**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #49 was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur, muscle weakness, acute respiratory failure with hypoxia, pressure ulcer of sacral region, urinary tract infection, dysphagia, congestive heart failure, encephalopathy, chronic obstructive pulmonary disease, dementia, attention deficit hyperactivity disorder, Alzheimer's disease, chronic kidney disease, atherosclerotic heart disease, depression, hypertension, anemia, and deaf nonspeaking. Review of his Minimum Data Set (MDS) assessment, dated 11/14/23, revealed the resident had a mild cognitive impairment. Review of Resident #49's weights revealed the following: On 07/11/23 (188 pounds), 08/14/23 (187.8 pounds), and 11/05/23 (175 pounds). No weight was obtained in December 2023 and no re-weights were obtained to verify the resident's weight loss. The resident's next weight was on 12/05/23, there was no documentation that a re-weight was taken in a timely manner to verify the weight loss. Review of Resident #49's physician orders revealed he was to be weighed once per month which by documentation was not occurring. Interview with the DON on 01/08/24 at 11:30 A.M. revealed staff were to notify the physician when the dietitian looked at the weights/nutritional status and made a new order. She confirmed staff do not notify the dietitian or physician when they take weights, and they had not been responsible to report significant changes; but rather the dietitian reviews this routinely. She confirmed the facility weight change policy was to notify the physician and dietitian when there was a change of five pounds or more. Review of facility Weight Change policy, dated March 2018, revealed a significant weight loss was defined as five percent in one month, 7.5 percent in three months, and 10 percent in six months. Recheck weights were to be obtained for a five-pound loss or gain if resident weights over 100 pounds and a three-pound gain or loss on a resident weighing less than 100 pounds. A five-pound gain or loss on a resident weighing 100 pounds or more and three-pound gain or loss on a resident weighing less than 100 pounds would be reported to the dietician and physician. Based on observation, medical record review, hospital record review, staff, physician and Registered Dietician (RD) interview, review of the Ohio Board of Dietetics (OBD) Standards of Practice in Nutrition Care, contract reviews, and facility policy review, the facility failed to ensure Resident #32, who was identified at nutritional risk, was provided a comprehensive and individualized nutritional plan to include monitoring weights and nutritional status, physician and dietitian notification for weight loss and implementation of nutrition interventions to prevent severe weight loss. This resulted in Immediate Jeopardy and actual harm for Resident #32, who experienced severe weight loss from 09/07/23 to 10/04/23 when she lost 19.9 pounds, representing a weight loss of 10.05% in one month (September to October 2023); 6.5% from October to November and 6.0% from November to December 2023 with a total weight loss over this time period of 21.6 % of her body weight (a 43 pound weight loss) due to the facility repeated and systemic failures to assess and address the resident's nutritional status and to implement pertinent interventions based on such an assessment resulting in continued significant/severe weight loss and functional decline. The resident was admitted to the hospital on [DATE] and returned to the facility on [DATE], continuing to lose weight. Additionally, a concern that did not rise to an Immediate Jeopardy occurred when the facility failed to monitor weights per physician orders and notify the physician and/or dietician of weight loss for Resident #49. This affected two residents (#32 and #49) of 11 residents reviewed for nutrition. The facility census was 83. On 01/25/24 at 3:35 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 10/04/23 when Resident #32 experienced a severe weight loss of 19.9 pounds/10.05% of her body weight in a one month period of time (September to October 2023); 6.5% from October to November 2023 and 6.0% from November to December 2023 with a total weight loss over this time period of 21.6 % of the resident's body weight (43 pounds) with the weight loss not being comprehensively addressed and monitored ultimately leading to the resident being given the diagnoses of malnutrition related to poor intake and a subsequent admission to the hospital. The Immediate Jeopardy was removed on 01/29/24 when the facility implemented the following corrective actions: • On 01/23/24 Resident #32 