**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to identify a severe weight loss and decline in 1 or more Activities of Daily Living (ADL) as a significant change in a resident's condition and failed to complete a significant change assessment after a severe weight loss for 1 Resident (#30) of 4 residents reviewed for assessments. The facility's failure placed Resident #30 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #30 experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. The Administrator was informed of the IJ in the Administrator's office on 2/15/2022 at 6:48 PM. The Immediate Jeopardy was effective 12/2/2021 - 2/17/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 2/18/2022. The corrective actions were validated by the surveyors onsite on 2/18/2022. The findings include: Review of the facility policy Care Plans-Comprehensive undated, revealed .The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans; When there has been a significant change in the resident's condition; When the desired outcome is not met .At least quarterly . Review of the facility policy titled .Weight Management . dated 9/27/2017 revealed .MDS [Minimum Data Set] Coordinator will follow RAI guidelines for .a significant change related to weight loss . Review of CMS's RAI Version 3.0 Manual Chapter 2 dated 10/2019 revealed .A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self-limiting'; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan An SCSA [Significant Change Status Assessment] is appropriate when: There is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; and The resident's condition is not expected to return to baseline within two weeks .Guidelines to Assist in Deciding If a Change Is Significant or Not .An SCSA is appropriate if there are either two or more areas of decline .Any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as Extensive assistance, Total dependence .since last assessment .Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days) . Resident #30 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances, History of Traumatic Brain Injury, Blindness to Left Eye, and Cerebral Vascular Accident. Record review of the admission MDS assessment dated [DATE] revealed Resident #30 had severe cognitive impairment. The resident's functioning for ADLs included limited assistance for bed mobility; extensive assistance for transfers; activity of walking in room and walking in corridor did not occur; total dependence for locomotion on and off the unit; extensive assistance for dressing; supervision and setup help only for eating and toilet use; and extensive assistance for personal hygiene. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #30 had severe cognitive impairment. The resident's functioning for ADLs included limited assistance for bed mobility; extensive assistance for transfers, walking in room, and walking in corridor; total dependence for locomotion on and off the unit and dressing; limited assistance for eating; and total dependence for toilet use and personal hygiene. The MDS documented the resident experienced an unplanned weight loss of 5% or more in a month or loss of 10% or more in the last 6 months. Record review of Resident #30's weight record showed the following recorded weights: - On 9/7/2021 200.5 pounds (lbs.) - On 10/7/2021 194.5 lbs., a 5.5 lb. weight loss or 2.99% weight loss in 30 days - On 11/3/2021 186.5 lbs., a 14 lb. weight loss or 6.98% weight loss in almost 60 days - On 11/29/2021 a re-admission weight to the facility from the hospital was 176.0 lbs., a 24.5 lb. weight loss or 12.2% - On 12/2/2021 177.5 lbs., a 23 lb. weight loss or 11.4% weight loss in almost 90 days - On 1/10/2022 172.5 lbs., a 28 lb. weight loss or 13.9% weight loss in 125 days Record review revealed a significant change of status MDS assessment was not completed after Resident #30 had a decline in 1 or more ADL care needs and an unplanned weight loss of 5% in 30 days or 10% or more in 180 days. The failure to complete a significant change assessment prevented a change in the resident's care plan with initiation of interventions to prevent further weight loss per the facility's Weight Management Policy. During a telephone interview on 1/26/2022 at 1:18 PM, the MDS Coordinator confirmed she failed to identify a significant change in Resident #30's condition when the resident was identified on the 12/21/2021 quarterly MDS assessment to have experienced a decline in 2 or more ADL care needs and an unplanned weight loss greater than 10%. Further interview revealed due to the facility's failure to identify the significant change in the resident's condition on 12/21/2021, Resident #30 had further weight loss on 1/26/2022 of 12.5 lbs. (a total of 40.5 lb. weight loss, or 20.2 %, since admission on [DATE]). Interview with the Administrator on 2/15/2022 at 6:48 PM, confirmed the facility failed to identify and submit a significant change MDS for Resident #30's severe weight loss. Facility Corrective Actions included: 1. On 2/16/2022 an Interdisciplinary (IDT) team meeting was held to establish the team - Director of Nursing (DON) #1, DON #2, Assistant Director of Nursing (ADON), MDS Coordinator, Registered Dietitian (RD) via telephone or email (in the RD's absence the physician will be notified), Dietary Manager or Designee, and the Activities Director. Discussion included meeting daily, review of Resident #30's weight loss, and review the IDT Meeting agenda. On 2/17/2022 and IDT meeting addressed the RD's recommendations, audited 100% of the charts for the nutritional care plan, and updated with the interventions/recommendations. On 2/18/2022, the Physician will review the RD notes. The Census of 42 residents were evaluated for weight changes. There were 6 residents with weight loss (including Resident #30), 5 residents with weight gain, and 2 significant weight changes (including Resident #30) which were noted. The minutes of the IDT meeting will be taken by one of the IDT members, put into a folder, and maintained in the DON's office. The DON or designee will be responsible for follow-up action taken in the IDT meetings. Concerns will be identified using the 24-hour report, incidents, weight tools, electronic medical record dashboard alerts, and audits. 2. The Medical Director was notified of Resident #30's weight loss on 1/27/2022 and the diagnoses of Weight Loss and Anorexia were added to the medical record. The Physician ordered to continue weekly weights for 3 weeks or until trend turn around. The Clinical Notes had previously implemented visualized 1 on 1 feeding of Resident #30 on 1/9/2022 and a high protein nutritional supplement beverage on 1/27/2022. 3. The RD completed Comprehensive Nutrition Assessments on 2/16/2022 and 2/17/2022 for 10 residents demonstrating significant weight changes including Resident #30. The RD's recommendations included to continue the current diet and high protein nutritional supplement beverage 3 times daily, continue eating in the dining room, and assist with meals, and to confer with provider to rule out changes in medication that may cause drowsiness. Further review showed the No Added Salt to Resident #30's diet was discontinued. The RD Comprehensive Nutritional Assessment included pertinent resident information, recommendations, and goals. The RD will be involved in the IDT daily meeting via telephone or email (if RD unavailable, the MD will be notified). The administrator or designee will audit the RD's dietary notes utilizing a checklist of documentation requirements of comprehensive nutrition analysis on a weekly basis for 6 weeks and then monthly for 3 months. 4. The MDS Coordinator completed the Significant Change MDS Assessment on 1/26/2022. The MDS Coordinator will be involved in the IDT daily meeting. The DON or designee will audit the nutrition assessments for new admissions, quarterly assessments, significant changes, and annual assessments on a weekly basis for 6 weeks and then monthly for 3 months. 5. The IDT completed a webinar on Significant Change Assessment with a post-test on 2/16/2022. On 2/18/2022, the surveyors validated by review of sign-in sheets, and interview with IDT members, an IDT meeting was conducted on 2/16/2022. Interviewed staff included the Administrator, DON #1, ADON, RD via phone, Activities Director (AD), and MDS Coordinator. The surveyors reviewed the electronic medical records and comprehensive care plans of 11 residents (Resident #4, #9, #13, #14, #17, #23, #30, #32, #35, #90, and #91) which were identified with weight changes and validated the facility had revised and updated the care plans, accordingly. The surveyors validated the IDT meeting minutes held on 2/16/2022 was obtained and maintained in the DON's office. Interview with DON #1 validated DON #1 was knowledgeable about the IDT meetings, the agenda, obtaining and maintaining the minutes of the meetings, and the responsibilities of follow up on any issues identified during the meetings. On 2/18/2022, the surveyors reviewed an agenda used for daily meetings held with the DON, ADON, MDS, RD via telephone or email, Physician as needed or in absence of the RD, Dietary Manager or designee, and the Activities Director. The surveyors reviewed the agenda form from a meeting conducted on 2/17/2022. The surveyors validated the agenda information was discussed and included the weight loss of Resident #30, by review of the completed agenda form and interviews with the department head staff including a dietary manager designee, MDS Coordinator, ADON, DON #1, Maintenance Director, the Activities Director, and the Administrator. The agenda and meeting minutes were maintained by the DON. Continued review by the surveyors on 2/18/2022, validated the identified information discussed during the meeting included weight loss, weight gain, and significant weight change of 11 residents (Resident #4, #9, #13, #14, #17, #23, #30, #32, #35, #90, and #91). On 2/18/2022, the surveyors validated the IDT Meeting dated 2/17/2022 had been conducted and included the care plan chart audits. The meeting was held with DON #1, the ADON, and the MDS Coordinator and the findings were communicated to