**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation review, and interview, the facility failed to ensure 1 of 3 (Resident #10) sampled residents reviewed for accident hazards received adequate supervision to prevent elopement (a situation where a resident leaves the premises or safe area without necessary supervision). On 4/27/2024, at approximately 1:00 PM, Resident #10, a vulnerable and cognitively impaired resident with a history of wandering behaviors, eloped from the facility when the receptionist unlocked the main entrance door for a vendor to exit the building. Resident #10 followed the vendor out of the main entrance. A staff member observed the Resident on the sidewalk across a 2-lane street and assisted the Resident inside the facility within 2-3 minutes of his elopement. The facility failed to continue increased supervision after 4/30/2024 at 9:45 AM. On 5/5/2024, at approximately 9:00 PM, staff discovered Resident #10 was not accounted for during a head count, after a staff member heard the main entrance door alarming and determined no one was at the main entrance. Resident #10 eloped from the facility, undetected, through the main entrance. The Resident was found at a convenience store by a staff member, approximately 0.1 miles from the facility. The Resident returned to the facility with the staff member at 9:19 PM. The facility's failure to provide adequate supervision to Resident #10 resulted 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) for Resident #10 and placed 2 other residents identified as having the potential for elopement at risk for Immediate Jeopardy. The Administrator and Regional Director of Clinical Services were notified of the Immediate Jeopardy on 6/4/2025 at 5:35 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ began on 4/27/2024 and continued through 5/8/2024. The facility's corrective actions were completed on 5/8/2024. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for the past noncompliance, was received and validated on-site on 6/4/2025. The IJ was cited as past noncompliance for F-689 and the facility is not required to submit a Plan of Correction. The findings include: 1. Review of the undated facility policy titled, Elopement Risk, revealed .This facility ensures that residents who exhibit unsafe wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to unsafe wandering or elopement risk .Elopement occurs when a resident leaves the premises or a safe area without authorization .supervision .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement .and monitoring for effectiveness and modifying interventions when necessary .Supervision will be provided to help prevent accidents or elopements .The effectiveness of interventions will be evaluated, and changes will be made as needed .Active exit seeking residents will be placed under staff supervision .The patient is always accompanied by the staff member . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Dementia, Alzheimer's Disease, Restlessness, and Agitation. Review of an elopement Risk Assessment for Resident #10 dated 4/16/2024, revealed the Resident was a high risk for elopement. Review of a significant change in status Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had severe cognitive impairment. Wandering behaviors were not identified on the MDS. Review of a nurse's progress note dated 4/27/2024 at 3:57 PM, revealed .At approximately 1pm, [Resident #10] went outside from the front lobby door. Staff immediately went after [Resident #10] and was able to safely escort [Resident #10] back into the building without incident. Vitals WNL [within normal limits]. Full head to toe assessment was done and resident has a small skin tear to lower right forearm. Measures 0.8cm [centimeters] X [by] 0.8cm. Area cleansed with normal saline and covered with a dry dressing. No complaints of pain voiced. Resident on 1:1 [one to one] supervision . Review of a comprehensive care plan for Resident #10 dated 4/27/2024, revealed .Resident is at risk for elopement r/t [related to] history of exit seeking behavior .4/27/24 [2024] Resident elopement from building .1:1 supervision at time of incident [elopement] and then every 15 minute checks . Review of facility documents titled, 15 Minute Increments to Verify Intense Supervision with 1:1 Acuity, for Resident #10 revealed the Resident was on every 15 minute checks from 4/27/2024 at 1:15 PM - 4/30/2024 at 9:45 AM. Review of Certified Nursing Assistant (CNA) R's written witness statement dated 4/27/2024, revealed .I was bringing my dirty dish cart to the dining area and looked out the door and saw [Resident #10] outside across the street .He was walking outside with clothes in hand across the street .Yelled out for others and notified them that [Resident #10] was outside .going after [Resident #10] during this time as well . Review of Housekeeper BB's written witness statement dated 4/27/2024, revealed .I heard [CNA R] call out Code Orange [elopement]. [Resident #10] went out the door. He crossed the road to the other side. Then I went .to grab him . Review of Receptionist S's written witness statement dated 4/27/2024, revealed .I was sitting at the front desk and let the lab tech [technician] out the door. [Resident #10] followed behind her with clothes in his hand as if he was a visitor. [Resident #10] was able to make it across the street unharmed. A nursing aid [CNA R] recognized him and went into action and secured him safely and walked him back into the building. The entire incident only lasted about 3 minutes . Review of a nurse's progress note for Resident #10 dated 5/6/2024 at 5:39 AM, revealed .