was transferred to the hospital for evaluation and treatment related to pneumonia, urinary tract infection (UTI), sepsis, diverticulitis, abdominal pain and nausea/vomiting. The resident was re-admitted to the facility on [DATE]. The facility implemented a plan for the resident to be encouraged and assisted to attend the assist dining room for lunch and dinner to encourage increase intake of meals. Resident #32's supplement order was modified to include the percentage of intake of the supplement by the Director of Nursing (DON) on 01/25/24. The resident's plan of care was updated on 01/25/24 to review the weight loss. Registered Dietician (RD) #500 reviewed the resident and recommended to continue the supplements as ordered. Resident #32 was started on an appetite stimulant (Remeron) on 01/26/24. On 01/29/24 Dietary Manager (DM) #115 updated Resident #32's food likes and dislikes and on 01/30/24 Resident #32's house supplement was discontinued and an order for mighty shakes three times a day was added. • On 01/25/24 at 4:30 P.M. DON and Unit Managers #176 and #213 began in-person re-education for all direct care staff regarding the facility's weight loss policy and procedure. The direct care staff would be educated on the process for documenting the percentage of food intake at meals and the need to notify the nurse and/or dietician when there was a decrease in a meal or supplement intake that may need to be addressed. The direct care staff would document supplement intakes on the Medication Administration Record (MAR) via supplementary documentation. The direct care staff would document meal intakes on the point of care (POC) charting. Direct care staff would not be permitted to work until they have received the education. As of 01/26/24 there were 7 Registered Nurses (RN), 12 Licensed Practical Nurses (LPN), and 20 State Tested Nursing Assistant (STNA) who were educated. The clinical management team would be present at shift change to ensure staff did not work prior to being educated. The facility has 13 staff members RN #166, LPN #126, #283, #321 and STNA #122, #124, #168, #211, #259, #311, #320, #340 and #343 out of the country who would not be permitted to work until the education was provided by the clinical management team. • On 01/25/24, the facility re-implemented their Weight Change policy. The policy included how to respond to weight loss and significant weight loss and how it should be communicated to the Interdisciplinary Team (IDT), Physician #502, and responsible party. Direct care staff would obtain the weight; if a significant change was identified, they would notify the unit manager assigned to their hallway; that Unit Manager would initiate the standing orders, and contact the physician and dietician for recommendations. • On 01/26/24, the DON and Unit Manager #176 reviewed the weights of 82 residents in the facility for undesired significant changes. Seven residents, Resident #1, #9, #31, #42, #46, #57 and #76 triggered for a greater than 5 pound (lb) weight loss. For any residents who were triggered for weight loss during this review, the diet tech and physician were notified by the unit manager or designee (on 1/26/2024 at 11:41 A.M.). The Diet Tech and physician assessed the residents and recommendations were received by 1/27/2024. All residents who triggered were interviewed and/or family interviewed. Moving forward the care conference form has been updated to review nutrition as a systemic approach to address the individual needs of each resident. All residents who triggered to have an undesired weight loss would be reviewed by the IDT team, DON, Unit Manager #176, #213, Licensed Social Worker (LSW) #251, Administrator, Licensed Nursing Home Administrator (LNHA) #110, during the weekly risk meeting. The new weight review would be added to the weekly risk meeting beginning 1/29/2024. Standing orders for house supplements were in place for residents triggering for an undesired weight loss as recommended by the physicians on 1/26/2024. The Unit Managers #176 and #213 would enter the order during the daily IDT meeting. The RD/DR would also be part of the weekly meeting and updates would also be provided at that time. • On 01/26/24 supplement orders for Residents #3, #5, #7, #9, #12, #14, #16, #17, #18, #19, #23, #24, #30, #32, 335, #36, #37, #39, #40, #42, #45, #47, #48, #52, #53, #54, #56, #57, #58, #59, #60, #64, #70, #72, #73, #76, #81 and #84 were modified by Unit Manager #176 to track intake percentages for residents who were at risk for weight loss. The documentation would be located in the resident's MAR under supplementary documentation. • The facility implemented a plan