the Administrator. The surveyors validated the nutrition care plans had been revised. The surveyors validated the 24-hour report form had been completed during the IDT meeting dated 2/17/2022. Interviews with the ADON, the MDS Coordinator, 1 Registered Nurse (RN), 1 Agency RN, 4 Licensed Practical Nurses (LPN) validated the staff were knowledgeable regarding the 24-hour report and importance of discussing the report during the daily Stand-Up meetings. On 2/18/2022, the surveyors validated Resident #30 had new diagnoses added to the electronic medical record and was updated on the comprehensive care plan which included Weight Loss and Anorexia. The surveyors validated Resident #30 had been on weekly weights implemented on 1/27/2022 and continued the weekly weight monitoring form. The surveyors reviewed the Physician's Orders, Comprehensive Care Plan, and Meal Tray Card for Resident #30 and validated the documentation matched for a pureed diet with high protein nutritional supplement beverage 3 times daily. On 2/18/2022, the surveyors observed, and validated Resident #30 received the diet as ordered and consumed 100% of the meals. Continued observation revealed Resident #30 was provided his meals in the dining room with the assistance of staff. On 2/18/2022, the surveyors validated the Comprehensive Nutritional Assessment for Resident #30 had been completed by the RD on 2/16/2022. The Comprehensive Nutritional Assessment included Resident #30's pertinent information and included weight history, laboratory values, recommendations, goals, and metabolic needs. The surveyors reviewed Comprehensive Nutritional Assessments had been completed on 2/16/2022 and 2/17/2022 on 11 residents (Resident #4, #9, #13, #14, #17, #23, #30, #32, #35, #90, and #91). During a telephone interview on 2/18/2022, the RD verbalized understanding and was knowledgeable of the new comprehensive nutritional assessment tool and when the assessment was to be completed. The RD verbalized understanding of the new IDT process and her role in those meetings. The surveyors reviewed the Comprehensive Nutritional Assessment and interview with the Administrator on 2/18/2022 validated the Administrator had conducted the audits using the Nutritional Assessment Tool. On 2/18/2022, the surveyors reviewed and validated a teachable moment dated 2/16/2022 had been conducted by the Administrator. Interviews with the Administrator and the MDS Coordinator verified understanding of the teachable moment which consisted of review of the weekly and monthly weights to determine if any significant changes had occurred and if cases were identified, the MDS Coordinator was to bring the information to the IDT meeting. After the IDT determined a significant change existed, the MDS Coordinator was responsible to submit the significant change MDS. Interview with the MDS Coordinator on 2/18/2022 validated she received and understood the education provided. Review of a Significant Change MDS showed the MDS had been submitted on Resident #30. On 2/18/2022, the surveyors validated by review of post-test documentation, sign-in sheets, and interviews with the Administrator, ADON, MDS coordinator, Certified Nursing Assistant (CNA) #4, and CNA #5, the staff had completed an on-line webinar related to Significant Change MDS and completed the posttest documentation. The interviewed staff verbalized understanding of a Significant Change. CNA #4 and CNA #5 verbalized their roles with obtaining weights and notifying DON #1 or DON #2, ADON, and MDS Coordinator of any significant weigh changes. Noncompliance at F-637 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a plan of correction. Refer to F-657 and F-692

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to revise the care plan for an unplanned weight loss for 1 resident (Resident #30) of 4 residents reviewed. Resident #30 experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. The facility's failure placed Resident #30 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was informed of the IJ in the Administrator's office on 2/15/2022 at 6:48 PM. The Immediate Jeopardy was effective 12/2/2021 - 2/17/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 2/18/2022. The corrective actions were validated by the surveyors onsite on 2/18/2022. The findings include: Review of the facility policy Care Plans-Comprehensive undated, revealed .an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans; When there has been a significant change in the resident's condition; When the desired outcome is not met .At least quarterly . Review of the facility policy titled .Weight Management . dated 9/27/2017 revealed .Purpose: To provide a systematic, interdisciplinary approach to obtaining weights, intervention for 'true' significant weight loss and prompt identification of at risk residents .to intervene on any resident that .has experienced a significant weight loss .A significant weight loss is to be identified as 5% in one month or 7.5% in three months or 10% in six months .Care plan updated to reflect interventions . Resident #30 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances, History of Traumatic Brain Injury, Blindness to Left Eye, and Cerebral Vascular Accident. Review of Resident #30's care plan dated 9/7/2021 revealed .NUTRITION: The resident has the potential for nutritional problems, weight changes and dehydration related to teeth and diet restrictions .Goal The resident will maintain adequate nutritional status as evidenced by maintaining weight through review date. Interventions: Monitor intake and record every meal, Provide and serve diet as ordered for all meals and snacks .RD [Registered Dietician] to evaluate on admission, quarterly and as needed to make diet change recommendations . Record review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had severe cognitive impairment and required setup help only for eating. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #30 had severe cognitive impairment and required limited assistance of 1 for eating. The MDS documented an unplanned weight loss of 5% or more in a month or loss of 10% or more in the last 6 months. Record review of Resident #30's weight record showed the following recorded weights: - On 9/7/2021 200.5 pounds (lbs.) - On 10/7/2021 194.5 lbs., a 5.5 lb. weight loss or 2.99% weight loss in 30 days - On 11/3/2021 186.5 lbs., a 14 lb. weight loss or 6.98% weight loss in almost 60 days - On 11/29/2021 a re-admission weight to the facility from the hospital was 176.0 lbs., a 24.5 lb. or 12.2% weight loss - On 12/2/2021 177.5 lbs., a 23 lb. weight loss or 11.4% weight loss in almost 90 days - On 1/10/2022 172.5 lbs., a 28 lb. weight loss or 13.9% weight loss in 125 days - On 2/10/2022 159.0 lbs., a 41.3 lb. weight loss or 20.6% weight loss in 156 days - On 2/15/2022 158.0 lbs., a 42.3 lb. weight loss or 21.2% in 161 days Review of a comprehensive care plan for Resident #30 showed the care plan had not been updated with any nutritional interventions after the resident experienced weight loss on 11/3/2021, 11/29/2021, 12/2/2021, or 1/10/2022. During a telephone interview on 1/26/2022 at 1:18 PM, the MDS Coordinator confirmed she failed to identify a significant change in Resident #30's condition when the resident was identified on the 12/21/2021 quarterly MDS assessment to have experienced an unplanned weight loss greater than 10%. Further interview revealed the facility's failure to identify the significant change in the resident's condition on 12/21/2021 resulted in the facility failing to update the resident's care plan with interventions to prevent further severe weight loss. Further interview revealed the main goal of the facility's weight management meetings was to identify and prevent further weight loss with appropriate interventions. Resident #30 had further weight loss on 1/26/2022 of 12.5 lbs. (A total of 40.5 lb. weight loss, or 20.2% since admission on [DATE]). Review of Resident #30's comprehensive care plan revised 1/27/2022, showed interventions of a high protein nutritional supplement beverage 3 times daily and 1 on 1 feeding was added to the care plan. During an interview on 2/14/2022 at 2:20 PM, the Registered Dietitian (RD) stated .the at-risk residents including [Resident #30] should be discussed during the Weekly Weight Management meetings but I don't know if he is or not. I don't participate in that meeting and do not participate in the care planning for the residents . During an interview on 2/15/2022 at 6:48 PM, the Administrator confirmed the facility failed to revise Resident #30's care plan after a severe weight loss. Facility Corrective Actions included: 1. Resident #30's Care plan was revised by the nursing staff on 1/27/2022 to reflect the Resident's change in weight loss, and interventions were implemented as follows: - Alert dietitian if the resident's consumption was poor. - Feed the resident all his meals and snacks. - A copy of the monthly and weekly weight record will be given to the Administrator. - Nutritional Supplement are to be given to the resident as ordered. - If the resident's weight decline persists, the (physician) MD and the Registered Dietitian (RD) are to be contacted. - The resident food intake at each meal to be recorded -Offer substitutes as requested or indicated -Weigh at same time of day and record weekly 2. The Medical Director was notified of Resident #30's weight loss on 1/27/2022. Resident #30 was examined by the Medical Director on 2/10/2022. Medical diagnoses of Weight Loss and Anorexia were added. The Medical Director stated to continue weekly weights x (times) 3 (weeks) until trend turned around. The Medical Director had previously implemented 1 on 1 visualized feeding on 1/9/2022 and high protein nutritional supplement on 1/27/2022. 3. On 2/16/2022 the Administrator conducted a teachable moment with the MDS Coordinator concerning reviewing the weight sheets on a weekly and monthly basis to determine if there are any resident cases that qualify for a significant change, taking this information to the Interdisciplinary Team (IDT) meeting, and entering significant change MDS within the allotted 14 days. 4. Monthly weights for 2/2022 were reviewed and compared by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) against the last 6 months to gain percentages. 