Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not used to treat the resident ' s symptoms .Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to a. facility staff; . 2. Develop and implement policies and protocols to prevent and identify: . neglect of residents; . Resident #20 Cross reference F580, F656, F692 During an observation and interview with Resident #20 on 2/11/24 at 3:19 PM, revealed her lying in a fetal position at the foot of the bed. Upon entrance to the room the door was closed, the room was dark and it was observed that a garbage can was located on the floor beside the resident. The resident stated she was sick to her stomach and she had a washcloth in her hand and was wiping her face. The resident 's color was pale, lips were dry, and she was thin in appearance. During an observation and interview with Resident #20 on 2/11/24 at 6:07 PM, revealed her lying on her right side in bed. The resident stated she was nauseated and could not eat dinner and stated, I'm just sick. During an observation of Resident #20 on 2/12/24 at 8:29 AM, revealed her lying on her right side in bed. The garbage can was located on the floor, close by the resident. The breakfast tray was located on the bedside table untouched. CNA #2 entered the resident's room, and stated the resident refused to eat or drink due to nausea. CNA #2 removed the tray cover, and the resident began to retch and vomited a small amount of clear substance into the garbage can. The resident was observed as weak and pale, and her lips were dry. During an interview with CNA #2 on 2/12/24 at 8:35 AM, revealed she had worked at the facility for three (3) weeks and Resident #20 had refused to eat or drink everyday since then. She explained that the resident had been nauseated, dry heaving, and vomiting for the past three (3) weeks, that she had been employed at the facility. She confirmed that she had reported the symptoms to the medication nurse every day that she worked. Record review of Resident #20's Progress Notes from 11/01/23 through 2/11/24, revealed there was not any documentation that the resident had nausea and vomiting or that she refused meals. Record review of the Occupational Therapy Progress Notes dated 2/01/24 revealed, Patient refused: pt (patient) is refusing to eat and has poor appetite. pt (patient) c/o (complains of) nausea almost every day, but is not eating even with max encouragement and assist from therapist. Also revealed under, Assessment and Summary of Skilled Services: . therapist encouraging pt (patient) daily to eat and providing assist, but pt (patient) refuses to eat and c/o (complains of) nausea . Record review of the Order Summary Report for Resident #20 revealed an order dated 2/11/24 at 1827 (6:27 PM), Ondansetron HCL (Hydrochloride) Tablet (Zofran) 4 (four) MG (milligrams) Give 1 (one) tablet by mouth every 6 (six) hours as needed for Nausea and Vomiting . Record review of Resident #20's January and February Medication admission Record (MAR) revealed, there was not a physician ' s order for nausea/vomiting medication before the new order for Zofran started on 2/11/24, which indicated the resident's symptoms of prolonged nausea and vomiting were left untreated. Record review of the Meal Intake Documentation Report completed by the Certified Nurse Aides (CNAs) revealed, Resident #20 refused eighteen (18) meals from 12/18/23 through 12/31/23. She refused thirty-one (31) meals in the month of January 2024, with a total of thirty-nine (39) meals consumed at 0-25% (percent), and she refused sixteen (16) meals from 2/01/24 through 2/11/24, with a total of fourteen (14) meals consumed at 0-25% (percent). Record review of Resident #20's Order Summary Report revealed an order dated 1/08/24, Weekly weights x (times) 4 (four) weeks one time a day every 7 day(s) . Record review of Resident #20's weights revealed a significant weight loss of 13.9% (percent) in one (1) month, 21.6% (percent) in three (3) months, and 26.2% (percent) in six (6) months. Record review of the Order Summary Report for Resident #20 revealed an order dated 1/04/24, Regular diet Regular texture, Regular consistency . Also revealed an order dated 1/04/24, Med Pass 2.0 two times a day for supplement. During an interview with the Director of Nursing (DON) on 2/11/24 at 3:55 PM revealed Resident #20's condition had declined over the past couple of months. She explained that the resident had a significant decline after she fell in December 2023, and received a fracture of the T-12 vertebrae and had to be placed on strong pain medications. She stated, to her knowledge, the resident had not experienced any nausea and vomiting until yesterday when the Survey Agent brought it to her attention. She stated none of the staff had reported it to her and that she should be aware of what was happening with the resident. She revealed she was aware that the resident was not eating or drinking and had been refusing meals and that she had made the physician aware of the resident's decline, and the significant weight loss, and the Registered Dietician (RD) had evaluated her. An interview with Licensed Practical Nurse (LPN) #3 on 2/11/24 at 4:20 PM, revealed Resident #20 had a decline over the past several weeks. She explained that the resident would not eat or drink anything, including the med pass supplement. She stated that usually they cannot get her to take her medications. She revealed that the resident would eat crushed ice chips, but that's about it. LPN #3 explained that she noticed a change after the resident fell and hurt her back and was in a lot of pain. She confirmed that she had not notified the resident's physician of the change in condition. During a telephone interview with Medical Director on 2/12/24 at 6:05 PM, revealed the staff had contacted him last night regarding Resident #20 having nausea and vomiting, and he had ordered Zofran as needed. He confirmed that the staff had not contacted him or made him aware of the residents' decline in condition or her refusal to eat or drink. He stated that he was not notified of her significant weight loss (40.5 pounds in 6 months) or the Registered Dietician (RD) recommendations. He confirmed Resident #20's current condition was serious and stated What you have relayed screams neglect. Record review of Resident #20's Order Summary Report revealed an order dated 1/08/24, RD (Registered Dietician) consult . Record review of the Consultant Registered Dietician (RD) Note dated 12/27/23, for Resident #20 revealed the RD (Registered Dietician) recommended, Med Pass 2 oz (ounces) BID (twice daily), weekly weights x (times) 4 (four) weeks, and add Fortified Pudding BID (twice daily) at lunch and dinner . Record review of the Consultant Registered Dietician (RD) Note dated 1/5/24, for Resident #20 revealed, Resident w/(with) significant wt (weight) loss x (times) 1 (one) mo (month) (-9%) and x (times) 6 (six) mo (months) (13.7%) (percent). Po (by mouth) intake likely not meeting nutritional needs. Resident is at risk for skin breakdown and wt (weight) loss d/t (due to) decreased appetite . NO N/V/c/D (nausea, vomiting, complaints of diarrhea) documented. Also revealed under REC (recommendations): Resident may benefit from an appetite stimulant, please document % (percentage) of supplement consumed daily, add