for the IDT Team to review food intakes for all residents during the weekly risk meeting beginning 01/29/24. • On 01/26/24, an ad hoc Quality Assessment Performance Improvement (QAPI) meeting was held with Physician #501, the Administrator, the DON, Regional Registered Dietician (RRD) #503, Unit Manager #176, LNHA #110, Registered Nurse (RN) #508 and RN #510, to discuss the plan of action. The facility also reviewed the re-implemented weight policy for any changes. • On 01/29/24 at 12:00 P.M., the Administrator, DON, and RD #500 discussed alternative supplement options (if the resident prefers a different supplement than the one as part of the standing orders). The Dietician/Diet Tech would be attending the communities risk management meeting beginning the week of 01/29/2024 and weekly, thereafter. • On 01/29/24 at 12:25 P.M. Resident #32 was interviewed for updated preferences In addition, the resident food committee meets the first Friday of each month to review the menu and add preferences. • The facility implemented a plan for the DON/designee to audit 10 resident records three times a week to ensure that meal and supplement intakes were being documented, weights were being obtained in accordance with the plan of care, weight changes were being reported to the IDT and physician as appropriate, and interventions were implemented related to weight changes. The audits would begin on 01/29/24 and continue for 12 weeks. Although the Immediate Jeopardy was removed on 01/29/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of Resident #32's medical record revealed an admission date of 03/28/22 with a re-admission date of 08/18/23. The resident's diagnoses included encephalopathy, need for assistance with personal care, displaced subtrochanteric fracture of right femur, vitamin D deficiency, major depressive disorder, deaf and nonspeaking, type II diabetes, mild intellectual disabilities, secondary malignant neoplasm of the breast, acquired absence of left breast and nipple and anxiety disorder. Review of the resident is at risk for altered nutrition/hydration related to diagnoses encephalopathy, diabetes mellitus, developmental disabilities (DD), vitamin D deficiency, depression, anxiety, history of need for therapeutic diet, usually good by mouth intakes, abnormal labs, body mass index (BMI) indicates obesity and refuses weights occasionally plan of care, dated 04/04/22, revealed interventions which included to educate resident/representative regarding nutritional needs and requirements, modify diet as appropriate according to resident's food tolerance and preferences, monitor for alteration in chewing or swallowing status, alert physician and speech therapy (ST) as needed, provide diet as ordered, encourage intakes of diet and fluids, assist with meals as needed, provide medications as ordered, report to physician any signs/symptoms of dysphagia (swallowing difficulty) report to physician as needed any signs/symptoms of malnutrition, report the physician any signs/symptoms of dehydration, weights as ordered. The care plan also reflected the following weight documentation: On 10/12/23 significant weight loss at one week/30/90/180 days, 11/02/23 significant weight loss at 30/90/180 days, 11/28/23 significant weight loss with varied meals and abnormal labs, 01/15/24 significant weight loss at 90 and 180 days. Review of the resident's re-admission initial nursing assessment dated [DATE], authored by Licensed Practical Nurse (LPN) #191, revealed the resident required set-up, supervision with meals, was non-weight bearing to the right leg and required two staff members with bed mobility and transfers. Review of the medical record revealed no re-admission weight and the first documented weight following the resident's re-admission was obtained on 08/25/23 at 202.7 pounds. Review of the resident's meal percentage intakes for August 2023 revealed the facility failed to document the resident's meal intakes on the following days: 08/06/23, 08/07/23, 08/10/23 for lunch and dinner, 08/14/23, 08/19/23, 08/20/23, 08/21/23, and 08/24/23 for the dinner meal. Review of the resident's weights revealed from 08/25/23 (202.7 pounds) to 09/07/23 (197.9 pounds) the resident had a weight loss of 4.8 pounds or (2.37%) weight loss in 13 days. Review of the resident's meal percentage intakes for September 2023 revealed the facility failed to document the resident's meal intakes on the following days: 09/03/23, 09/04/23 for the dinner meal, 09/07/23, 09/08/23, 09/09/23, 09/17/23, 09/18/23, 09/22/23, 09/25/23, 09/27/23, 09/29/23 and 09/30/23. Review of the resident's weights revealed from 09/07/23 (197.9 pounds) to 10/04/23 (178.0 pounds) the resident had a weight loss of 19.9 pounds or (10.05 %) weight loss in one month. Review of the resident's progress notes revealed no documented evidence Registered Dietician (RD) #500 or Physician #502 were notified of the significant weight loss of 19.9 pounds or 10.05 % in one month until 10/16/23. Further review revealed RD #500 recommended to add house supplement 2.0 240 milliliters (ml) daily and notify the physician or Certified Nurse Practitioner (CNP) of the significant weight loss. The RD was to continue to monitor weight trend and follow up as needed. Review of the resident's physician orders revealed the house supplement 240 ml by mouth daily recommendation from RD #500 was not implemented by the facility until 10/27/23. Review of the resident's weights from 10/04/23 (178 pounds) to 11/01/23 (166.5 pounds) revealed the resident had a significant weight loss of 11.5 pounds or 6.5 % of her total body weight loss in 28 days. Further review of the medical record revealed no documented evidence that the physician was notified of the significant weight loss. Review of the resident's meal percentage intakes for October 2023 revealed the facility failed to document the resident's meal intakes on the following days: 10/05/23, 10/06/23, 10/09/23, 10/13/23, 10/14/23, 10/16/23, 10/17/23, 10/19/23, 10/20/23, 10/21/23, 10/23/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23 and 10/31/23. Review of the Medication Administration Record (MAR) for October 2023 revealed the facility failed to document the percentage of the house supplement consumed. Review of the resident's weights from 11/01/23 (166.5 pounds) to 12/14/23 (156.5 pounds) revealed the resident had a significant weight loss of 10 pounds or 6% weight loss. Review of the weight change note dated 11/02/23 at 12:48 P.M., authored by RD #500, revealed the resident had a significant weight loss at 30/90/180 days and continued with a pressure ulcer to the right heel. The resident continued to receive a regular diet and had no recent meal intakes to review. The resident was receiving house supplement of 240 milliliters (ml) by mouth daily and 30 ml protein supplement twice daily. The note documented all supplements were accepted well. The RD recommended to increase the house supplement to 240 ml twice daily and continue to monitor weights weekly. Review of the medical record revealed the resident's weights were not obtained on 11/08/23 and 11/15/23 as physician ordered. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior section of the assessment revealed the resident had not rejected care. The assessment indicated the resident's weight was 161 pounds and she had a significant weight loss and was not on a prescribed weight loos regimen. Review of the dietary progress note dated 11/29/23, authored by RD #500 revealed the resident continued to have a significant weight loss of 7% in 30 days, 21% in 90 days and 21% in 180 days. The RD recommended to increase the house supplement to 240 ml three times a day, obtain weekly weights as physician ordered and notify the physician and/or CNP of the continued weight loss. Review of the physician's progress note dated 11/30/23, authored by Physician #502, revealed the physician was seeing the resident for unintentional weight loss. Following the review of the medical record the resident had lost approximately 40 pounds in the past six months. The physician gave orders to encourage by mouth intake, increase house supplement to 240 ml to three times a day and obtain weight weekly. Further review revealed the physician ordered a chest x-ray, calcium (CA) laboratory test, carcinoembryonic antigen (CEA) (a type of tumor marker used to monitor for cancer) laboratory test, complete metabolic panel laboratory and stool for guaiac three times (test used to detect blood in stool). Review of the medical record revealed no evidence the CEA, CA or the stool for guaiac three times had been obtained. Review of the resident's meal percentages intakes for November 2023 revealed the facility failed to document the resident's meal intakes on the following days: 11/02/23, 11/05/23, 11/06/23, 11/07/23 and 11/08/23. Review of the MAR for November 2023 revealed the facility failed to document the percentage of the house supplement consumed. Review of the medical record revealed the resident's weights were not obtained on 11/30/23 and 12/07/23 as physician ordered. Review of the resident's weight for 12/14/23 (156.5 pounds) revealed the resident had lost another four pounds or 2.5% weight loss in 22 days continuing the resident's weight loss trend. The medical record contained no documented evidence that the