100% of care plans were audited on 2/17/2022 for weight loss or gain. Census of 42 residents evaluated with 6 weight losses, 5 weight gains, and 2 significant weight changes noted. The Physician reviewed the weights on 2/10/2022 and RD reviewed on 2/16/222 and made recommendations. 5. Care plans will be revised at the same time a significant change is determined by the IDT. 6. On 2/16/2022, the DON, the ADON, and MDS Coordinator evaluated the care planning process used to complete and update the care plans. IDT daily meetings were implemented. The care plan process includes the Certified Nursing Assistants (CNA) obtaining weights weekly and monthly, giving weights to nursing management, and evaluated by the IDT team and Stand-Up meeting members daily. The IDT identifies trends or significant weight changes, and nursing will notify the physician and the care plan will be updated. 7. Beginning 2/16/2022, education on implementation of stand-up meeting with Department Heads Monday thru Friday, establishment of Interdisciplinary Team (IDT) Clinical meetings directed by the DON with Clinical management staff daily, completing timely assessments when resident's condition decline, and review of the policies - Weight Management and Assessment for change in condition. In-services conducted 1 on 1 in person or by telephone. Any staff missing the in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressive discipline will begin as indicated. 8. On 2/15/2022, an agenda was developed to be used for meetings which include monitoring for weight loss. On 2/16/2022, the DON will begin daily IDT Clinical meetings to include DON, ADON, MDS, RD via phone or email and in the RD's absence, the Physician will be notified, Dietary Manager or Designee, and the Activities Director. The meetings will review falls, incidents, weight loss, pressure wounds, and all at risk issues that will aid in communicating issues to revise care plans. Each participant will be assigned a topic to be responsible for reporting at meetings. The minutes of the IDT meeting will be taken by one of the members present and the meeting and the minutes will be kept by the DON. On 2/17/2022, a Comprehensive Nutrition Assessment was added into the electronic medical record to be used upon admission, annually, and for significant change. On 2/18/2022, surveyors validated the comprehensive care plan for Resident #30 had been revised and included the pertinent information related to the resident's nutritional status, weight loss, and interventions. On 2/18/2022, surveyors validated the Medical Director had been notified of Resident #30's weight loss (after the weight loss was identified by the surveyor on 1/26/2022) and Resident #30 had been evaluated on 2/10/2022 with new diagnoses added of Weight Loss and Anorexia. The surveyors verified Resident #30 was scheduled for weekly weights beginning 1/27/2022 and had been obtained weekly since 1/27/2022. The surveyors verified the nutritional supplement of high protein nutritional supplement beverage was added 1/27/2022, Resident #30 was administered the high protein nutritional supplement beverage by the nursing staff, signed on the Medication Administration Records as being given, and was on the meal tray card. Observations on 2/18/2022 of Resident #30 during meals showed the resident received and consumed 100% of the meals and high protein nutritional supplement beverage. Continued observation showed Resident #30 ate his meals in the dining room and was assisted by the staff. On 2/18/2022, the surveyors reviewed a teachable moment dated 2/16/2022 and interviewed the Administrator and the MDS Coordinator. The teachable moment included the MDS Coordinator who was responsible for reviewing the weekly and monthly weights to determine if any significant changes had occurred. If cases were identified, the MDS Coordinator was to bring the information to the IDT meeting. After the IDT determines a significant change exists, the MDS Coordinator was responsible to submit the significant change MDS. Interview with the MDS Coordinator on 2/18/2022 validated she received and understood the education provided. Review of a Significant Change MDS showed the MDS had been submitted on Resident #30 on 1/26/2022. On 2/18/2022, the surveyors validated the RD had completed the Comprehensive Nutritional Assessment on 2/16/2022 and 2/17/2022 on 11 residents (Resident #4, #9, #13, #14, #17, #23, #30, #32, #35, #90, and #91) and the comprehensive care plans had been revised. The surveyors verified any recommendations noted on the Comprehensive Nutritional Assessments were updated on the comprehensive care plans. The surveyors validated all residents' weights were obtained (unless order to discontinue) 2/1/2022 - 2/4/2022. The IDT Clinical staff reviewed the weights on 2/10/2022, the IDT meeting minutes dated 2/17/2022, and the results of the weekly/monthly weights. The surveyors validated the documentation and verified the care plans had been revised, as needed on the 11 identified residents of the facility. On 2/18/2022, the surveyors validated the corrective actions onsite through interviews with the Administrator, Assistant Director of Nursing, Nurse Educator (DON #1), MDS Coordinator, 1 Registered Nurse (RN), 1 Agency RN, 4 Licensed Practical Nurses (LPN), 10 Certified Nursing Assistants (CNAs), 2 Maintenance staff, and 1 housekeeper and through review of the in-service sign in sheets of remaining staff members. The interviews showed the staff were educated on how to communicate weights and aid residents with assisted feedings, recording of the amounts of intake of foods, liquids, and snacks, and implementing person centered care plans for each resident that required assisted feeding. Staff verbalized knowledge of the new plan for nutrition and weight loss reporting, and how to assess residents to determine person centered needs/interventions. The surveyors validated by interview with the Dietary Manager Designee on 2/18/2022 the understanding of obtaining food preference upon admission and/or readmission to the facility, bi-annually, and as needed. The Dietary Manager Designee was able to state her role and responsibilities regarding weight loss and communication and participation during the IDT meetings. On 2/18/2022, the surveyors reviewed an agenda used for daily meetings held with the DON, ADON, MDS, RD via telephone or email, Physician as needed or in absence of the RD, Dietary Manager or designee, and the Activities Director. The surveyors reviewed the agenda form from a meeting conducted on 2/17/2022. The surveyors validated the agenda information discussed, including the weight loss of Resident #30, by review of the completed agenda form and interviews with the department head staff including a dietary manager designee, MDS Coordinator, ADON, DON #1, Maintenance Director, the Activities Director, and the Administrator. The agenda and meeting minutes were maintained by the DON. Continued review by the surveyors on 2/18/2022, validated the identified information discussed during the meeting including weight loss, weight gain, and significant weight changes. On 2/18/2022, surveyors validated IDT Meeting dated 2/17/2022 and included the care plan chart audits. The meeting was held with DON #1, the ADON, and the MDS Coordinator. The findings were communicated to the Administrator. The surveyors validated the nutrition care plans had been revised accordingly by review of the care plans and interviews with the IDT members. On 2/18/2022, the surveyors validated the Weight Management Policy had been revised on 2/17/2022. Noncompliance at F-657 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. Refer to F-692

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of physician logs, interviews, and observations, the facility failed to identify a significant weight loss and implement interventions to prevent further weight loss for 1 resident (Resident #30) of 4 residents reviewed for nutrition and hydration status. Resident #30 experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. The facility's failure placed Resident #30 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was informed of the IJ in the Administrator's office on 2/15/2022 at 6:48 PM. The facility was cited F-692 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective 12/2/2021 - 2/17/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 2/18/2022. The corrective actions were validated by the surveyors onsite on 2/18/2022. The findings include: Review of the facility policy titled .Weight Management . dated 9/27/2017 revealed .Purpose: To provide a systematic, interdisciplinary approach to obtaining weights, intervention for 'true' significant weight loss and prompt identification of at risk residents .It is the policy to promptly .identify and track all weights and to intervene on any resident that .has experienced a significant weight loss .A significant weight loss is to be identified as 5% in one month or 7.5% in three months or 10% in six months .Weights will be immediately reviewed and the Dietary Manager or their designee will calculate the actual weight loss/gain .Weights will be obtained on all admission (admits and readmits) weekly for four weeks .A resident that has experienced a significant weight loss will be placed on the Review Program .The physician .will be notified of the significant weight loss .Weight loss will be documented on the Weight Loss Notification Form .Each resident will be discussed weekly in the Weight Management Meeting .Documentation shall include, but not limited to: What is being done to promote weight gain .The resident's response to the intervention .If a resident requires weekly weights for the sole purpose of weight monitoring, the resident will be placed [on the] Review Program, and it shall be understood that the following will automatically occur .The resident will be placed on weekly weights until the resident's weight is stable for four consecutive weeks .Completion of a weight loss notification