fortified pudding BID (twice daily) at lunch and dinner, weekly weights x (times) 4 (four) weeks to assure stable weight . Record review of the Consultant Registered Dietician (RD) Note) dated 2/10/24, for Resident #20 revealed, Resident w/(with) significant wt (weight) loss x times 1 (one) mo (month), x (times) 3 (three) mo (months) and x (times) 6 (six) mo (months) . consuming <25% w/(with) refusals of meals . Po (by mouth) intake likely not meeting nutritional needs . NO N/V/c/D (nausea, vomiting, complaints of diarrhea) documented. Also revealed under REC (recommendations): Resident may benefit from an appetite stimulant, please document % of supplement consumed daily, weekly weights x 4 weeks to assure stable weight, if po (by mouth) intake and wt (weight) status does not improve, resident may benefit from an alternate means of nutrition support. Record review of the Order Summary Report for Resident #20 revealed there was not a physician's order for fortified pudding at lunch and supper or a medication to stimulate appetite per Registered Dietician (RD) recommendations. Record review of Resident #20's Physician Nursing Home Visit dated 1/26/24 revealed, No concerns reported by the nursing staff The physician progress note did not identify any documentation to support the resident's nausea and vomiting or weight loss. An interview with Licensed Practical Nurse (LPN) #2 on 2/13/24 at 7:45 AM, revealed Resident #20 was not drinking the med pass supplement, and was refusing meals. She stated that the resident had been refusing meals for several weeks and that the resident's family was highly involved with her care, and the resident would report nausea to them, and the family would come and let us know when they were there for a visit. LPN #2 confirmed that there was no documentation in the nurses notes to indicate that the resident had nausea or vomiting. During an interview with the Dietary Manager (DM) on 2/13/24 at 8:13 AM, revealed that she was new to the role and had been in the position since June 2023. She revealed that the facility had weekly PAR (Patients at Risk) meetings where the weights of the residents were discussed and stated all the department heads attend the meetings. The DM revealed, if a resident should need a RD (Registered Dietician) consult, she would notify the RD after the weekly PAR meeting by texting or calling. She stated that the RD would usually text her back to let her know she had the resident down on her list. She revealed that the RD did not come to the facility and did all her consultations remotely. She explained that the RD was consulted on Resident #20 in January 2024, but confirmed that she had not seen any RD recommendations since that time. She stated that the resident had never received fortified pudding, and to her knowledge, had never started on an appetite stimulate. She explained that the facility had trouble getting the RD recommendations and that she just realized last week on Friday 2/9/24 that the RD recommendations were going to her spam email. She revealed that she tried to open the email and the email read it was quarantined. She revealed that she told the Director of Nursing (DON) that she was not receiving anything from the RD, and she thought the DON had texted her and took care of it. She confirmed that lack of implementation of the RD recommendations could cause the resident to have further weight loss and malnourishment. During a telephone interview with the Registered Dietician (RD) on 2/13/24 at 9:56 AM, she stated she was notified in late December that Resident #20 needed to be seen due to a significant weight change. She confirmed that she recommended med pass 2 ounces twice daily as a supplement, weekly weights and fortified pudding added with lunch and dinner. She revealed that she also did a consultation on Resident #20 on 1/5/24 and 2/10/24 and recommended that the resident would benefit from an appetite stimulant. She explained that she emailed all her recommendations to the Administrator (ADM), Director of Nursing (DON), Dietary Manager (DM), and the Regional Nursing Consultant (RNC). She explained that she marked on the recommendations if the physician needed to be contacted for a physician order and confirmed that Resident #20's recommendation was marked to contact the physician for an appetite stimulant and adding the fortified pudding. She stated that she was unable to contact the doctor or write orders because she did not have the authority with her contract with the facility. She stated that she had not been contacted by anyone from the facility reporting that they had not received Resident #20's dietary recommendations During an interview with the DON on 2/13/24 at 10:38 AM, revealed Resident #20 functional status had declined since her fall. She confirmed after reviewing the progress notes, she observed there was no documentation to support a decline, nausea, and vomiting or food refusal. She revealed before the fall the resident was ambulatory, rarely in bed, and she took herself to the bathroom. She revealed that she would sit up in a chair in her room. She stated after the fall the resident required more help with her Activities of Daily Living (ADLs), stayed in bed, became incontinent, had more falls, and required the staff to assist with eating. She confirmed that the facility should have notified the physician immediately when the decline came about, and verbalized that was a failure on their part. She explained that the facility had spoken with the son about placing the resident on hospice today, and he had agreed. She explained that she knew it looked bad that they had consulted hospice, but she stated we had talked to the son before, and he thought she might recover. The DON stated that the facility did not reach out to the physician to inquire about drawing labs or any intravenous fluids throughout these months of the resident refusing to eat or drink and experiencing significant weight loss. She stated that she did report the weight loss to the physician while he was inside the facility. She stated, I do not recall the date or month I notified him, and confirmed that she did not have documentation to support her notification. She stated that the facility was not receiving any of the dietary recommendations, and the Dietary Manager (DM) determined that the emails were going to her junk folder. The DON stated that the RD would also add her notes to the Electronic Medical Record (EMR) and would not tell anyone. The DON revealed that she had never received any emails from the RD, and confirmed that she had not gone into her junk email to search and see if they came to her that way. The DON stated, I have over 700 junk emails and I do not have time to do that. The DON confirmed that with 60 residents in the facility she should have noticed when she was not getting anything from the RD each month but confirmed that she hadn't noticed. During an interview with the ADM on 2/13/24 at 2:10 PM, revealed the Registered Dietician (RD) worked remotely, and she had seen her in the facility twice. She revealed that the facility usually communicates with the current RD through email or text messages and confirmed that the last RD recommendation she had received by email was in August 2023. She stated that the Dietary Manager (DM) had received some, but they went to her spam folder encrypted. She revealed in November 2023 she started going into the resident notes and printing out the recommendations. She explained that she had not reached out to the RD herself to follow up. The ADM stated they tried to go over the recommendations in the High-Risk meetings and that Resident #20 had been discussed in January 2024 during a PAR (patients at risk) meeting. The ADM confirmed that the Dietary Recommendations for Resident #20 had not been implemented and that the facility failed to document the significant changes that occurred in the resident's condition. She stated, I know the documentations not there. It looks bad on our part. During an interview with Social Services (SS) on 2/13/24 at 3:00 PM, revealed she had reached out to the family of Resident #20 about the functional decline on 1/10/24. She revealed that the son did not want to do hospice at that time and was hoping the resident would perk up. She explained that since then, she followed up with the family and explained that the resident continued to decline and asked them to reconsider hospice services again. The SS confirmed that she was unaware that the physician had not been notified of the significant changes with the resident. Record review of the Progress Notes for Resident #20 dated 2/14/24, Proper Name Hospice consulted per md (medical doctor) order and family request . for declining condition related to Alzheimer's disease . During an interview with the Minimum Data Set (MDS) Nurse on 2/14/24 at 5:23 PM, revealed that she did a significant change MDS after Resident #20 fell in December 2023, and after it was identified in the facility's clinical meeting that the resident had a significant weight loss in January 2024. She revealed that after the fall, the resident declined in her ability to get out of bed, and she was no longer able to sit in a chair, which was what the resident liked to do. She explained that the resident experienced increased pain, worsening incontinence and was required to wear a back brace when she was out of the bed. She confirmed that the documentation was absent to support a decline in the resident's condition, and stated she went off what was discussed in the High-Risk meetings. She revealed that she was aware that the resident did not have a physician order for the fortified pudding or an appetite stimulant that was recommended by the Registered Dietician (RD). Record review of the Transfer/Discharge Report revealed the facility admitted Resident #20 on 1/24/22 with medical diagnoses that included Alzheimer's disease, rheumatoid arthritis, primary open-angled glaucoma, and wedge compression fracture of T 11-T 12 vertebra, subsequent encounter for fracture with delayed healing. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/10/24 revealed a Brief Interview for Mental Status (BIMS) of 03 which indicated the resident had severe cognitive impairment. Prior MDS's dated 09/18/23 revealed a BIMS of 11, MDS dated [DATE] revealed a BIMS of 9. Resident #13 Cross reference F580, F656, F692 An observation and interview on 2/13/24 at 11:05 AM, Resident #13, lying in bed, stated she had lost weight while in the facility. She revealed there were times she did not eat well and she was not on supplements. An interview on 2/14/24 at 11:40 AM, the Director of Nursing (DON) revealed Resident #13 had a significant weight loss which was not reported to the physician for interventions, therefore, her weight continued to decrease. She stated the Registered Dietician (RD) had not been consulted concerning the significant weight loss. She confirmed that due to the physician and the RD not being notified, the resident had a weight loss that could have possibly been avoided if interventions had been put in place for the resident's nutritional well-being. She confirmed each resident has the right to appropriate care, and the facility failed to provide the needed nutritional care. She confirmed the facility neglected to recognize, evaluate, and address the resident's weights, failed to notify the physician of the weight decline, and failed to consult the RD, therefore, appropriate evaluations and interventions were not ordered or initiated which put the resident at risk for a continued weight loss. She confirmed these failures led to a significant weight loss of 6.92% during Resident #13's first month at the facility and to a 17.52% weight loss during her first four months at the facility. An interview with the facility's Regional Nurse Consultant on 2/15/24 at 8:45 AM, revealed the physician nor the nurse practitioner were notified of Resident #13's significant weight loss and therefore, no interventions were initiated and weight continued to decline. She stated the initial consult with the Registered Dietician (RD) was on admission due to her wounds and once her weight was trending down, no additional consults were made. She confirmed each resident has the right to receive appropriate care and the facility failed to provide the needed nutritional care for this resident. She confirmed the facility neglected to identify, evaluate, and intervene for nutritional concerns and, therefore, an avoidable weight loss occurred due to the facility's failure to appropriately manage the resident's nutritional needs. An interview on 2/15/24 at 12:00 PM, the Dietary Manager confirmed she was unaware of the resident's significant weight loss and failed to ensure the Registered Dietician was notified of the weight loss concern. Record review of Weights and Vitals Summary revealed Resident #13's admission weight on 10/3/23 was 166.1 pounds and a weight on 11/2/23 was 154.6 pounds which listed a comparison weight of an 11.5 pound decrease and a 6.9% weight loss. Resident #13's weight on 2/5/24 was 137 pounds and compared to the admission weight 4 months previously of 166.1 pounds on 10/3/23 listed a comparison weight of a 29.1 pound decrease and a 17.5% weight loss. Record review of Resident #13's admission Record revealed she was admitted to the facility on [DATE]. Diagnoses included Stevens-Johnson Syndrome, Non-pressure Ulcers, Anxiety Disorder, Major Depressive Disorder. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/12/23 revealed a Brief Interview for Mental Status (BIMS) of 12 which indicated the resident had a moderate cognitive impairment. The facility submitted the following removal plan: On 02/13/2024 at 4:30 PM the Mississippi State Department of Health (MSDH) state survey team notified the Administrator of an Immediate Jeopardy for failing to ensure processes were in place to review and implement Registered Dietician (RD) recommendations, notify the physician of weight loss, and implement interventions to address weight loss for Resident #20, who had lost 40.5lbs in the last six months. Resident #20 also had nausea and vomiting and was not eating or drinking adequately for the last three weeks and the facility had failed to notify the physician of the significant change. The facility failed to follow care plan interventions to identify weight loss and address weight loss for Resident #20. The facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) meeting to ensure all recommendations from the Registered Dietician were addressed in a prompt manner. Review of