[On 5/5/2025 at approximately 9:00 PM] Nurse responded to door alarm panel at the nurses [nurses ' ] station alerting the front door. Nurse did not see anyone at the door or outside the door. Nurse alerted all staff to do a head count of residents. Staff unable to locate [Resident #10] inside building or outside. [Licensed Practical Nurse-LPN T] got in vehicle and observed [Resident #10] ambulating at a fast pace down the street toward the convenience store. [Resident #10] Said 'hey how did you know I was here?' when [LPN T] called his name. [Resident #10] Stated he was headed to his apartment .Assisted into vehicle and back to the facility. No injuries noted. Mood pleasant. 1 on 1 care provided. Administrator, DON [Director of Nursing] MD [Medical Doctor], and wife notified . Review of a comprehensive care plan for Resident #10, revised 5/5/2024, revealed .5/5/24 Resident elopement from building .1:1's until discharge to another community .Door alarm company to come out and check all doors . Review of Licensed Practical Nurse (LPN) T's written witness statement dated 5/5/2024, revealed .At approximately 9 pm [9:00 PM] I heard the front door alarm sound on the panel at the nurses station. I immediately went to the front door. I did not see anyone in the front lobby or outside the front door or parking lot/road. I then went back to the floor to alert staff and do a head count. We were unable to locate [Resident #10]. While searching the building inside and outside the supervisor received a call that [Resident #10] was walking down the road. I got in my personal vehicle and drove towards [named boulevard]. I observed [Resident #10] walking at a fast pace on the side of the road towards the convenience store. I pulled over and called his name. [Resident #10] said 'hey! How did you know I was here?' I assisted [Resident #10] into my vehicle. Was in a pleasant mood without any distress noted. Said 'I was headed home to my apartment' .Reoriented to his home at [named facility] and taken to his room. 1 on 1 care provided for the remainder of the shift. [Resident #10] was assisted into my vehicle at 9:18 PM. The administrator, DON [Director of Nursing], MD [Medical Doctor], and his POA [Power of Attorney] was notified per supervisor . Review of Registered Nurse (RN) A's written witness statement dated 5/5/2024, revealed .At around [9:05 PM], I heard the door alarm sound. [Named LPN T] went to the front [and] found the door locked with no one outside or in the lobby. I and the other staff started a search .A search did not find [Resident #10] in the building. At this point I received a phone call informing me that he had been spotted outside. I went out to search for along with [Named LPN T].I continued to search for him until I received news from [Named LPN T] that she had [Resident #10] and was returning to the facility . Review of CNA Z's written witness statement dated 5/5/2024, revealed .[Resident #10] was hanging out in the front prior to eloping. In which I made him come to his room around [8:45 PM] so we could see him. [Resident #10] let us know that he opened the door by pushing it open. And was placed on 1:1 supervision for the rest of the night . Review of the medical record for Resident #10 revealed the resident remained on 1:1 supervision from the time he returned to the facility on 5/5/2025 at approximately 9:20 PM, until he was transferred to a different facility on 5/8/2024 at 12:00 PM. During an interview on 6/2/2025 at 2:00 PM, the Administrator confirmed Resident #10 had eloped on 4/27/2024 when the receptionist opened the door for a lab technician to exit the main entrance. The resident walked out of the facility behind the lab technician. The Administrator stated a staff member saw Resident #10 outside of the facility, immediately went to the resident, and brought him safely back into the facility. Resident #10 was taken to the nurse's station, where he could be monitored more closely, and was placed on every 15 minute checks. Following the incident, risk assessments were performed for every resident and the Administrator ensured warning postings were visible regarding not allowing anyone to follow visitors/vendors out of door as they leave. Resident photos in the elopement book at the receptionist desk were updated. All staff received education on the elopement policy. The Administrator stated the facility was in the process of finding placement for Resident #10 at a facility with a secure unit when the resident eloped again on 5/5/2024. The Administrator stated the Resident had been observed in the lobby at 8:45 PM and had been redirected and assisted back to his room. The Administrator stated, on 5/5/2024 at approximately 9:00 PM, a staff member heard the main entrance door alarm. A nurse (LPN T) went to the entrance, looked outside, checked the dining room and restroom, and saw no one. Other staff on duty did a head count and discovered Resident #10 was not accounted for. The Administrator stated an off-duty employee saw Resident #10 at a store .down the road . and notified the facility. LPN T drove to the store, picked up the resident, and returned the resident to the facility at 9:19 PM. Resident #10 was immediately placed on 1:1 supervision until he was discharged to a facility with a secure unit on 5/8/2024. On 5/6/2024, a