form .Discuss in the weekly Weight Management meeting .Care plan updated to reflect interventions .Address any unavoidable weight change . Review of the facility policy titled, HEIGHT AND WEIGHT MONITORING undated, showed .The purposes of the procedure are to determine the resident's weight .to provide a baseline and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident .Significant unintended changes in weight (loss or gain) .may indicate a nutritional problem .It is the facility's standards of practice to weigh the resident on admission or readmission (to establish a baseline weight), weekly for the first 4 weeks after admission and at least monthly . Resident #30 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances, History of Traumatic Brain Injury, Blindness to Left Eye, and Cerebral Vascular Accident. Review of Resident #30's care plan dated 9/7/2021 revealed .NUTRITION: The resident has the potential for nutritional problems, weight changes and dehydration related to teeth and diet restrictions .Goal The resident will maintain adequate nutritional status as evidenced by maintaining weight through review date. Interventions: Monitor intake and record every meal, Provide and serve diet as ordered for all meals and snacks .RD [Registered Dietician] to evaluate on admission, quarterly and as needed to make diet change recommendations . Review of the Weight Summary Report for Resident #30 showed the following 3 admission weights were obtained upon admission to the facility. - admission weight on 9/7/2021 was 200.5 pounds (lbs.) - admission weight on 9/8/2021 was 199.5 lbs. - admission weight on 9/9/021 was 199.0 lbs. Review of Resident #30's Nutritional assessment dated [DATE] showed .preferred beverages milk, juice, water .Diet order NAS [No Added Salt] puree .no decrease in food intake .no weight loss .His weight is 201 lbs. and age of 80. He eats 89.2% Breakfast, 85.7% of lunch 87.5% of supper for a total of 87.4% of his meals . The assessment did not indicate the resident's caloric, fluid, carbohydrate, fat, or protein needs. Review of the Weekly Weight form dated 9/13/2021 for Resident #30 showed a weight of 193.5 lbs. Review of a Medical Doctor/Nurse Practitioner (MD/NP) Log dated 9/16/2021 showed .Chief Complaint .New admit 9/7 [9/7/2021] BLE [bilateral lower extremity] edema .Weight .200.5 . Further review showed the weight noted on the MD/NP log was the initial admission weight of 200.5 lbs. and did not reflect the 193.5 lbs. obtained on 9/13/2021, which showed a 7 lb. weight loss. Review of the Weekly Weight form for Resident #30 showed the following weights were obtained. - Weekly Weight on 9/20/2021 was 194.5 lbs. - Weekly Weight on 9/27/2021 was 196 lbs. - Weekly Weight on 10/4/2021 was 194.5 lbs. Review of the Monthly Weight form dated 10/7/2021 for Resident #30 showed a weight of 194.5 lbs. Review of a MD/NP Visit Log dated 10/21/2021 showed .recommendation .Basic Metabolic Panel [BMP] [a laboratory blood test for kidney function, glucose (sugar) levels, and electrolytes in your blood] .Weight .194.5 . Review of a Monthly Weight form dated 11/3/2021 for Resident #30 showed a weight of 186.5 lbs. Continued review showed Resident #30 had a weight loss of 14 lbs. or 6.98% in 60 days. Further review showed weekly weights were not implemented after the resident's weight loss on 11/3/2021. Review of the Weight Summary report showed .Warnings . for a significant weight loss on 11/3/2021. Medical record review showed a comprehensive nutritional assessment had not been completed by the RD on Resident #30 after a weight loss of 14 lbs. (6.98%) on 11/3/2021. Review of a MD/NP Visit Log dated 11/11/2021 showed .Weight .186.5 . Continued review revealed no new orders were noted. Review of Resident #30's Emergency Department to Hospital Admission/discharge date d 11/23/2021 [resident hospitalized [DATE]-[DATE]] showed .Persistent significant fecal retention .the entirety of the colon, from the right colon through the rectum, is moderately distended with stool. Findings most consistent with ileus/constipation .Assessment and Plan .will be hospitalized .He is not ill-appearing .[Resident #30] had epistaxis [nosebleed] which prompted medical attention leading to the finding of distention and dilated loops of bowel . Review of the weight record dated 11/29/2021, on re-admittance from the hospital to the facility, showed Resident #30 weighed 176.0 lbs. (a loss of 10.5 lbs. from 11/3/2021 - 11/29/2021 and a loss of 24.5 lbs. since facility admission). Continued review showed the facility did not obtain weekly weights for Resident #30 upon re-admission to the facility per the facility's policy. Review of the Monthly Weight form dated 12/2/2021 for Resident #30 showed a weight of 177.5 lbs. (a loss of 24 lbs. or 11.4% in 90 days). Review of a MD/NP Visit Log dated 12/9/2021 showed .Chief Complaint .re-admit [to the long-term care facility] 11/29/21 [11/29/2021] .Weight 177.5 .Orders .No [no new orders] . Review of a Physicians progress note dated 12/9/2021 showed .Well-developed, well-nourished .Epistaxis .had polyp .Healing well .cont [continued] weight loss. Will direct visualized feeding assistance . Continued review showed no additional nutritional interventions were ordered. Review of Resident #30's RD nutritional assessment dated [DATE] showed .resident is on .pureed diet with thin liquids, no decrease in po [by mouth] intake, weight loss greater than 6 pounds, preferred drinks milk, juice, and water. Body Mass Index (BMI) 22 [normal body weight BMI range 18.5-24.9] . The assessment did not indicate the resident's caloric, fluid, carbohydrate, fat, or protein needs. Continued review showed no nutritional interventions were recommended or ordered by the RD. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had severe cognitive impairment and required limited assist of 1 for eating. The MDS documented an unplanned weight loss of 5% or more in a month or loss of 10% or more in last 6 months. Review of an Order Summary Report dated 12/21/2021 showed No Added Salt Pureed Texture diet, Furosemide (diuretic) 40 milligram (mg) every morning, Multivitamin 1 daily, Quetiapine (antipsychotic) 200 mg in the evening and at bedtime, and Spironolactone (diuretic) 50 mg 3 times daily. Review of a Physician's Order dated 1/9/2022 showed .Feed Resident [Resident #30] . Continued review showed no other nutritional interventions were ordered. Review of a Monthly Weight form dated 1/10/2022 for Resident #30 showed a weight of 172.5 lbs. (a loss of 28 lbs. or 13.9% in 4 months). Review of the Weight Summary report showed .Warnings . for a significant weight loss on 1/10/2022 (28 lbs. or 13.9% in 4 months). Continued review showed the Monthly Weight form dated 9/2021 - 2/2022 showed Resident #30 had a Body Mass Index (BMI) of 24.1 and an Ideal Body Weight (IBW) of 165.9. The Monthly Weight form did not provide a date the BMI had been calculated and was unclear if the BMI was calculated upon admission or after the severe weight loss. Review of Resident #30's RD assessment dated [DATE] showed the resident was eating 25-75% of meals and drinking 1000 milliliters (ml)-1500 ml daily. There was no further documentation related to the weight loss or nutritional interventions. The assessment did not indicate the resident's caloric, fluid, carbohydrate, fat, or protein needs. Review of a Nutrition/Dietary Note dated 1/25/2022 showed .[Resident #30] needs cueing more at meals .given opportunity to eat independently at meals, initially, but recent staff is needed to assist him .Diet NAS puree .Will be assisted with meals .11.5% wt [weight] loss in 3 months, 3% wt loss in one month, 13.9% wt loss since admission .Currently at healthy BMI range 22. Prevent further wt loss .Continue current interventions [1 on 1 feeding] . The assessment did not indicate the resident's caloric, fluid, carbohydrate, fat, or protein needs. Continued review showed no additional nutritional interventions were implemented. During a telephone interview on 1/25/2022 at 3:16 PM, the RD stated she was at the facility on 12/16/2021 and on 1/7/2022 and was aware of a 6 lb. weight loss (from 9/7/2021 - 12/16/2021). She stated she was not aware of the additional weight loss and had not made any new recommendations to prevent further weight loss for Resident #30. The RD stated .The Director of Nursing [DON] usually gives me a communication form for residents who have had weight loss. The communication form triggers the resident for weight loss program review . The RD could not recall if she had received a notification specifically regarding Resident #30 but had received the monthly and weekly weight forms of the residents in the facility. During a telephone interview on 1/26/2022 at 8:40 AM, the Medical Director stated he was aware of the weight loss on 12/9/2021 during a visit, .resident lost more weight than I like .usually add [high protein nutritional supplement beverage], or appetite stimulant for weight loss but did not add on 12/9/2021. Not sure why; did not write orders . Continued interview confirmed the Medical Director could not recall why he had not put new interventions in place to prevent further weigh loss for Resident #30. During an interview on 1/26/2022 at 9:41 AM, Certified Nursing Assistant (CNA) #5 reported Resident #30 was weighed on 1/26/2022 at 9:30 AM, with a lift scale, and weighed 160.0 lbs. The resident was reweighed on 1/26/2022 with a wheelchair scale and weighed 160.0 lbs. The CNA stated she reported the weight loss to the nurse assigned to the hall. Review of the medical record showed no documentation Resident #30's weight of 160.0 lbs. obtained on 1/26/2022 was recorded in the medical record. Continued review showed no documentation the RD or the Medical Director were notified of the weight and weight loss of an additional 12.5 lbs. from 1/10/2022 to 1/26/2022. Review of a Physician's Order dated 1/27/2022 showed a high protein nutritional supplement beverage was added 3 times daily with meals. Review of a Weekly Weight form dated 1/31/2022 for Resident #30 showed a weight of 159 lbs. Review of a Weekly Weight form dated 2/7/2022 for Resident #30 