facility processes revealed that the recommendations from the registered dietician was being sent to the Dietary Manager via email and the emails were not received and not presented to the interdisciplinary team and reviewed by the provider and implemented. Interview with staff indicates that resident has had poor appetite since January, and it was not documented in the medical record. On 02/11/2024 at 6:27 PM, the facility nurse notified the provider and obtained orders for anti-emetic. On 2/12/2024 at 9:27 am, the facility attempted to transfer resident to the emergency room for evaluation and treatment as indicated. The Responsible Party refused for resident to be sent to the emergency room on this date. The facility obtained a physician's order for hospice services. On 02/13/2024 5:00 PM, In-services began on Abuse and Neglect for all staff by the Assistant Director of Nursing. All staff will be trained prior to returning to work. In-services began by Assistant Director of Nursing on Documentation, Provider Notification, and Change of Condition. All staff will be trained prior to returning to work. On 02/13/2024 at 5:15 PM, Social Services and Medical Records Nurse interviewed all residents regarding Nausea and Vomiting to ensure all significant changes of conditions were reported to the providers. It was noted upon interview that nine (9) residents reported recent complaints of nausea and vomiting, one (1) resident noted to have yellow discharge from mouth and nose, 1 resident was unable to recall when nausea or vomiting occurred with no staff being knowledgeable of nausea or vomiting, two (2) residents reported nausea or vomiting after eating, 2 residents reported not having appetite or eating, 1 resident reported nausea but did not report to nurse, 2 residents reported nausea and medications received. On 02/13/2024 at 5:30 PM, all residents were audited for weight loss by the Director of Nursing, Regional Nurse Consultant, and Minimum Data Set Nurse. Results of weight loss audit were reviewed by the medical director (15 unplanned weight losses, 1 planned) and new orders and diagnoses were provided by the medical director. All nutrition care plans audited by Minimum Data Set Nurse on 02/13/2024 with 5 residents whose registered dieticians' recommendations were not on care plans, dietary recommendations reviewed with providers and orders received per providers. On 02/13/2024 at 6:05 PM, the Director of Nursing notified the physician of all 9 residents, notified the Institutional Specialized Needs Plan (ISNP) nurse practitioner of all residents (4) and hospice of all residents (1) with Nausea and Vomiting with new orders received from provider. 1 resident reviewed with new orders for chest x-ray due to cough, congestion, and yellow discharge from mouth and nose, 2 residents were ordered medications for reflux, 1 resident noted to be receiving antibiotics and has orders in place for anti-emetic medications, 1 resident reported abdominal pain and MD was notified and seen resident on 02/12/2024 with new orders for stool softener, 1 resident noted to have diarrhea and has been antibiotics new orders received for Zofran and anti-diarrheal, 1 resident noted to have weight loss and nausea and vomiting new orders received on 2/11/2024 to start Zofran and start peri-actin the family was not agreeable to start peri-actin and wanted to wait to speak to hospice on 02/14/2024, 2 residents did not report nausea to nurses at time of occurrence. On 02/13/2024 at 6:59 PM, Social Services and Medical Records nurse interviewed residents with BIMS 10 or higher to ensure feeling of safe and are free of health concerns, no health or safety concern during interviews. On 02/13/2024 at 8:30 PM, all Registered Dietician recommendations for last 90 days audited by Dietary Manager and Minimum Data Set Nurse with 5 residents whose registered dietician recommendations were not addressed. All Dietary recommendations reviewed with the Medical Director (5) and subsequent providers as appropriate Hospice (2 residents who have been on hospice services prior to survey entrance) and Institutional Special Needs Program nurse practitioner (1), new orders received from providers as appropriate. On 02/13/2024 at 8:40 PM, All nutrition care plans audited by Minimum Data Set Nurse with 5 residents whose registered dieticians' recommendations were not on care plans, dietary recommendations reviewed with providers and orders received per providers and care plans updated. On 02/13/2024 at 9:00 PM, all residents noted with weight loss were reviewed with the Medical Director, the Medical Director performed medication review on all residents with weight loss. Ad Hoc QAPI was held on 02/13/2024 at 10:15 PM with the Medical Director via phone, Administrator, Director of Nursing, Social Services, Minimum Data Set Nurse, Life Connections Coordinator, Regional Nurse Consultant, Regional Director of Operations, Assistant Director of Nursing, Registered Nurse Supervisor, Dietary Manager, and Medical Records Nurse. The Minimum Data Set Nurse has been designated as the Quality Assurance Nurse with responsibility reviewing all audits, Performance Improvement Plans, Quality Measures, and actively participating in the Quality Assurance and Performance Improvement meetings. All areas of deficiencies were reviewed in Ad-Hoc Quality Assurance and Performance Improvement meeting. Medical Records nurse or Assistant Director of Nursing will be responsible for receiving Registered Dietician recommendations, reviewing with providers, entering orders, and progress notes. New processes for Medical Director to review facility weight losses each week on visit, Registered Dietitian recommendations to be revi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and job description review, the facility failed to be administered in a manner that ensured residents with significant weight loss would get the necessary nutritional support and services to ensure their well-being for two (2) of three (3) residents sampled for abuse/neglect as evidenced by: Resident #13 and Resident #20 1) failed to recognize, evaluate, and address a resident's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. Resident #13. The facility's failure to consult a Registered Dietician (RD), notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. 