contracted electric service verified the door's locking mechanism was receiving electricity and was working properly. On 5/7/2024, the facility's Regional Life Safety/Maintenance Director determined the door would close but bounced away from the doorframe not allowing the door's magnetic lock assembly to energize correctly and secure the door in the locked position. Adjustments were made to the door's self-closing device to prevent the door from bouncing away from the doorframe. Verification the locking mechanism was working correctly occurred on 5/8/2024. The facility ordered a system with wearable devices (bracelets) which tracked a resident's location and triggered alerts when they approached restricted areas or exit points on 5/8/2024. The Administrator confirmed Resident #10 eloped from the facility on 4/27/2024 and 5/5/2024. During a telephone interview on 6/2/2025 at 7:13 PM, CNA R stated Resident #10 eloped from the facility on 4/27/2024. CNA R stated .I know I recognized him [Resident #10], and it was my duty to get him back inside and keep him safe .I called a code [elopement code] and got some backup . CNA R stated [Housekeeper BB] went to Resident #10 and brought him back inside the facility. When asked if Resident #10 crossed the street, CNA R asked .what did my statement say . CNA R's statement was read verbatim .I was bringing my dirty dish cart to the dining area and looked out the door and saw the resident outside across the street . CNA R stated, .I gotta [got to] stick with whatever my statement said, cause my memory is not that vivid . During a telephone interview on 6/3/2025 at 3:45 PM, Receptionist S stated she had looked at the elopement book when her shift started [4/27/2024] to see if anyone new had been added to the book. Receptionist S stated .I had never met or seen [Resident #10] before .only saw him in the book .On this particular day, someone came in to draw blood .Had families coming in and out .It's common for families to pick up laundry on the weekend .The picture [of Resident #10] in the book didn't look like him .When I was letting out the phlebotomist [lab technician], there was a man behind her with a bag and clothes over his arm . Receptionist S stated when she opened the door for the lab technician, Resident #10 went out behind her. One of the techs (CNA R) happened to walk by and recognized the resident who had walked across the street. Receptionist S stated Resident #10 was out of the facility for 2-3 minutes. Observation of the reception desk on 6/3/2025 at 4:00 PM, revealed an elopement book was located at the desk. Resident photos who were high risk for elopement were in the notebook. During a telephone interview on 6/3/2025 at 4:10 PM, LPN T stated .I heard the alarm [front door] go off [on 5/5/2024 at approximately 9:00 PM], so I went to the front door .didn't see anybody around it or outside .had everyone do a head count .discovered [Resident #10] wasn't in there .went down the road and found [Resident #10] .he was going toward the store .he was almost there [store] .got him back in the building .We did 1:1 .had a nurse sit with him all night . LPN T stated Resident #10 was discharged to a facility with a secure unit. During an observation and interview on 6/4/2025 at 10:00 AM, with the Maintenance Director, all doors were verified as in good working condition and locking mechanisms were working appropriately. The Maintenance Director stated the doors were checked monthly to ensure the locking mechanisms were working properly. During a telephone interview on 6/4/2025 at 4:41 PM, the Medical Director stated she was aware of Resident #10 eloping from the facility on 4/27/2024 and 5/5/2024. The Medical Director stated she participated in AdHoc (urgent meetings to address specific issues which require immediate attention) Quality Assurance and Performance Improvement (QAPI) Meetings after both of Resident #10's elopements and was involved in determining next steps to prevent further resident elopements. Observations by the survey team from 6/2/2025-6/4/2025 revealed residents who were high risk for elopement were wearing bracelets which alerted staff when a resident approached an exit point. The facility's corrective actions for the removal plan were issued to the state surveyors on 6/4/2025. The corrective action plan included the following: /5/2024 - Resident #10 returned to the facility with LPN T at 9:19 PM. A complete assessment was performed for Resident #10 upon return to the facility with no injuries or change in condition noted. Resident #10 was placed on 1:1 observation. Resident #10's spouse and physician were notified. Staff ensured all facility exits were locked properly. Ad-Hoc QAPI call with leadership and Governing Board to discuss Resident #10's elopement. 100% staff educated on facility's Elopement Policy with Post-Test and was ongoing. Elopement drills were conducted on day and night shifts for both rotations on 5/6/2024, 5/8/2024, 5/20/2024, and 6/4/2024 to ensure knowledge and compliance. Resident #10's care plan was updated by MDS to include 1:1 supervision until discharge. Resident #10 was evaluated by psychiatric services on 5/6/2024. Resident #10 was seen by physician on 5/7/2024. Ad-Hoc QAPI meeting was held on 5/6/2024 with QAPI Committee and leadership team in attendance. 