showed a weight of 157 lbs. Review of a Monthly Weight form dated 2/10/2022 for Resident #30 showed a weight of 159 lbs. (a loss of 41.3 lbs. or 20.6% in 5 months). Review of a Physician's Progress Note dated 2/10/2022 showed .Nursing staff reports no new issues with visualized feeding .Wt. [weight] 159 lbs .Past Vitals [vital signs] .12/09/2021 Wt. 177.5 lbs .Weight loss .Anorexia . The Progress Note showed weekly weights would continue for 3 weeks until trend turned around .I [Medical Director] believe he will regain weight slowly unless this is directly related to his mentation/dementia. If [weight] has been lost due to age related changes, anything short of feeding tube will only slow down process, Time will tell . Review of a Weekly Weight form dated 2/14/2022 for Resident #30 showed a weight of 158 lbs. During an observation on 2/14/2022 at 11:40 AM, Resident #30 was assisted with his meal in the dining room. Continued observation showed the resident consumed 100% of his lunch meal and high protein nutritional supplement beverage. Review of the meal intake records dated 12/16/2021 - 2/14/2022 showed Resident #30 consumed 0-25% of 12 meals, 26-50% of 42 meals, 51-75% of 29 meals, and 76-100% of 74 meals over the 60-day period. During a telephone interview on 2/14/2022 at 2:20 PM, the RD stated .I do not do an assessment that identifies what calorie, protein or fluid needs are for the resident, and I do not put it in my notes. I just ask the staff how they are eating .I don't compare estimated nutritional needs to actual intake. I do not do any nutritional analysis of individual menus .I have not charted on him [Resident #30] for February, he is still on my list to chart on. I am aware he [Resident #30] has had continued weight loss and should have been a priority when I was there on February 10th [2/10/2022]. I will not be back in the facility until March 7th . Continued interview showed the RD stated the resident was on an evening snack but was unable to specify the type of snack, how much the resident consumed, and whether the resident received it daily. The RD stated the resident's ideal body weight range was 159-189 lbs. The RD stated she reviewed monthly weights and reviewed the weights during quarterly and annual assessments.I do not review weekly weights. That is nursing responsibility .if they want to, they can call me .they haven't called me during the last 2 months . The RD further stated .I can put someone on weekly weights but nursing usually does that .the ADON reviews the weekly weights, and I am usually notified by the weight sheet on my next visit. It is up to nursing to notify the physician for him to order something or they can put in an intervention that does not require a physician's order such as snack or needs assist with eating .I'm not sure why I didn't do an intervention .[Resident #30s] weight [referring to weight on 1/10/2022] was not available when I did my January 7th visit [a weight on 12/2/2021 was 177.5 lbs., a loss of 24.5 lbs. in 90 days] . The RD stated nursing had identified him as having weight loss, .but I missed it .He should be discussed during the Weekly Weight Management meeting, but I don't know if he is or not. I don't participate in that meeting . Review of a meal tray card, undated (printed on 2/15/2022) showed Resident #30 had no dislikes, was on a pureed, no added salt diet, and regular liquids. The tray card showed the high protein nutritional supplement beverage or equivalent had been added. During an observation and interview with Resident #30 on 2/15/2022 at 7:50 AM, Resident #30, who had severe cognitive impairment, was seated in a Geri-chair slightly reclined in the dining room. The resident was assisted with his meal and consumed 100% of his food and drank 8 ounces of the high protein nutritional supplement beverage. The resident was questioned if he was hungry, and the resident replied .uh huh . indicating he was still hungry. Continued observation showed no other food was offered by the staff. During an interview on 2/15/2022 at 9:00 AM, Certified Nursing Assistant (CNA) #5 stated .[Resident #30] eats better for some CNA's than others .He drinks his high protein nutritional supplement beverage .he will eat 100% .sometimes I do well to get him to eat 50-75% .we try to pair him with the staff he will eat better for . Continued interview revealed she and CNA #4 obtained the weekly and monthly weights. After the weights were obtained and a weight loss of 3 lbs. or more was noted, she or CNA #4 notified the Assistant Director of Nursing (ADON) or the MDS Coordinator. CNA #5 further confirmed after an initial weight loss was identified and the ADON or MDS Coordinator were notified, she did not continue to communicate any additional weight losses noted on the same resident(s) because the weights were listed on the weekly or monthly weight forms. CNA #5 stated the forms were updated weekly. During an interview on 2/15/22 at 9:32 AM, the Assistant Director of Nursing (ADON) stated she was not aware of a document entitled weight loss notification form from the facility's 2017 Weight Management policy. The ADON stated she had been on vacation since 1/7/2022 (1/7/2022-2/15/2022) and was not aware of Resident #30's severe weight loss. The ADON further stated informal meetings with the MDS Coordinator were held after the scheduled care plan meetings each week to discuss any identified concerns with residents, and Resident #30 had not been discussed. The ADON confirmed the facility had not been following their Weight Management Policy. The ADON further confirmed she did not know what process the staff had followed regarding weight loss in her absence. During a telephone interview on 2/15/2022 at 3:00 PM, the Medical Director stated he was notified of weight changes of residents by review of the weekly and monthly weights provided by the nursing staff on each visit to the facility. The Medical Director stated he usually visited the facility weekly except in December 2021 and January 2022, due to COVID outbreaks, and he had visited the facility twice during those two months. The Medical Director stated he was aware of Resident #30's initial weight loss from 9/2021 - 11/2021 and had attributed the weight loss to administration of diuretics and going from a heavy meat laden diet to a vegetarian diet. The Medical Director stated he was not concerned with the weight loss at the time due to the resident being over his ideal body weight and adjustment to a new diet. The Medical Director stated the resident was hospitalized for a week in November 2021 due to a bowel obstruction and the continued weight loss was attributed to the resident's hospitalization, the bowel obstruction, and the NPO (nothing by mouth) status during the hospitalization (11/23/2021-11/29/2021). The Medical Director stated after his assessment of Resident #30 on 12/9/2021, he implemented 1 on 1 visualized meals to determine what and how much food intake Resident #30 consumed during meals and to get an overall picture of the resident during the meals. The Medical Director stated he re-evaluated the resident's weight on 1/9/2022 and after interviewing the nursing staff, he ordered for Resident #30 to be fed all meals. Continued interview revealed after the MD was made aware of Resident #30's weight loss on 1/27/2021, a nutritional supplement was added to his diet. The Medical Director stated Resident #30 was at a good body weight (weight on 2/14/2022 was 158 lbs. and 1 lb. below the IBW) and confirmed no other nutritional interventions had been ordered since 1/27/2022. Facility Corrective Actions included: 1. The RD completed a Comprehensive Nutritional Assessment for Resident #30 on 2/16/2022. Director of Nursing (DON) #1 and Dietitian reviewed the assessment with the MD and recommendations were made. The ADON increased Resident #30's nutritional calories and the increase matched the meal tray card. The total calories for 3 meals added 1,937 calories. 2. The RD completed Comprehensive Nutrition Assessments on 2/16/2022 and 2/17/2022 for 11 residents who demonstrated weight changes including Resident #30. The RD's recommendation for Resident #30 included to continue the current diet and the high protein nutritional supplement beverage, assist with meals, and confer with Provider to rule out changes in medication that may cause drowsiness, and discontinue the No Added Salt Diet due to diagnosis of Hyponatremia. 3. The Medical Director was notified of Resident #30's weight loss on 1/27/2022. Resident #30 was examined by the Medical Director on 2/10/2022 and the diagnoses of Weight Loss and Anorexia were added. The Medical Director had implemented 1 on 1 visualized feeding on 1/9/2022 and high protein nutritional supplement beverage on 1/27/2022. 4. On 2/16/2022, the Administrator conducted a teachable moment with the RD concerning the completion of Comprehensive Assessments and assessments for change in weight in a timely manner. Assessments will be reviewed by the Administrator or designee weekly for 6 weeks and then monthly for 3 months. 5. Beginning 2/16/2022 and ending 2/18/2022, DON #1 and the Administrator conducted multiple mandatory in-services with all employees including Agency staff. The in-services included the implementation of the Stand-up meetings with the Department Heads, Monday thru Friday, and the establishment of Interdisciplinary Team (IDT) Clinical meetings, directed by the DON, with Clinical management staff daily, completing timely assessments when a resident's condition declined, and review of the Weight Management policies, and Assessment for change in condition. The in-services were conducted 1 on 1 in person or by telephone. Any staff who did not attend the in-services would not work until the education was received. Any staff who failed to comply with the points of the in-services would be further educated and/or progressively disciplined. 