2) failed to identify and address a resident at risk for malnutrition due to prolonged nausea and vomiting, and failure to identify a decrease in food intake due to pain and nausea resulted in an unintended significant weight loss of 40.5 pounds in six (6) months. Resident #20. The facility's failure to implement a Registered Dietician (RD) recommendation, notify the attending physician of a significant change in condition, and address the residents' prolonged symptoms of nausea and vomiting, and decreased food intake placed the resident and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. The facility's neglect also resulted in a functional decline for Resident #20, which possibly resulted in the resident's admission to hospice services on 2/14/24. The State Agency (SA) identified an Immediate Jeopardy (IJ) that began on 11/02/23 when the facility failed to recognize, evaluate, and address Resident #13's nutritional needs. The IJ existed at: 42 CFR §483.70 Administration - F835- Scope/Severity K The facility Administrator was notified of the IJ on 2/13/24 at 4:30 PM and provided the IJ Template. The facility provided an acceptable Removal Plan on 2/14/24, in which they alleged all corrective actions to remove the IJ were completed on 2/13/24 and the IJ removed on 2/14/24. The SA validated the Removal Plan on 2/20/24 and determined the IJ was removed on 2/14/24. Therefore, the scope and severity for 42 CFR §483.70 Administration - F835 was lowered from a K to an E while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the Job Description for the Nursing Home Administrator (NHA) with a revision date of 8/10/27 revealed, Summary: As Nursing Home Administrator, you will be responsible for the overall operations, leadership, management and success of the facility in accordance with resident/employee needs, government regulations, and company policy. Responsible for . quality assurance, regulatory management, . and resident care .Essential Duties And Responsibilities: . Direct and coordinate medical, nursing and administrative staffs and services. Conduct regular rounds to monitor delivery of nursing care and operation of support departments. Ensure consultants and other support resources are appropriately utilized. Review of the Job Description for the Director of Nursing (DON) with a revision date of 8/10/17 revealed, Summary: To manage overall operation of the Nursing Services Department in accordance with Company Policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all the Residents' and employee's needs .Essential Duties And Responsibilities: Work with the Administrator, Consultants, and facility staff in planning all aspects of nursing services to include interface with other disciplines and departments. Conduct regular rounds to review care. Assess resident's physical and psychosocial status. Monitor care activities and documentation to ensure the delivery of nursing care according to the physician's order, care plans, and established standards and facility policies. Follow and ensures compliance with State, Federal, and company QAPI (Quality Assurance and Performance Improvement) standards. Follow and ensures medication administration is conducted in accordance with nursing standards and facility policies . Review of the Job Description for the Assistant Director of Nursing (ADON) with a revision date of 8/10/17 revealed, Summary: . Also assist the Director of Nursing in managing overall operations of the Nursing Services Department in accordance with Company policies, standards of nursing practices and government regulations so as to maintain excellent care of all the Residents' and employee's needs Essential Duties And Responsibilities: . Responsible for overseeing nursing services in the absence of the Director of Nursing. Assists in conducting regular rounds to monitor resident activity and ensure resident quality of care. Assess resident's physical and psychosocial status. Personally participates in the assessment and delivery of care. Follow and ensures compliance with State, Federal, and Company QAPI standards. Record review of the facility policy titled Dietician with a review date of 7/24/23 revealed, Policy Interpretation and Implementation: 1. A qualified dietician or other clinically qualified nutrition professional will help oversee food and nutrition services provided to the residents. 9. Our facility's dietician is responsible for, but not necessarily limited to: a. assessing nutritional needs of residents; . f. participating in quality assurance and performance improvement (QAPI) when food and nutrition services are involved . Resident #20 Observation and interview with Resident #20 on 2/11/24 at 3:19 PM, revealed her lying in a fetal position at the foot of the bed with garbage can located on the floor beside the resident. The resident stated she was sick to her stomach and had a washcloth in her hand and was wiping her face. The resident's color was pale, lips were dry, and she was thin in appearance. Interview with the DON on 2/11/24 at 3:55 PM, revealed Resident #20's condition had declined over the past couple of months. She explained that the resident had a significant decline after she fell in December 2023, and received a fracture of the T-12 vertebrae and had to be placed on strong pain medications. She stated, to her knowledge, the resident had not experienced any nausea and vomiting until yesterday when the Survey Agency brought it to her attention. She stated none of the staff had reported it to her and that she should be aware of what was happening with the resident. She revealed she was aware that the resident was not eating or drinking and had been refusing meals. An interview with the Assistant Director of Nursing (ADON) on 2/11/24 at 6:18 PM, revealed she had not been informed by the staff that Resident #20 had been experiencing nausea and vomiting and stated she was unsure how long the resident had been sick. Observation of Resident #20 on 2/12/24 at 8:29 AM, revealed her lying on her right side in bed. The garbage can was located on the floor, close by the resident. The breakfast tray was located on the bedside table untouched. Certified Nurse Aid CNA #2 entered the resident's room and stated the resident refused to eat or drink due to nausea. CNA #2 removed the tray cover, and the resident began retching and vomited a small amount of clear substance. The resident was weak, pale, and her lips were dry. Interview with CNA #2 on 2/12/24 at 8:35 AM, revealed she had worked at the facility for three (3) weeks and that the resident had been refusing to eat or drink since then. She explained that the resident had been nauseated, dry heaving, and vomiting for the three (3) weeks since she had been employed, and she had reported it to the medication nurse every day that she worked. Interview with CNA #1 on 2/15/24 at 8:35 AM revealed Resident #20 refused breakfast due to nausea and she had notified the nurse each time that she witnessed the resident with nausea and vomiting or refusing to eat and drink. Record review of Resident #20's Progress Notes from 11/01/23 through 2/11/24, revealed there was not any documentation that the resident had nausea and vomiting or that she refused meals. Record review of the Occupational Therapy Progress Notes dated 2/01/24 revealed, Patient refused: pt (patient) is refusing to eat and has poor appetite. pt (patient) c/o (complains of) nausea almost every day, but is not eating even with max encouragement and assist from therapist. Also revealed under, Assessment and Summary of Skilled Services: . therapist encouraging pt (patient) daily to eat and providing assist, but pt (patient) refuses to eat and c/o (complains of) nausea. Record review of the Order Summary Report for Resident #20 revealed an order dated 2/11/24 at 1827 (6:27 PM), Ondansetron HCL (Hydrochloride) (Zofran) Tablet 4 (four) MG (milligrams) Give 1 (one) tablet by mouth every 6 (six) hours as needed for Nausea and Vomiting . Record review of Resident #20's January and February 2024 Medication admission Record (MAR) revealed, there was not a physician's order for nausea/vomiting medication before the new order for Zofran started on 2/11/24, which indicated the resident's symptoms of prolonged nausea and vomiting