5/7/2024 - Verification electricity to the door locking mechanism was working properly and incident did not occur due to an electrical failure Ad-Hoc QAPI meeting was held on 5/7/2024 with Medical Director. Regional Life Safety/Maintenance Director determined the main entrance door would close, but bounced away from the doorframe, not allowing the door's magnetic lock assembly to secure the door in the locked position. Adjustments were made to the door's self-closing device. The door was tested numerous times, and the magnetic lock secured the door each time to lock securely. 5/8/2024 - Contracted company verified the locking mechanism on the main entrance door was working correctly. 5/8/2024 - Resident #10 remained on 1:1 supervision until he was discharged on 5/8/2024. Resident #10 was admitted to a facility with a secure unit as planned prior to the elopement on 5/5/2024. 5/9/2024 - Follow-up with Governing Board was held. Maintenance department conducted random door audits to ensure the doors were locking properly with no concerns noted. Monthly audits were ongoing. Results of the random door audits were reported to the QAPI committee monthly for 3 months to ensure continued working compliance of door. The Removal Plan was validated onsite by the surveyors on 6/4/2025 which included review of the facility documentation to show each step was completed and staff interviews to confirm completed and ongoing actions, elopement education, and participation in elopement drills.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status, obtain admission weights, monitor weights, accurately assess residents for weight loss, and implement and monitor nutritional interventions for 7 of 11 (Resident #2, #15, #17, #32, #51, #52, and #158) sampled residents reviewed for nutritional status. The facility failed to accurately assess for weight loss and implement and monitor interventions to prevent severe weight loss for Resident #17, #32, and #52. The facility's failure to identify and address severe weight loss resulted in Immediate Jeopardy for Resident #17, #32, and #52. Resident #17 experienced severe weight loss of 25.9 percent (%) in 3 months, Resident #32 experienced severe weight loss of 27.2% in 3 months, and Resident #52 experienced severe weight loss of 9.41% in one month. Immediate Jeopardy (IJ) is 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, Director of Nursing (DON), Regional Director of Clinical Services, Wound Care Nurse, and [NAME] President (VP) of Reimbursement were informed of the Immediate Jeopardy on 6/4/2025 at 7:49 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-692. The facility was cited at F-692 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy for F-692 began on 2/11/2025 and continued through 6/6/2025. The Immediate Jeopardy was removed on 6/7/2025. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/6/2025 at 2:50 PM, and was validated onsite by the surveyors on 6/9/2025, through review of in-services, audits, and staff interviews conducted on all shifts. The facility's noncompliance at F-692 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. The findings include: 1. Review of the facility's undated policy titled, Weight System, revealed Residents are weighed at admission, readmission .Weekly weights are completed for an additional 3 weeks (or longer if not stable) on the following .Admit .Readmit .Significant weight change of 5% [percent] or more in 1 month or less, 7.5% in 3 month or 10% in 6 months .Physician's orders .Residents are to be weighed on admission and re-admission. These weights are to be completed within 24 hours of admission/readmission. Weight (how obtained standing, lift or wheelchair) is to be recorded on the EMR [Electronic Medical Record] clinical record .Monthly weights .on all residents (including re-weighs) must be completed, and entered in the EMR, by the 10th of each month .Residents with a significant weight loss or gain (5%, 7.5% or 10% or more) will be placed on weekly weights x [times] 4 weeks or until weight is stable and no weight concerns are noted .If weight concerns .notify the RD [Registered Dietician] and continue the weekly weights until stable .All weight changes are considered unplanned unless the MD [Medical Doctor] has documented a plan for desired weight change and the facility has care planned PRIOR to the weight change occurring .A designated person(s) will be assigned to obtain weights for accuracy and consistency .DON .will review monthly and weekly weights prior to Weekly At-Risk Meeting .Request reweights on a resident's weekly weight if a change greater than 2% change and a residents monthly weight if greater than a 5%, 7.5% or 10% change is noted. DON .will .validate that monthly and weekly weights are recorded on the .medical record .monthly At-Risk Meeting should take place no later than the 15th of the month .Residents with significant weight loss .of 5% x 1 month will be weighed every week for four weeks .Significant weight changes .should be referred to the RD .or restorative as necessary to resolve weight concerns .Implement or request interventions as needed for residents with significant weight change at the weekly At-Risk Meeting .Care plan weight change and interventions .Review dietary intake of residents with significant weight change .Notify direct care staff of residents .DON or designee to notify the MD and resident representative of significant weight change and/or intervention in the EMR[electronic medical record .] 2. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Depression, Anxiety, Dysphagia, Lymphedema, Peripheral Vascular Disease, and Neuropathy. Review of Resident #17's admission weight dated 8/18/2023, revealed the resident weighed 239 pounds (Lbs) using a mechanical lift. The facility failed to weigh Resident #17 on admission. Review of the Care Plan dated 7/29/2024, revealed .NAS [no added salt] diet regular texture, thin liquids .Actual Weight Loss: Related to decreased caloric intake, increased metabolic needs, or lack of appetite .Resident will have no significant weight gain or significant weight loss through next review .encourage resident to consume meals/[and]fluids .RD to eval [evaluate] with recommendations .weigh per facility protocol .6/1/2025 .at nutritional risk r/t [related to] hx [history] of dysphagia [difficulty swallowing foods or liquids], morbid obesity, therapeutic diet, Hep [Hepatitis] C [Chronic Viral Infection of Liver], liver cirrhosis [liver damage] . The care plan was not revised until 6/1/2025, and did not include interventions for weight loss. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the Brief Interview for Mental Status (BIMS) score was 14, indicating Resident #17 was cognitively intact. Additional information revealed Resident #17 weighed 245 pounds. Review of the .Weights and Vitals Summary, revealed the following: a. 1/19/2025 285.5 Lbs (Wheelchair) b. 2/14/2025 283.0 Lbs (Mechanical lift) c. 3/4/2025 264.5 Lbs (Mechanical lift) d. 4/25/2025 211.5 Lbs (Wheelchair) e. 6/2/2025 212 Lbs (Wheelchair) Review of Resident #17's meal percentages revealed 7 instances of consumed 50% or less of meals. a. 3/10/2025 breakfast 0%-25% of meal eaten b. 3/29/2025 breakfast 26%-50% of meal eaten c. 4/26/2025 breakfast 26%- 50% of meal eaten d. 5/4/2025 breakfast 26%-50% of meal eaten e. 5/4/2025 lunch 26%-50% of meal eaten f. 5/4/2025 supper 26%-50% of meal eaten g. 5/18/2025 supper 26%-50% of meal eaten Review of the progress notes for Resident #17 revealed no documentation related to the meal percentage consumption. Review of the Nutrition assessment dated [DATE], revealed .weight 283 lbs .Significant wt [weight] gain .Some wt fluctuations .Rec'd [recommend] reweigh Review of the medical record revealed no documentation the facility implemented the RD's recommendation of a re-weight for Resident #17. Review of the Nutrition/Dietary Note dated 3/25/2025, revealed Resident #17's .Weight Note .Significant wt loss 18.5# [pounds] x 18 days . Wounds non - PI [non pressure injury] RT [right] lower shin, Venous RT distal, Medial, Calf, Mid leg, DTI [deep tissue injury] to RT 1st toe and left 1st toe per [Named Wound] notes. Recommend: 1. Weekly weights x [for] 4 [weeks] r/t significant wt fluctuations 2. Liquid protein 30 ml [milliliter] BID [twice a day] x 14 days for wounds . Review of the medical record revealed no documentation the facility implemented the RD's recommendation of weekly weights x 4 weeks or Liquid Protein 30 ml BID. Review of the medical record revealed Resident #17 lost a total of 74 Lbs from 1/19/2025 to 4/25/2025, which was a severe weight loss of 25.9% in 3 months. Review of medical record revealed no nutrition or weight loss documentation for April 2025 or May 2025. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating Resident #17 was cognitively intact. Additional information included Resident #17's weight was 212 pounds. No weight loss or gain was identified on the MDS. During an interview on 6/4/2025 at 2:23 PM, the Director of Nursing (DON) confirmed meal percentages less than 50% should be addressed in the resident's progress notes. The DON was asked if the Resident (#17) was offered alternatives and was Resident (#17) experiencing weight loss. The DON stated, .I have no idea . During an interview on 6/4/2025 at 3:55 PM, the DON was asked how often weights are obtained, who makes the weight list, and how they communicated the weight loss. The DON stated .there are monthly weights, admission weights and weekly .The RD gives us a list .I don't know who the significant weights are .I don't know how she calculates that list .she emails me a list of weights and recommendations maybe monthly, then I pass it on to the Medical Director . The DON was asked what she considers weight loss. The DON stated, I cannot answer that . The DON was asked when the weight meetings were held. The DON stated, We started the weight meetings 2 weeks ago .prior to that we did not have weight meetings . The DON was asked should hospital weights be documented as admission weights. The DON stated, .No, the hospital weight is not what we are supposed to use. The DON was asked what do you consider significant weight loss. The DON stated, I cannot answer .the RD kept up with that . The DON was asked if a physician order was required for weekly weights. The DON stated Yes. The DON was asked why Resident #17 was not assessed for excessive weight loss and have documentation (of the assessment) for the weight loss. The DON stated, I do not know but she should have been assessed for weight loss and the MD [Medical Director] should have been made aware . The DON was asked why the RD's recommendations from 3/25/2025 were not documented or initiated. The DON stated, .I wasn't aware of the RD recommendations for 3/25/2025 for weekly weights for 4 weeks or the supplement .I would have notified [Named Physician] .we should have put something into place .like I said we have only had weight meetings for the past 2 weeks . The DON was asked does the facility have an efficient weight loss system in place. The DON stated