6. On 2/16/2022, an IDT meeting was held to establish the team (DON #1/#2, ADON, MDS, RD via phone or email, and in the absence of the RD, the MD will be notified, Dietary Manager or Designee, and Activities Director) and discussed meeting daily, the review of Resident #30's weight loss and to review the new Agenda. On 2/17/2022, an IDT meeting addressed the RD's recommendations, audited 100% of the medical charts for the nutritional care plans, and updated the care plans with any new interventions or recommendations. A Census of 42 residents were evaluated. Six residents were noted with weight loss (including Resident #30), 5 residents were noted with weight gains, and 2 residents were noted with significant weight changes (including Resident #30). The IDT meeting minutes will be taken by one of the IDT members present at the minute and put into a folder in the DON's office, and later into a binder. The DON or designee will be responsible for any follow up action taken in the IDT meetings. 7. All Residents were weighed 2/1/2022-2/4/2022 by the CNAs. DON #1 and the Dietitian reviewed the weights on 2/10/2022. The residents identified or who demonstrated significant weight changes which included any 5 lb. weight change, or more was verified by obtaining a reweight by the next day. Once the weights were verified, any significant change was reported to the MD. All weights will be reviewed in the daily IDT meetings indefinitely. 8. Starting 2/16/2022, newly admitted /re-admitted residents' food preferences will be obtained by the dietary manager or designee within 72 hours of admission and entered in Dining Record for listing on the tray cards. Food preferences will be completed bi-annually and as needed for all residents. 9. Beginning 2/16/2022, weights will be reviewed in the IDT Clinical Meetings daily, Monday thru Friday, and any recommendations from the RD concerning the residents are addressed at that meeting and the physician will be notified immediately. The Dietary Manager or designee is to report any nutrition concerns of residents with the group. The minutes of the IDT meetings will be maintained in the DON's office. This new process will replace the previous weight management procedure defined in the current weight management policy. That policy will be updated on 2/17/2022 to reflect the new process. On 2/18/2022, the surveyors validated the removal plan. The surveyors reviewed a Comprehensive Nutrition Assessment for Resident #30 which was completed on 2/16/2022. Review of the electronic medical record, the physician's order, and the meal tray card had been updated and matched. Observations of Resident #30 for 2 meals on 2/18/2022 showed additional foods of whole milk for breakfast and lunch, and 4 ounces (oz) ice cream, 4 oz pudding, and ½ cup fruit puree at lunch and dinner had been added. The tray card matched the observations and Resident #30 consumed 100% of the meals. On 2/18/2022, the surveyors validated the RD had completed the Comprehensive Nutritional Assessments on 2/16/2022 and 2/17/2022 on 11 residents (Resident #4, #9, #13, #14, #17, #23, #30, #32, #35, #90, and #91) and interventions had been implemented. The surveyors verified any recommendations noted on the Comprehensive Nutritional Assessments were updated on the electronic medical record, the physician was notified of any recommendations, and the care plans were revised, accordingly. The new Comprehensive Nutritional Assessments included the resident's name, date of birth , pertinent diagnoses, supplement orders, food allergies, oral intake and appetite, dining ability, chewing ability, adaptative equipment, swallowing ability, height, usual weight/IBW, weight trends, weight changes in 1 month, 3 months, and 6 months, the resident skin status, communication ability, pertinent nutrition related medications, laboratory results, energy needs, protein needs, fluid needs, and recommendations. The surveyors validated all the residents' weights were obtained (unless order to discontinue) 2/1/2022-2/4/2022 by review of the monthly weight form. The IDT Clinical staff reviewed the weights on 2/10/2022 and notified the RD/MD as needed, nutritional interventions were implemented, and the care plans and electronic medical records were revised. The surveyors validated the information by review of the electronic medical records and interviews conducted with the IDT members on 2/18/2022. On 2/18/2022, the surveyors validated the Medical Director had been notified of Resident #30's weight loss by the nursing staff. The Medical Director evaluated Resident #30 on 2/10/2022 and added new diagnoses of Weight Loss and Anorexia. The surveyors validated the information by review of the electronic medical record. The surveyors verified Resident #30 was scheduled for weekly weights beginning 1/27/2022 and the weights had been obtained weekly since 1/27/2022. The surveyors verified the high protein nutritional supplement beverage was added 3 times daily beginning 1/27/2022. Resident #30 was administered the high protein nutritional supplement beverage by the nursing staff, signed on the Medication Administration Records by the nursing staff as being given, and was on the meal tray card. Observations on 2/18/2022 of Resident #30 during 2 meals showed the resident received and consumed 100% of the high protein nutritional supplement beverage. On 2/18/2022, the surveyors validated the Administrator had conducted a teachable moment with the RD on 2/16/2022 regarding Comprehensive Assessments and Change in Weight Loss. Interview with the RD and the Administrator confirmed the education had been provided. The surveyors validated the content of the Comprehensive Nutrition Assessment to be completed by the RD which included pertinent resident information, oral intake, energy, protein, and fluid needs. On 2/18/2022, the surveyors reviewed the education and sign in sheets. The documentation showed all staff working on 2/18/2022 had been provided the education on nutrition, DON #1 and DON #2 roles and responsibilities, and weight loss policies. The surveyors validated all staff working on 2/18/2022, which included Administrator, Assistant Director of Nursing, Nurse Educator (DON #1), MDS Coordinator, 1 Registered Nurse (RN), 1 Agency RN, 4 Licensed Practical Nurses (LPN), 10 CNAs, 2 Maintenance staff, and 1 housekeeper had been educated and were knowledgeable about the new procedures related to nutrition and weight loss and person-centered care planning. The surveyors validated the division of DON #1 and DON #2 responsibilities by interview with DON #1, signed acceptance by DON #2, and review of the divided roles. The surveyors verified DON #1 responsibilities included staffing schedule, staffing issues, equipment needs, admissions and discharges, ensure the committees are meeting, in-services are conducted, and quality assurance. The DON #2 responsibilities included review of the doctor notes, psychiatric notes, RD notes, consultant notes, therapy notes, incident reports, weights, wounds, physician order reviews, narcotic reviews, medication administration process, review of pharmacy reports, review of labs, x-rays and other diagnostic reports, infection prevention, vaccinations, MDS review, and review of care plans. On 2/18/2022, the surveyors validated the corrective actions onsite through interviews with the Administrator, Assistant Director of Nursing, Nurse Educator (DON #1), MDS Coordinator, 1 RN, 1 Agency RN, 4 Licensed Practical Nurses, 10 CNAs, 2 Maintenance staff, and 1 housekeeper. The interviews showed the staff were educated on how to communicate weights and aid residents with assisted feedings, recording of the amounts of intake of foods, liquids, and snacks, and implementing person centered care plans for each resident that required assisted feeding. The nursing staff verbalized knowledge of the new plan for nutrition and weight loss reporting, and how to assess residents to determine person centered needs/interventions. The surveyors validated by interview with the Dietary Manager Designee on 2/18/2022 the understanding of obtaining food preference upon admission and/or readmission to the facility, bi-annually, and as needed. The D[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of staff job descriptions, review of facility policy, medical record review, review of facility documentation, review of staffing schedules, review of staff time punches, and interview, the facility failed to employ a Registered Nurse (RN) acting as the Director of Nursing (DON) for 18 of 52 weeks and failed to provide RN coverage for 8 consecutive hours, 7 days per week in the facility for 4 of 30 days. The failure of the facility to provide an RN as a DON from 9/1/2021-2/18/2022 resulted in a failure to identify and implement interventions to prevent a severe weight loss for Resident #30, who experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. The facility's failure to have an RN as a DON placed the facility in an Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) in the Administrator's office on 2/15/2022 at 6:48 PM. The facility was cited Immediate Jeopardy at F-637 (J), F-657 (J), and F-692 (J). The facility was cited at F-692 at a scope and severity of J level, which is Substandard Quality of Care. The Immediate Jeopardy was effective 12/2/2021 - 2/17/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 2/18/2022. The corrective actions were validated by the surveyors onsite on 2/18/2022. The findings include: Review of facility documentation titled, Job Description Director of Nursing undated, showed .Qualifications .a Registered Nurse in the state of Tennessee . Review of the facility policy titled .Weight Management . dated 9/27/2017 revealed .Purpose: To provide a systematic, interdisciplinary approach to obtaining weights, intervention for 'true' significant weight loss and prompt identification of at risk residents .It is the policy to promptly .identify and track all weights and to intervene on any resident that .has experienced a significant weight loss .A significant weight loss is to be identified as 5% in one month or 7.5% in three months or 10% in six months .A resident that has experienced a significant weight loss will be placed on the Review Program .Weight loss will be documented on the Weight Loss Notification Form .Each resident will be discussed weekly in the Weight Management Meeting . Resident #30 