were left untreated. Record review of the Meal Intake Documentation Report completed by the Certified Nurse Aides (CNAs) revealed, Resident #20 refused eighteen (18) meals from 12/18/23 through 12/31/23. She refused thirty-one (31) meals in the month of January 2024, with a total of thirty-nine (39) meals consumed at 0-25% (percent), and she refused sixteen (16) meals from 2/01/24 through 2/11/24, with a total of fourteen (14) meals consumed at 0-25% (percent). Record review of Resident #20's weights revealed a significant weight loss of 13.9% (percent) in one (1) month, 21.6% (percent) in three (3) months, and 26.2% (percent) in six (6) months. Record review of the Dietary Recommendations dated 12/27/23, for Resident #20 revealed the RD (Registered Dietician) recommended, Med Pass 2 oz (ounces) BID (twice daily), weekly weights x (times) 4 (four) weeks, and add Fortified Pudding BID (twice daily) at lunch and dinner . Record review of the Consultant Registered Dietician (RD) Note dated 1/5/24, for Resident #20 revealed, Resident w/(with) significant wt (weight) loss x (times) 1 (one) mo (month) (-9%) and x (times) 6 (six) mo (months) (13.7%) (percent). Po (by mouth) intake likely not meeting nutritional needs. Resident is at risk for skin breakdown and wt (weight) loss d/t (due to) decreased appetite . NO N/V/c/D (nausea, vomiting, complaints of diarrhea) documented. Also revealed under REC (recommendations): Resident may benefit from an appetite stimulant, please document % (percentage) of supplement consumed daily, add fortified pudding BID (twice daily) at lunch and dinner, weekly weights x (times) 4 (four) weeks to assure stable weight . Record review of the Consultant Registered Dietician (RD) Note) dated 2/10/24, for Resident #20 revealed, Resident w/(with) significant wt (weight) loss x times 1 (one) mo (month), x (times) 3 (three) mo (months) and x (times) 6 (six) mo (months) . consuming <25% w/(with) refusals of meals . Po (by mouth) intake likely not meeting nutritional needs . NO N/V/c/D (nausea, vomiting, complaints of diarrhea) documented. Also revealed under REC (recommendations): Resident may benefit from an appetite stimulant, please document % of supplement consumed daily, weekly weights x 4 weeks to assure stable weight, if po (by mouth) intake and wt (weight) status does not improve, resident may benefit from an alternate means of nutrition support. Record review of the Order Summary Report for Resident #20 revealed there was not a physician's order for fortified pudding at lunch and supper or a medication to stimulate appetite per Registered Dietician (RD) recommendations. Telephone interview with Medical Director on 2/12/24 at 6:05 PM, revealed the staff had contacted him last night regarding Resident #20 having nausea and vomiting, and he had ordered Zofran as needed. He confirmed that the staff had not contacted him or made him aware of the residents' decline in condition or her refusal to eat or drink. He stated that he was not notified of her significant weight loss (40.5 pounds in 6 months) or the Registered Dietician (RD) recommendations. He confirmed Resident #20's current condition was serious and stated what you have relayed screamed neglect. Record review of Resident #20's Physician Nursing Home Visit dated 1/26/24 revealed, No concerns reported by the nursing staff The physician progress note did not identify any documentation to support the resident's nausea and vomiting or weight loss. Interview with Licensed Practical Nurse (LPN) #2 on 2/13/24 at 7:45 AM, revealed Resident #20 was not drinking the med pass supplement, and was refusing meals. She stated that the resident had been refusing meals for several weeks. She revealed that the resident's family was highly involved with her care, and the resident would report nausea to them, and they would come and notify her. Interview with the Dietary Manager (DM) on 2/13/24 at 8:13 AM, revealed that the RD was consulted on Resident #20 in January 2024, but confirmed that she had not seen any RD recommendations. She stated that the resident had never received fortified pudding, and to her knowledge, had never started on an appetite stimulate. She explained that the facility had trouble getting the RD recommendations. The DM stated she just realized last week on Friday 2/9/24 that the RD recommendations were going to her spam email. She revealed that she tried to open the email and the email read it was quarantined. She revealed that she told the DON that she was not receiving anything from the RD, and she thought the DON had texted her. She revealed that the administrator had been going into all the residents' progress notes and printing out the recommendations to make sure they were being implemented. She confirmed that lack of implementation of the RD recommendations could cause the resident to have weight loss and malnourishment. Telephone interview with the Registered Dietician (RD) on 2/13/24 at 9:56 AM, the RD stated she was notified in late December that Resident #20 needed to be seen due to a significant change. She revealed that she recommended med pass 2 ounces twice daily as a supplement, weekly weights and fortified pudding added with lunch and dinner. She revealed that she also did a consultation on Resident #20 on 1/5/24 and 2/10/24 and recommended that the resident would benefit from an appetite stimulant. She explained that she emailed all her recommendations to the ADM, DON, DM, and the Regional Nursing Consultant (RNC). She explained that she marked on the recommendations if the resident's physician needed to be contacted for a physician order. She stated that she had not been contacted by anyone from the facility reporting that they had not received Resident #20's dietary recommendations. Interview with the DON on 2/13/24 at 10:38 AM. she confirmed after reviewing the progress notes, she observed there was no documentation to support Resident #20's decline, nausea, and vomiting or food refusal. She confirmed that the facility should have notified the physician immediately when the decline came about, and verbalized that was a failure on their part. The DON stated that the facility did not reach out to the physician to inquire about drawing labs or starting any Intravenous fluids (IV) throughout these months of the resident refusing to eat or drink. She stated that she did report the weight loss to the physician while he was inside the facility. She stated, I do not recall the date or month I notified him. She confirmed that she did not have documentation to support her notification. She stated the RD recommendations were not implemented because the facility was not receiving any of them, and the DM determined that the emails were going to her junk folder. She explained that the Administrator was going into the resident notes and printing them out to ensure they were all implemented. She revealed she was unsure if an audit was conducted to ensure all the recommendations were implemented. The DON stated that the RD would also add notes into the Electronic Medical Record (EMR) and would not tell anyone. She revealed that she had texted the RD to tell her that the recommendations were not received, and the RD would reply that she would resend them. The DON stated she had never received any emails from the