No. The DON was asked who is responsible for the weight loss in the facility. The DON stated, The DON. During an interview on 6/4/2025 at 6:10 PM, the RD was asked if Resident #17 had documentation for her excessive weight loss with interventions put into place for her significant weight loss. The RD stated, I do not know, but we should have documented [the weight loss] and put something into place and the MD should have been made aware . The RD was asked what her expectations were for her weight loss recommendations, and how often does she review the weights. The RD stated, .I send an email to the DON .I would expect the DON to inform the MD and to put my recommendation in immediately and if they don't agree with the recommendation, they could just talk to me .I look at the weights weekly in [Named EMR] . The RD was asked how she follows up on her recommendations. The RD stated, I try to follow up weekly, but we only started weight meetings 2 weeks ago . The RD was asked if she documented Resident #17's significant weight loss for April or May 2025. The RD stated, No. The RD was asked if the facility weight loss program was working. The RD stated, No, it isn't . During an interview on 6/5/2025 at 9:30 AM, the MD was asked if she was notified of Resident #17's significant weight loss. The MD stated, No, I wasn't aware. The MD was asked what's your expectation of the facility with weights and nutrition monitoring. The MD stated, .to follow their policy and identify the weight loss, notify me of significant weight loss, and document the patient's medical condition in the electronic medical records .their progress notes are very limited, if you do it, document it . I'm not notified of a lot of different things . 3. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, Anxiety and Dysphasia. Review of the Care plan dated 2/10/2025, revealed .Actual Weight Loss: Related to decreased caloric intake, increased metabolic needs, or lack of appetite .Date Initiated .2/21/2025 .Interventions .Diet per md order .medication per md order .RD to eval [evaluate] with recommendations . Review of the .Nutritional Assessment, dated 2/11/2025, revealed .Weight: 141.5 .Recommend [named nutritional supplement] 90 ml TID [three times a day] . Review of the signed Order Review History Report, revealed . [named nutritional supplement] three times a day .Order Date 02/21/2025 . The order was not written for the nutritional supplement until 10 days after the RD recommendation. Review of the Nutrition/Dietary Note, dated 4/7/2025, revealed . Significant wt loss -25# (-17.7%) x 21 days .Recommend new weight to verify . Review of the medical record revealed no weights were documented for April 2025. Review of the .Nutritional Assessment, dated 5/16/2025, revealed .Weight: 102.5 . Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6 which indicated Resident #32 was severely cognitively impaired. Additional information included Resident #32's weight was103 pounds, with a weight loss of 5% or more in the last month or 10% or more in 6 months, and Resident #32 was not on a physician-prescribed weight loss regimen. Review of the .Weights and Vitals Summary, dated June 3, 2025, revealed: a. 2/11/2025 141.5 pounds (Lbs) (Hospital weight) b. 3/4/2025 116.5 Lbs (Standing) c. 5/1/2025 102.5 Lbs (Wheelchair) d. 5/12/2025 102.5 Lbs (Wheelchair) e. 5/21/2025 102.9 Lbs (Wheelchair) Weekly weights were not documented for the week of 2/17/2025, 2/24/2025 and 3/10/2025. Review of the medical record revealed Resident #32 lost a total of 25 Lbs from 2/11/2025 to 3/4/2025, which was a severe weight loss of 17.6% in less than 1 month. Review of the medical record revealed Resident #32 lost a total of 14 Lbs from 3/4/2025 to 5/1/2025, which was a severe weight loss of 12% in less than 2 months. Review of the medical record revealed Resident #32 lost a total of 38.6 Lbs in 3 months, which was a severe weight loss of 27.2% and no additional weight loss interventions were implemented after the nutritional supplement was begun on 2/21/2025. The facility failed to obtain an admission weight, weekly weights, and monthly weights, failed to reweigh Resident #32 per the RD recommendation, failed to administer Med Pass until 10 days after the RD recommendation, and failed to implement nutritional interventions in March for the significant weight loss. During an interview on 6/4/2025 at 5:12 PM, the DON was asked if staff should use a hospital weight on admission. The DON stated, No. The DON was asked if there was a weight for Resident #32 for April 2025. The DON stated, No. The DON was asked if they would have noted the weight loss sooner if there would have been an April Weight. The DON stated, Yes. During an interview on 6/4/2025 at 6:59 PM, the RD stated, I put her [Resident #32] on weekly weights on 5/12/2025, assistance with meals, and [named nutritional supplement] with meals .the MD and staff are not really looking at recommendations .they should not use the hospital weight . During an interview on 6/9/2025 at 10:59 AM, the Administrator was asked if she was aware of the significant weight loss (Resident #32) at the facility. She stated, I didn't know it was significant . I didn't identify the weight loss as an issue. I was listening to the DON . 4. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, and Respiratory Failure with Hypoxia. Review of the care plan dated 4/13/2025, revealed .Resident at nutrition risk .Date Initiated 4/14/2025 .Diet per md order Date Initialed 5/2/2025 . Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated Resident #52 was moderately cognitively impaired. Resident #52 required partial to moderate assistance with meals and weighed 152 pounds. Review of the .Weights and Vitals Summary, revealed: a. 4/14/2025 152.9 Lbs (Hospital weight) b. 5/1/2025 138 Lbs (Wheelchair) c. 5/14/2025 138.5 Lbs (Wheelchair) d. 5/21/2025 138.9 Lbs (Wheelchair) Weekly weights were not documented for the week of 4/21/2025 and the week of 5/5/2025. Review of the medical record revealed Resident #52 lost a total of 14.4 Lbs from 4/14/2025 to 5/14/2025, which was a severe weight loss of 9.41% in one month. The facility failed to implement nutritional interventions after Resident #52 experienced severe weight loss one month after admission to the facility. Observation in the Resident's room on 6/3/2025 at 7:52 AM, revealed Resident #52's breakfast on the over bed table next to the bed, the meal was not touched, and there was no one to assist the Resident with the meal. During an interview on 6/4/2025 at 5:12 PM, the DON was asked should a hospital weight be used as an admission weight. The DON stated, .they [facility staff] should not use a hospital weight and should be weighed on admission at the facility . The DON was asked, .Should Resident #52 have been weighed in April. The DON stated, Yes The DON stated that monthly weights are done the first week of the month and if a resident has weight loss it is done weekly. The DON was asked if she was aware Resident #52 was a significant weight loss. She stated, .152.9 [Lbs] on admit and 138 pounds . During an interview on 6/4/2025 at 6:10 PM, the RD stated that she put Resident #32 on weekly weights on 5/12/2025. During an interview on 6/4/2025 at 6:52 PM, the RD stated she recommended fortified foods for weight loss on 5/19/2025. The RD confirmed that her recommendation from 5/19/2025 had not been implemented. Review of the medical record revealed the RD's recommendation for fortified foods was not documented in the medical record and was not implemented according to the RD's recommendation. During an interview in the conference room on 6/5/2025, the MD confirmed that a hospital weight was not an accurate weight to use for an admission weight, she was not notified of the Resident's (#52) weight loss, there should have been a note or new orders for weight loss, and (Resident #52) should have weekly weights. The MD was asked what her expectations on weights were and how should staff follow up with weights. The MD stated .Follow the policy and notify me and if they see significant change either loss or gain, tell me what the plan is . 5. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Quadriplegia, Injury Cervical Spinal Cord, Anxiety, and Depression. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #2 was cognitively intact, and weighed 204 pounds. Review of the .Weights and Vitals Summary, dated 9/2/2024, revealed Resident #2's documented weight on 9/2/2024 was 204 Lbs (Hospital weight). On 9/12/2024 Resident #2 weighed 203.7 Lbs (Mechanical Lift). Review of the Nutrition assessment dated [DATE], revealed .Most Recent Weight .204.0 [Lbs] .Date 9/2/2024 .Diet Type .Regular .based on hospital record 204# [pounds] .Obtain new wt [weight] measure . The facility failed to obtain an admission weight until 9/12/2024, 14 days after admission on [DATE]. 6. Review of the medical records revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Chronic Obstructive Pulmonary Disease, and Dysphagia. Review of Resident #15's admissions and .Weights and Vitals Summary, included the following: a. 8/20/2024 159 Lbs. Resident #15 was readmitted following a hospitalization on 8/16/2024 and weight was not obtained until 8/20/2024. b. 10/11/2024 114.4 Lbs. Resident #15 was readmitted following a hospitalization on 9/28/2024 and weight was not obtained until 10/11/2024. c. 3/6/2025 114.4 Lbs. Resident #15 was readmitted following a hospitalization on 3/2/2025 and weight was not obtained until 3/6/2025. d. readmission following hospitalization on 3/13/2025 and no weight was obtained. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #15 was cognitively intact. Additional information included Resident #15 had a feeding tube, and total calories received through parenteral, or tube feeding, was 51% or more. 7. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Fracture of the Left Femur, Neurologic Neglect Syndrome, and Dysphagia. Review of the .Weights and Vitals Summary, for Resident #51, revealed the following: a. admission date was 3/27/2025 and no weight was obtained b. 4/21/2025 161.7 Lbs (Hospital weight) c. 5/1/2025 1st weight obtained while in the facility was 143.8 Lbs (mechanical lift) d. 5/20/2025 132.8 Lbs (mechanical lift) Review of the Nutritional Assessment for Resident #51 dated 4/21/2025, revealed .Weight 161.7 .Hospital weight . Review of the RD Progress Note for Resident #51 dated 4/21/2025, revealed .Hospital weight 161.7 .new weight needed . Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #51 was severely cognitively impaired. Resident #51 needed partial to moderate assistance with meals. Resident #51's weight on the admission assessment was 143 pounds. Review of the medical record revealed Resident #51 was not weighed on admission to the facility. Resident #51 went out to the hospital on 4/3/2025 and was not weighed on readmission to the facility on 4/18/2025. Resident #51's first weight in the facility was 5/21/2025. During an interview on 6/4/2025 at 3:53 PM, the DON confirmed Resident #51 should have been weighed on admission and readmission from the hospital. 