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances, History of Traumatic Brain Injury, Blindness to Left Eye, and Cerebral Vascular Accident. Record review of Resident #30's weight record showed the following recorded weights: - On 9/7/2021 200.5 pounds (lbs.) - On 10/7/2021 194.5 lbs., a 5.5 lb. weight loss or 2.99% weight loss in 30 days - On 11/3/2021 186.5 lbs., a 14 lb. weight loss or 6.98% weight loss in almost 60 days - On 11/29/2021 a re-admission weight to the facility from the hospital was 176.0 lbs., a 24.5 lb. or 12.2% weight loss - On 12/2/2021 177.5 lbs., a 23 lb. weight loss or 11.4% weight loss in almost 90 days - On 1/10/2022 172.5 lbs., a 28 lb. weight loss or 13.9% weight loss in 125 days - On 2/10/2022 159.0 lbs., a 41.3 lb. weight loss or 20.6% weight loss in 156 days - On 2/15/2022 158.0 lbs., a 42.3 lb. weight loss or 21.2% in 161 days Medical record review revealed on 12/9/2021 the physician documented in the progress notes Will direct visualized feeding assistance for Resident #30. Review of a Physician's Order dated 1/9/2022 showed .Feed Resident [Resident #30] . Medical record review revealed there were no other interventions put in place to address Resident #30's weight loss until a high protein nutritional supplement was ordered on 1/27/2022. Review revealed the facility had not identified and intervened to prevent continued weight loss for Resident #30. Review of a letter authored by the Administrator and dated 9/20/2021, showed .Effective September 1, 2021 .RN resigned as our Director of Nurses [DON] .Currently .LPN [Licensed Practical Nurse], our Assistant Director of Nursing [ADON] is serving as our Acting DON . Review of the RN schedules and time punches dated 12/1/2021 - 1/25/2022 showed the following dates without 8 consecutive hours of RN coverage in the facility: On 12/4/2021 and 12/29/2021 there were no recorded hours of RN coverage. On 12/18/2021 there was 2.75 hours of RN coverage (no coverage for 5.25 hours), and on 1/1/2022 there was 6.5 hours of RN Coverage (no coverage for 1.5 hours). During a telephone interview on 1/25/2022 at 3:16 PM, the Registered Dietitian [RD] stated she was at the facility on 12/16/2021 and on 1/7/2022 and was aware of a 6 lb. weight loss (from 9/7/2021 - 12/16/2021). She stated she was not aware of the additional weight loss and had not made any new recommendations to prevent further weight loss for Resident #30. The RD stated .The Director of Nursing [DON] usually gives me a communication form for residents who have had weight loss. The communication form triggers the resident for weight loss program review . The RD could not recall if she had received a notification specifically regarding Resident #30. During an interview on 1/26/2022 at 1:45 PM, the Administrator confirmed the facility had not employed an RN serving as the DON since 9/1/2021. Continued interview confirmed the facility had not provided 8 consecutive hours of RN coverage 7 days per week on 12/4/2021, 12/29/2021, 12/18/2021, and on 1/1/2022. During an interview on 2/15/22 at 9:32 AM, the ADON stated she was not aware of a document entitled weight loss notification form from the facility's 2017 Weight Management policy. The ADON stated she had been on vacation since 1/7/2022 (1/7/2022 - 2/15/2022) and was not aware of Resident #30's severe weight loss. The ADON further stated informal meetings with the Minimum Data Set (MDS) Coordinator were held after the scheduled care plan meetings each week to discuss any identified concerns with residents, and Resident #30 had not been discussed. The ADON confirmed the facility had not been following their Weight Management Policy. The ADON further confirmed she did not know what process the staff had followed regarding weight loss in her absence. During an interview on 2/17/2022 at 1:42 PM, the MDS Coordinator stated there had been a lapse in communication related to weight loss, and weight loss meetings had not been held in the absence of the DON and recent vacation of the ADON from 1/7/2022 - 2/15/2022. Facility Corrective Actions included: 1. A facility RN accepted the position of DON on 2/16/2022 on a part-time basis (16-hours/week). A second RN accepted the position of DON on a part-time basis on 2/16/2022 (24 hours/week). The two RN's will cover the role of DON for a combined total of 40 hours/week. 2. The roles and responsibilities for both DON positions were identified and included in a revised job description. Both the DON's signed the job description documents on 2/16/2022. 3. The roles of each DON were reviewed by the Medical Director, Department Managers, Nursing Staff, and all facility staff to ensure understanding of how the responsibilities are shared on 2/16/2022. A copy of the responsibilities of each DON, as well as assigned workdays, was provided to the facility Medical Director, the Nursing Staff, and the Department Managers on 2/16/2022. 4. The facility had DON coverage at least 40 hours/week effective 2/16/2022. Oversight of the duties of DON #1 and DON #2 will be communicated by a written weekly report of issues addressed when each DON worked, the outcomes, and any follow up needed. The report will be shared with the other DON, the Administrator, and the nursing management team. On 2/18/2022, interviews with DON #1 and DON #2 validated the acceptance of part-time DON positions which combined provided 40 hours per week of RN DON coverage in the facility. The DONs were aware of their individual job responsibilities and roles. Review of the DON Division of Responsibilities validated the individual roles. The surveyors validated the division of DON #1 and DON #2 responsibilities by interview with DON #1, signed acceptance by DON #2, and review of the divided roles. The surveyors verified DON #1 responsibilities included staffing schedule, staffing issues, equipment needs, admissions and discharges, ensure the committees are meeting, in-services are conducted, and quality assurance. The DON #2 responsibilities included review of the doctor notes, psychiatric notes, RD notes, consultant notes, therapy notes, incident reports, weights, wounds, physician order reviews, narcotic reviews, medication administration process, review of pharmacy reports, review of labs, x-rays, and other diagnostic reports, infection prevention, vaccinations, MDS review, and review of care plans. On 2/18/2022, the surveyors reviewed and validated the education and sign in sheets, and the corrective action plans which were provided by the Administrator. The documentation showed all staff working on 2/18/2022 had been provided the education on the new DONs divided responsibilities. The surveyors validated all staff working on 2/18/2022 had been educated and were knowledgeable about the new procedures. On 2/18/2022, the surveyors validated the corrective actions onsite through interviews with the Administrator, ADON, Nurse Educator, MDS Coordinator, 1 RN, 1 Agency RN, 4 Licensed Practical Nurses, 10 Certified Nursing Assistants (CNAs), 2 maintenance men, and 1 housekeeper. The interviews showed the staff were educated on how the DON position had been split between 2 RN's and their responsibilities. The staff verbalized knowledge of the new plans. Noncompliance at F-727 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction. Refer to F-692

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility's Quality Assurance Performance Improvement (QAPI) program failed to identify a quality deficiency by failing to identify and implement interventions to prevent a severe weight loss for Resident #30. Resident #30 experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. The facility's failure placed Resident #30 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) in the Administrator's office on 2/15/2022 at 6:48 PM. The facility was cited Immediate Jeopardy at F-637 (J), F-657 (J), F-692 (J), and F-727 (J). The facility was cited at F-692 (J) at a scope and severity of J level, which is Substandard Quality of Care. The Immediate Jeopardy was effective 12/2/2021 - 2/17/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 2/18/2022. The corrective actions were verified onsite by the surveyors on 2/18/2022. Findings include: Review of the facility program .Quality Assurance Performance Improvement Program .Nursing Home Quality Assurance Performance Improvement Program is demonstrated through a proactive, comprehensive, ongoing approach to improving the quality and safety of the services it delivers. The facility employs a systems approach to evaluating all the systems and processes, identifying problems that have occurred or that potentially might result from the Facility's practices and getting to root causes of problems rather than just superficially addressing one problem at a time. The Facility's QAPI program is a collaborative and interdisciplinary approach. It is through this collaborative approach that the organization can plan, implement, and maintain an effective, ongoing, improvement program. The program demonstrates measured improvements in resident health outcomes and improves resident safety by using quality indicators or performance measures associated with improved health outcomes and by the identification and reduction of medical errors. The program measures, analyzes, and tracks quality indicators, adverse resident events, infection control and other aspects of performance that includes care and services furnished in the Facility . Record review showed Resident #30 was admitted to the facility on [DATE] with diagnosis Dementia with Behavioral Disturbances, History of Traumatic Brain Injury, Blindness to Left Eye, and Cerebral Vascular Accident. The resident's admission weight on 9/7/2021 was 200.5 pounds (lbs.) and on 2/10/2022 the resident's weight was 159 lbs. (a loss of 41.3 lbs. or 20.6% in 5 months). Review of a letter authored by the Administrator and dated 9/20/2021, showed .Effective September 1, 2021 .RN [Registered Nurse] resigned as our Director of Nurses [DON] .Currently .LPN [Licensed Practical Nurse], our Assistant Director of Nursing [ADON] is serving as our Acting DON . During an interview on 1/26/22 at 12:39 PM, the Administrator stated the QAPI