RD, and confirmed that she had not gone into her junk email to search and see if they came to her that way. The DON stated, I have over 700 junk emails and I do not have time to do that. Interview with the Administrator (ADM) on 2/13/24 at 2:10 PM, revealed that the facility usually communicates with the current RD through email or text messages. The ADM stated the last RD recommendation she had received by email was in August 2023 and that the Dietary Manager (DM) had received some, but they went to her spam folder encrypted. She explained that she had not reached out to the RD herself to follow up and confirmed that the facility had not started an audit and stated they tried to go over the recommendations in the High-Risk meetings. She stated that Resident #20 had been discussed in January 2024 during a PAR (patients at risk) meeting. The ADM confirmed that the Dietary Recommendations for Resident #20 had not been implemented and that the facility failed to document the significant changes that occurred in the resident's condition. She stated, I know the documentations not there. She revealed that she was told the DON had reached out to the physician and stated, It looks bad on our part. Record review of Resident #20's Order Summary Report revealed an order dated 1/02/24, Norco Oral Tablet 7.5 -325 MG (milligrams) (Hydrocodone-Acetaminophen) Give 7.5 mg (milligrams) by mouth every 6 (six) hours related to Pain . Record review of Resident #20's Order Summary Report revealed an order dated 12/13/23, Tramadol HCL (Hydrochloride) Tablet 50 MG (milligrams) Give 1 tablet by mouth every 12 (twelve) hours as needed for pain. Also revealed an order dated 12/13/23, Tramadol HCL (Hydrochloride)Tablet 50 MG (milligrams) Give 2 (two) tablets by mouth every 12 (twelve) hours as needed for pain . Record review of Resident #20's Pain Care Plan revealed under, Interventions/Tasks: . Observe/document for side effects of pain medication. Observe for constipation; . nausea; vomiting; . Report occurrences to the physician. Record review of Resident #20's BM (bowel movement) Report dated 1/29/24 through 2/13/24 revealed one (1) medium BM documented on 2/04/24. All other days documented as None or Not Applicable . Interview with the Assistant Director of Nursing (ADON) on 2/13/24 at 5:10 PM, revealed the aides were responsible for documenting the bowel movements every shift. She revealed if a resident did not have a bowel movement in 3 days, it will trigger the charting system dashboard and will alert the DON. She revealed that the dashboard was checked every morning by the DON after the daily stand-up meeting to identify which residents had not had a BM. She explained that the DON would then check with the nurses and the aides on the floor to identify if a resident had a BM, and maybe it was not documented. If a resident had not had a BM, a process was followed through with pulling a standing order for a laxative. She revealed that Resident #20's BM report was not firing to the dashboard to alert the staff of no BM. Interview with the DON on 2/13/24 at 5:36 PM, confirmed the facility did not have a monitoring tool in place for the residents receiving high doses of opioid pain medication to monitor for the common side effects of constipation, nausea, and vomiting. She revealed that Resident #20's BM Report was not firing to the charting system database to alert the staff of no BM. She confirmed that Resident #20 had not had a documented BM since 2/4/24. She explained that the resident was incontinent, so if she did have a bowel movement, the staff would have known. She stated that the physician had not been notified at this point. She revealed that she was going to tell Resident #20's nurse to administer a laxative, and she would follow up with the resident in the morning. Interview with the Director of Nursing (DON) on 2/14/34 at 9:20 AM, revealed she was unsure if Resident #20 had a bowel movement (BM) overnight. She revealed that with everything going on in the facility yesterday, she forgot to notify the nurse caring for the resident last night that she needed a laxative. She explained if a laxative had been administered it would be documented on the Medication Administration Record (MAR) and it was not. She stated, I will get someone to do it now. Interview with the Director of Nursing (DON) on 2/14/24 at 2:55 PM, revealed she had not notified the nurse on the floor caring for Resident #20 to give her a laxative and confirmed the physician had not been made aware. Interview with the Regional Nursing Consultant (RNC) and Regional Director of Operations (RDO) on 2/14/24 at 3:05 PM, confirmed they were not aware Resident #20 had not had a bowel movement (BM) since 2/04/24. They both revealed that a situation such as that should be taken seriously, and the physician should have already been notified and that they would take care of it right away. Record review of the progress Notes for Resident #20 dated 2/14/24 at 15:52 (3:52 PM) revealed, Note Text: Resident has not had a bm since 2/04/24. This nurse notified (Proper Name of Doctor) and he gave a one time order for lactulose. He also gave an order for xray flat and upright. This was ordered by the nurse. Record review of Resident #20's Abdominal X-Ray report dated 2/14/24 revealed under, Impression: 1. No free air or bowel obstruction. 2. Moderate stool in colon compatible with constipation. Record review of the Transfer/Discharge Report revealed the facility admitted Resident #20 on 1/24/22 with medical diagnoses that included Alzheimer's disease, Rheumatoid Arthritis, and Wedge compression fracture of T 11-T 12 vertebra, subsequent encounter for fracture with delayed healing. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/10/24 revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicated the resident had severe cognitive impairment. Prior MDS's dated 09/18/23 revealed a BIMS of 11, MDS dated [DATE] revealed a BIMS of 9. Resident #13 Cross reference F600, F692, F580, F684 Interview on 2/14/24 at 11:40 AM, the DON revealed Resident #13 had a significant weight loss which was not reported to the physician for interventions, therefore, her weight continued to decrease. She confirmed the facility neglected to recognize, evaluate, and address the resident's weights, failed to notify the physician of the weight decline, and failed to consult the RD, therefore, appropriate evaluations and interventions were not ordered or initiated which put the resident at risk for a continued weight loss. She confirmed these failures of the facility's administration led to a significant weight loss of 6.92% during Resident #13's first month at the facility and to a 17.52% weight loss during her first four months at the facility. InterIview with the facility's Regional Nurse Consultant on 2/15/24 at 8:45 AM, revealed the physician nor the nurse practitioner were notified of Resident #13's significant weight loss and therefore, no interventions were initiated and weight continued to decline. She confirmed the facility's Administration was responsible for overseeing the residents' care and ensuring the needed services were available and received, but the facility's administration failed to do this. She confirmed the facility neglected to identify, evaluate, and intervene for nutritional