resident's physician or RD were notified of the continued weight loss. Review of the resident's weights revealed the physician ordered weight was not obtained on 12/21/23. Review of the physician progress note dated 12/21/23, authored by Physician #502, revealed the physician reviewed the resident's labs and the complete metabolic panel (CMP) supported the diagnoses of malnutrition with an Albumin low at 2.4 and protein low at 4.6. Further review of the physician progress note revealed the physician again ordered the labs CA, CEA and stool for guaiac three times due to them not being previously obtained. Review of the resident's weights revealed the physician ordered weight was not obtained on 01/04/24. Review of the resident's weight revealed on 01/11/24 the resident's weight was 152.6 pounds indicating another 3.4 pound or 2.18% weight loss continuing the weight loss trend. Review of the dietary progress note dated 01/15/24 at 10:44 A.M., authored by RD #500 revealed the resident had no significant weight loss in the past 30 days however, the resident had an 11% weight loss in the past 90 days and 25% weight loss in the past 180 days. Review of the resident's weights revealed no weight was obtained on 01/18/24 as ordered by the physician. Review of the MAR for January 2024 revealed the facility failed to document the percentage of house supplements consumed. Review of the resident's meal percentage intakes for January 2024 revealed the facility failed to document the resident's meal intakes on the following days: 01/19/24 and 01/20/24. The facility did not identify the resident's weight loss as a severe weight loss. Review of the Centers for Medicare and Medicaid guidance under the intent for 4383.25 (g) revealed the suggested parameters for evaluating the significance of unplanned and undesired weight loss defined severe weight loss as greater than five percent lost in one month; greater than 7.5% in three months and greater than 10% in six months. Observation on 01/23/24 at 12:40 P.M. revealed the resident was offered her lunch meal tray. The resident communicated via sign language to Licensed Practical Nurse (LPN) #219 that she wanted her meal. The resident was served her meal, in a disposable container, which consisted of an oven fried pork chop, buttered parsley noodles, veggie blend, a slice of wheat bread, a slice of crème pie and tea for beverage. A bowl of chicken noodle soup was also on the tray, in a disposable bowl. The resident consumed 75% of her pork chop and bread and began using sign language to communicate that she was sick to her stomach. Interview on 01/23/24 at 12:43 P.M. with LPN #219 revealed the resident had complaints of nausea for the past few days. The LPN shared she had administered Zofran (an anti-nausea medication) to the resident, but she continued to complain of nausea. She revealed the resident was independent with eating and had just recently stopped eating. The LPN revealed the resident only takes sips of the physician ordered supplement but refused it the majority of time. She stated she had not communicated to the physician or the management team the resident's refusal of the supplement or the resident's decreased appetite. Interview on 01/23/24 at 12:56 P.M. with the Director of Nursing (DON) verified the lack of an individualized nutritional plan to include monitoring weights and nutritional status, physician and dietitian notification for weight loss and implementation of nutrition interventions to prevent severe weight loss for Resident #32. Interview on 01/23/24 at 1:06 P.M. with RD #500 revealed she was aware of the significant weight loss the resident had experienced. The RD verified the resident's meal percentages were not documented consistently, the percentage of nutritional supplement consumed was not documented and weekly weights were not obtained. The RD revealed it was difficult to determine if interventions implemented were appropriate due to the lack of charting. The RD stated she would expect her recommendations to be implemented within three days of receiving. The RD verified she was never told the resident refused to be weighed or refused supplements. Lastly, the RD shared she had no additional interventions to implement and was waiting for the physician to implement an appetite stimulant. Interview on 01/23/24 at 4:10 P.M. with the DON verified the physician ordered lab tests CA, CEA and guaiac stools three times were not obtained when ordered on 11/30/23 and again on 12/16/23. The DON also verified this was not communicated with the physician. Further review of the medical record revealed the resident was transferred to the hospital on [DATE] due to vomiting and was admitted with sepsis due to unspecified organism, pneumonia of the right lower lobe due to infectious organism, nausea and vomiting, pain of upper abdomen, fecal impaction and acute urinary tract infection. Review of the hospital documentation dated 01/24/24 provided by the facility revealed the resident was admitted to the local acute care hospital after being transferred from the facility for the final diagnoses of sepsis due to unspecified organism, pneumonia of right lower lobe due to infectious organism, nausea and vomiting, pain of upper abdomen, fecal impaction, and acute urinary tract infection. Further review revealed the resident's weight on 01/24/24 (in the hospital) was 149 pounds continuing the weight loss trend. In addition, review of the hospital documentation revealed a bedside modified barium swallow (an x-ray test that takes pictures of the patient's mouth and throat while he or she swallows various foods and liquids) was completed. The resident displayed mild to moderate dysphagia due to impaired cognition, impulsiveness and overall disorganized bolus (a ball-like mixture of food and saliva that forms in the mouth during the process of chewing) formation. Recommendations were made for thickened liquids and an altered diet texture. When the resident returned to the facility on [DATE], the resident had a new diet order for mechanical soft (restricts difficult to chew foods) and nectar thickened liquids (the fluid consistency is altered to the consistency of nectar and aides in swallowing of those with difficulty swallowing). Interview on 01/25/24 at 9:23 A.M. with Physician #502 revealed the resident was given the diagnoses of malnutrition based on the CMP laboratory results and the weight loss. He revealed the facility had not notified him of the resident's trending weight loss, decreased oral intake, decreased and/or refusal of supplements and labs not being completed as he had ordered. Review of the nursing progress notes dated 01/25/24 at 6:29 P.M. revealed the resident would have new medications including a 10-day course of Cefdinir (antibiotic), insulin changes and the resident was oriented to her room and call light. Medications were confirmed with the nurse practitioner (unidentified) at the time of her re-admission from the hospital. Review of the Ohio Board of Dietetics (OBD) Standards of Practice in Nutrition Care, effective 11/30/19 revealed the licensee monitors and evaluates indicators and outcomes data directly related to the nutrition diagnosis, goals and intervention strategies to determine the progress made in achieving desired outcomes of nutrition care and whether planned interventions should be continued or revised. Nutrition monitoring and evaluation is the fourth step of the nutrition care process. Monitoring specifically refers to the review and measurement of the patient / client / group's status at a scheduled (preplanned) follow-up point with regard to the nutrition diagnosis, intervention plans / goals and outcomes, whereas evaluation is the systematic comparison of current findings with previous status, intervention goals, or a reference standard. Monitoring and evaluation use selected outcome indicators (markers) that are relevant to the patient / client / group's defined needs, nutrition diagnosis, nutrition goals, and disease state. Review of the facility's contract with the RD, dated 01/24/20 included that RD would formulate nutritional assessments and care plans on all new admissions, make resident visitations, observe eating in rooms and dining areas, and monitor weight, skin, and hydration management programs. Review of the Medical Director (MD) Agreement dated 07/12/21 revealed the MD shall be responsible for the implementation of resident care policies and the coordination of medical care in the facility, overall coordination of physician services in the skilled nursing facility and wellness program. Maintains effective liaison with attending physicians and provides guidance to them regarding the implementation of facility patient care and documentation policies. Review of facility Weight Change policy, dated March 2018, revealed a significant weight loss was defined as five percent in one month, 7.5 percent in three months, and 10 percent in six months. Recheck weights were to be obtained for a five-pound loss or gain if resident weights over 100 pounds and a three-pound gain or loss on a resident weighing less than 100 pounds. A five-pound gain or loss on a resident weighing 100 pounds or more and three-pound gain or loss on a resident weighing less than 100 pounds would be reported to the dietician and physician.