Committee team met monthly, and at least quarterly, and consisted of the Administrator, the Medical Director, the Assistant Director of Nursing (ADON), the Housekeeping Director, the Dietary Manager designee, the Maintenance Director, the Activity Director, the Social Services Director, and a secretary. The Administrator stated the previous Director of Nursing (DON #1), the Social Services Director, and the Dietary Manager had not attended the meetings for several months of the last year, and the committee had been reviewing resources needed to improve communications across the departments early last year. The Administrator stated the QAPI Committee, due to in-servicing on emergency transfers and other concerns, had not fully implemented or tracked the effectiveness of the communication improvement process. Continued interview revealed the QAPI committee had not discussed weight loss or nutrition issues and did not know about Resident #30's weight loss. The QAPI committee failed to identify concerns related the weight management process and reporting to the QAPI Committee for review. The Administrator stated he had not been involved in the weight loss meetings and relied on the clinical staff to monitor and report to him if any concerns were identified. The Administrator further confirmed the facility had not employed an RN to serve as the DON since 9/1/2021. During a telephone interview on 1/26/2022 at 1:18 PM, the Minimum Data Set (MDS) Coordinator confirmed she failed to follow the facility's Weight Management Policy to identify a significant change in Resident #30's condition when the resident was identified on the 12/21/2021 quarterly MDS assessment to have experienced a decline in 1 or more ADL care needs and an unplanned weight loss greater than 10%. Further interview revealed the failure to identify these declines and report them per policy to the QAPI Committee to investigate and put new interventions in place caused Resident #30's continued weight loss on 1/26/2022 of 12.5 lbs. (A total of 40.5 lbs., or 20.2% weight loss since admission on [DATE]). During an interview on 2/15/22 at 9:32 AM, the Assistant Director of Nursing (ADON) revealed she was a member of the QAPI Committee and had not attended the January 2022 meeting. The ADON stated she had been on vacation since 1/7/2022 (1/7/2022 - 2/15/2022) and was not aware of Resident #30's severe weight loss. The ADON further stated informal meetings with the MDS Coordinator were held after the scheduled care plan meetings each week to discuss any identified concerns with residents and Resident #30 had not been discussed. The ADON confirmed the facility had not been following their Weight Management Policy and the ADON was not familiar with the specifics of the policy and the processes related to the policy. The ADON further confirmed she did not know what process the staff had followed regarding weight loss in her absence. During an interview on 2/15/2022 at 6:15 PM, the Administrator stated the QAPI committee had not discussed nutrition or weight loss during the last year and had focused on other areas of concern. The Administrator stated nutrition or weight loss issues, including Resident #30's weight loss, had not been brought to his attention and the facility did not follow the facility's Weight Management Policy of reporting weight changes to the QAPI Committee. During an interview on 2/17/2022 at 1:42 PM, the MDS Coordinator stated there had been a lapse in communication related to weight loss and the weight loss meetings had not been held or discussed in QAPI in the absence of the DON and recent vacation of the ADON. Refer to F-637, F-657, F-692, and F-727 Facility Corrective Actions included: 1. The QAPI Committee met on 2/17/2022 to revise the Weight Management Policy to include a new process for weight management that includes an IDT meeting that meets daily Monday - Friday (M-F) to review weight changes and a process for finding weight changes faster and avoiding weight changes. The committee also approved a new tool to audit the Registered Dietitian (RD) assessments to ensure accurate completion and Resident #30's weight loss was reviewed. Other residents with weight change were reviewed as well. The QAPI committee includes the Medical Director, the DON, the Administrator, the Activities Director, the Housekeeping Supervisor, the Dietary Manager Designee, the Maintenance Director, a secretary, and invitees from non-managerial staff. 2. Beginning on 2/1/2022, all residents were weighed by Certified Nursing Assistants (CNA's). Weights were reviewed by the nursing team on 2/10/2022 to identify any weight loss and update the care plans. Residents who had significant weight changes (defined as 5% weight change in one month, 7.5% in three months, or 10% in six months) and are at risk were evaluated by the Physician and RD. 3. On 2/16/2022, DON #1 and the Administrator completed a root cause analysis for weight loss and found that Resident #30 lost significant weight because upon admission he was feeding himself independently, however, he was not feeding himself enough calories. He was falling asleep while eating, losing interest in eating, and combative when attempts were made to encourage him to eat. Interventions included putting Resident #30 on the assisted feeding list and increasing calories in his diet. 4. On 2/16/2022, the DON began weekly Interdisciplinary Team (IDT) Clinical meetings to include DONs, ADON, MDS, RD, Dietary Manager designee, and Activities Director to review falls, incidents, weight changes, pressure wounds, and all at-risk issues that will aid in communicating issues to care plan. On 2/16/2022, an agenda was designated for use in future meetings. Each participant will be assigned a topic to be responsible for reporting at meetings. Care Plans will be updated at each IDT meeting daily. 5. Beginning 2/16/2022, the Administrator began daily (M-F) Stand-up meetings with Department heads to review resident and facility issues. Members of the meeting was established, agenda reviewed, and location of meeting established. 6. The QAPI/QA process, using monthly and weekly weight tools, will ensure that residents with significant weight changes, reported by DON/ADON, are assessed, and addressed by RD and Physician. The DON/ADON will report to QAPI committee weekly until full compliance is met, after compliance is met will report monthly. 7. The QAPI/QA process will ensure that residents with significant weight changes are addressed. The DON or ADON will report all significant weight changes to the QAPI Committee. If concerns are found the Administrator will investigate to ensure that the Weight Management Policy was followed. If failures are discovered, the DON(s) and the Administrator will perform a root cause analysis and suggest solutions. These causes and solutions will be brought back to the QAPI Committee and a Plan of Correction (POC) will be developed for the specific failure. The Administrator or his designee will then provide visual monitoring on a weekly basis for 4 weeks to see that the failure was properly addressed. If the failure is not corrected within that time, further interventions will be considered by the QAPI Committee and repeated monitoring until the process is operating successfully. 8. Beginning 2/16/2022 and ending 2/18/2022, DON #1 and the Administrator conducted multiple mandatory in-services with all employees including agency staff concerning the split roles of the DON position. Education covered Stand-up meetings with Department Heads Monday through Friday, establishment of IDT Clinical meetings directed by DON with Clinical management staff, completing assessments when resident's condition declines, and review of the Weight Management policies. These in-services were either in-person or by telephone. Any staff missing in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressively disciplined as indicated. As of 2/18/2022, all staff were educated. On 2/18/2022, the surveyors reviewed the education and sign in sheets which validated the corrective action plans onsite which was provided by the Administrator. The documentation showed all staff working on 2/18/2022 had been provided the education on nutrition, DON #1 and DON #2 roles and responsibilities, and weight loss policies. The surveyors validated all staff working on 2/18/2022 had been educated and were knowledgeable about the new procedures related to nutrition and weight loss and person-centered care planning. On 2/18/2022, the surveyors validated the corrective actions onsite through interviews with the Administrator, Assistant Director of Nursing, Nurse Educator (DON #1), MDS Coordinator, 1 Registered Nurse (RN), 1 Agency RN, 4 Licensed Practical Nurses (LPNs), 10 Certified Nursing Assistants (CNAs), 2 Maintenance staff, and 1 housekeeper. The interviews showed the staff were educated on how to communicate weights and aid residents with assisted feedings, recording of the amounts of intake of foods, liquids, and snacks, and implementing person centered care plans for each resident that required assisted feeding. Staff verbalized knowledge of the new plan for nutrition and weight loss reporting, and how to assess residents to determine person centered needs/interventions. The surveyors validated by interview with the Dietary Manager Designee on 2/18/2022 the understanding of obtaining food preference upon admission and/or readmission to the facility, bi-annually, and as needed. The Dietary Manager designee was able to state her role and responsibilities regarding weight loss and communication and participation during the IDT meetings. On 2/18/2022, the surveyors validated IDT Meetings occurred 2/16/2022, 2/17/2022, and 2/18/2022 and included chart audits. The surveyors validated by interviews the IDT meeting was held with DON #1, the ADON, and the MDS Coordinator. The findings were communicated to the Administrator. The surveyors validated the nutrition care plans had been revised accordingly. On 2/18/2022, the surveyors validated the Weight Management Policy had been revised on 2/17/2022. Noncompliance at F-867 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.