concerns and, therefore, an avoidable weight loss occurred due to the facility Administration's failure to appropriately manage the resident's nutritional needs. Record review of Resident #13's admission Record revealed she was admitted to the facility on [DATE]. Diagnoses included Stevens-Johnson Syndrome, Non-pressure Ulcers, Anxiety Disorder, Major Depressive Disorder. Record review of Resident #13's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/12/23 revealed a Brief Interview for Mental Status (BIMS) of 12 which indicated the resident had moderate cognitive impairment. The facility submitted the following removal plan: On 02/13/2024 at 4:30 PM the Mississippi State Department of Health (MSDH) state survey team notified the Administrator of an Immediate Jeopardy for failing to ensure processes were in place to review and implement Registered Dietician (RD) recommendations, notify the physician of weight loss, and implement interventions to address weight loss for Resident #20, who had lost 40.5 lbs in the last six months. Resident #20 also had nausea and vomiting and was not eating or drinking adequately for the last three weeks and the facility had failed to notify the physician of the significant change. The facility failed to follow care plan interventions to identify weight loss and address weight loss for Resident #20. The facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) meeting to ensure all recommendations from the Registered Dietician were addressed in a prompt manner. Review of facility processes revealed that the recommendations from the registered dietician was being sent to the Dietary Manager via email and the emails were not received and not presented to the interdisciplinary team and reviewed by the provider and implemented. Interview with staff indicates that resident has had poor appetite since January, and it was not documented in the medical record. On 02/11/2024 at 6:27 PM, the facility nurse notified the provider and obtained orders for anti-emetic. On 2/12/2024 at 9:27 am, the facility attempted to transfer resident to the emergency room for evaluation and treatment as indicated. The Responsible Party refused for resident to be sent to the emergency room on this date. The facility obtained a physician's order for hospice services. On 02/13/2024 5:00 PM, In-services began on Abuse and Neglect for all staff by the Assistant Director of Nursing. All staff will be trained prior to returning to work. In-services began by Assistant Director of Nursing on Documentation, Provider Notification, and Change of Condition. All staff will be trained prior to returning to work. On 02/13/2024 at 5:15 PM, Social Services and Medical Records Nurse interviewed all residents regarding Nausea and Vomiting to ensure all significant changes of conditions were reported to the providers. It was noted upon interview that nine (9) residents reported recent complaints of nausea and vomiting, one (1) resident noted to have yellow discharge from mouth and nose, 1 resident was unable to recall when nausea or vomiting occurred with no staff being knowledgeable of nausea or vomiting, two (2) residents reported nausea or vomiting after eating, 2 residents reported not having appetite or eating, 1 resident reported nausea but did not report to nurse, 2 residents reported nausea and medications received. On 02/13/2024 at 5:30 PM, all residents were audited for weight loss by the Director of Nursing, Regional Nurse Consultant, and Minimum Data Set Nurse. Results of weight loss audit were reviewed by the medical director (15 unplanned weight losses, 1 planned) and new orders and diagnoses were provided by the medical director. All nutrition care plans audited by Minimum Data Set Nurse on 02/13/2024 with 5 residents whose registered dieticians' recommendations were not on care plans, dietary recommendations reviewed with providers and orders received per providers. On 02/13/2024 at 6:05 PM, the Director of Nursing notified the physician of all 9 residents, notified the Institutional Specialized Needs Plan (ISNP) nurse practitioner of all residents (4) and hospice of all residents (1) with Nausea and Vomiting with new orders received from provider. 1 resident reviewed with new orders for chest x-ray due to cough, congestion, and yellow discharge from mouth and nose, 2 residents were ordered medications for reflux, 1 resident noted to be receiving antibiotics and has orders in place for anti-emetic medications, 1 resident reported abdominal pain and MD was notified and seen resident on 02/12/2024 with new orders for stool softener, 1 resident noted to have diarrhea and has been antibiotics new orders received for Zofran and anti-diarrheal, 1 resident noted to have weight loss and nausea and vomiting new orders received on 2/11/2024 to start Zofran and start peri-actin the family was not agreeable to start peri-actin and wanted to wait to speak to hospice on 02/14/2024, 2 residents did not report nausea to nurses at time of occurrence. On 02/13/2024 at 6:59 PM, Social Services and Medical Records nurse interviewed residents with BIMS 10 or higher to ensure feeling of safe and are free of health concerns, no health or safety concern during interviews. On 02/13/2024 at 8:30 PM, all Registered Dietician recommendations for last 90 days audited by Dietary Manager and Minimum Data Set Nurse with 5 residents whose registered dietician recommendations were not addressed. All Dietary recommendations reviewed with the Medical Director (5) and subsequent providers as appropriate Hospice (2 residents who have been on hospice services prior to survey entrance) and Institutional Special Needs Program nurse practitioner (1), new orders received from providers as appropriate. On 02/13/2024 at 8:40 PM, All nutrition care plans audited by Minimum Data Set Nurse with 5 residents whose registered dieticians' recommendations were not on care plans, dietary recommendations reviewed with providers and orders received per providers and care plans updated. On 02/13/2024 at 9:00 PM, all residents noted with weight loss were reviewed with the Medical Director, the Medical Director performed medication review on all residents with weight loss. Ad Hoc QAPI was held on 02/13/2024 at 10:15 PM with the Medical Director via phone, Administrator, Director of Nursing, Social Services, Minimum Data Set Nurse, Life Connections Coordinator, Regional Nurse Consultant, Regional Director of Operations, Assistant Director of Nursing, Registered Nurse Supervisor, Dietary Manager, and Medical Records Nurse. The Minimum Data Set Nurse has been designated as the Quality Assurance Nurse with responsibility reviewing all audits, Performance Improvement Plans, Quality Measures, and actively participating in the Quality Assurance and Performance Improvement meetings. All areas of deficiencies were reviewed in Ad-Hoc Quality Assurance and Performance Improvement meeting. Medical Records nurse or Assistant Director of Nursing will be responsible for receiving Registered Dietician recommendations, reviewing with providers, entering orders, and progress notes. New processes for Medical Director to review facility weight losses each week on visit, Registered Dietitian recommendations to be reviewed weekly with the Interdisciplinary Team and[TRUNCATED]