8. Review of the medical record revealed Resident #158 was admitted to the facility on [DATE], with diagnoses including Stage 2 Sacrum Pressure Ulcer, Metabolic Encephalopathy, and Urinary Tract Infection. Review of the .Weights and Vital Summary, dated 5/27/2025, revealed Resident #158 weighed 112.4 Lbs and the weight was obtained in a wheelchair. The facility failed to obtain an admission weight on Resident #158 until 5/27/2025, 3 days after admission on [DATE]. Review of the Nutrition assessment dated [DATE], revealed .Most Recent Weight .112.4 .Date 5/27/2025 .Will monitor nutrition parameters and f/u [follow up] as indicated . An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/6/2025 at 2:50 PM, and was validated onsite by the surveyors on 6/9/2025, through review of in-services, audits, and staff interviews conducted on all shifts. 1. A comprehensive facility-wide audit of all residents was conducted on 6/5/2025 with the Interdisciplinary (IDT) At Risk Team. All residents with greater than (>) 5% weight loss in 30 days, 7.5% weight loss in 90 days, or >10% weight loss in 180 days were flagged. Eleven residents triggered for significant weight loss. Of those 11 residents, 7 residents had previously been identified and had interventions implemented. One resident had a desired weight loss (as documented by RD). Three new weight losses were identified. All three are expected weight losses. One resident lost due to improvement of significant edema and diuretic orders. The other two residents are currently receiving end of life services including hospice services. Identified residents were reviewed by the IDT team. Appropriate interventions were initiated for each identified at-risk resident, including weekly weights, labs, supplements, medication changes, physician notifications and RP notification as indicated. The surveyors confirmed this by record review and interview. 2. On 5/5/2025, the IDT Team identified that the weight scale was not weighing accurately. A PIP (Performance Improvement Plan) was put in place and the scale was recalibrated. On 5/22/2025 the IDT team determined the weights were still inaccurate. The IDT Team ordered a new weight scale on 5/22/2025. The new scale was delivered to the facility on 6/2/2025. Between 6/2/2025 and 6/5/2025 all residents were re-weighed for accurate weights. Accurate weights were reviewed by the IDT At Risk Team on 6/4/2025 and 6/5/2025. Policy Revision: Facility's weight monitoring and nutrition policy were reviewed with no changes made. The processes were reviewed, and the following changes were made: Two CNAs (Certified Nursing Assistants) were identified to obtain all weekly and monthly weights on Mondays and Tuesdays. Weights will be completed on new admissions upon admission and readmissions. Hospital weights will not be utilized. i. DON and RD will review the monthly and weekly weights prior to the weekly weight meeting on Wednesdays. ii. IDT At Risk Meeting will be conducted every Wednesday Staff Education: iii. On 6/4/2025 the Regional Director of Clinical Services conducted an inservice with the IDT Team to educate them on weight loss policy/processes to include admission/readmission weight process, assessing nutritional status and implementing pertinent nutritional interventions. The surveyors confirmed this by record review and interview. On 6/4/2025 all On Duty Licensed Nurses were educated by the Interim Assistant Director of Nursing regarding admission and readmission weight process. All off duty, to include PRN (as needed) or Agency, Licensed Nurses will receive this education prior to beginning their next shift. Newly hired Licensed Nurses will receive this education prior to working a shift. On 6/4/2025 at 9:30 PM, the Ad hoc (for a particular purpose) QAPI (Quality Assurance and Performance Improvement) Committee along with the Governing body held a meeting to include the Administrator, Director of Nursing, Medical Director (via Telephone), Interim Assistant Director of Nursing, RD, Regional Director of Clinical Services, VP (Vice-President) of Reimbursement (MDS), and Chief Operating Officer (COO) (Governing Body) to discuss the notification of the Immediate Jeopardy, review all findings, develop an action plan and monitoring. All were in agreement with the Plan of Correction. The Surveyors confirmed this by record review and interview. QA Audits: DON or Interim ADON will review all new admission/readmissions weight records 3 times weekly x 3 weeks, then weekly for 4 weeks, then monthly for 3 months. Started 6/9/2025. Surveyors confirmed this by interview. The IDT will meet weekly on Wednesdays for review of admission/readmission weight process, assessing nutritional status and implementing pertinent nutritional interventions for identified residents. The Regional Director of Clinical Services and/or VP of Nutritional Services will be in attendance of IDT meetings weekly x 2, then monthly x 3 to ensure compliance. Meeting set for 6/11/2025. Surveyors confirmed this by interview The Maintenance Supervisor will ensure the scales are calibrated quarterly or more often if the IDT Team identifies possible inconsistencies. Reports will be submitted to the QAPI Committee quarterly for review. New scale will begin when due. Surveyors confirmed this by interview