**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to maintain acceptable parameters of nutritional status in such as usual body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicate otherwise for 1 of 8 (Resident #67) residents reviewed for weight loss. -The facility failed to ensure Resident #67 was monitored for weight loss resulting in a 14.5% or 24.8 pounds in a 3-month period. An Immediate Jeopardy (IJ) was identified on 6/6/25. The IJ template was provided to the facility on 6/6/25 at 3:16pm, While the IJ was removed on 6/8/25, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm the facility continued to monitor the implementation and effectiveness of their corrective systems. This failure could place residents at risk of malnutrition and medical complications due to severe weight loss. Finding included:Record review of Resident #67's admission Record generated on 6/8/25 revealed she was admitted to the facility on [DATE] with diagnoses of chronic venous hypertension (improper functioning of the vein valves in the leg, causing swelling and skin changes) with ulcer of bilateral lower extremity (refers to the lower legs and feet), schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly and may result in a mix of hallucinations, delusions disorganized thinking and behavior) and malignant neoplasm of breast (breast cancer). She was [AGE] years of age. Record review of Resident #67's care plan (undated) revealed the following focuses, goals and interventions: - Focus: Resident #67 would participate in liberalized dining. Resident received a regular diet, regular texture and thin consistency liquids. Goal: Resident #67 would make acceptable food choices based on diseases and diagnoses. Target date: 7/21/25. Interventions: Resident #67 would be educated on nutrition as it related to her diagnosis and serve diet as ordered. - Focus: Resident #67 has behavior of resisting activities of daily living related to a diagnosis of schizophrenia. Goal: Efforts would be made to lessen episodes of behaviors with use of medication and redirection. Target date: 7/21/25. Interventions: Be firm, not forceful, encourage compliance with care, and monitor and document behaviors. - Focus: Resident #67 had a nutritional problem or potential nutritional problem. Goal: Resident #67 would comply with recommended diet for weight reduction daily through review date. Target date: 7/21/25. Interventions: Administer medications as ordered, monitor/document/report to physician as needed for signs and symptoms of dysphagia (difficulty swallowing foods or liquids), including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals.- Focus: Resident #67 is at risk for weight loss related to 'weight loss abnormal.' Goal: Efforts would be made to prevent significant changes in weight and provide adequate nutrition. Target date: 7/21/25. Interventions: Assist Resident #67 with meals, verbally and physically as needed. Feed Resident #67 if needed, and dietary consult as needed. Record review of Resident #67's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 10, indicating moderate cognitive impairment. She had behaviors of inattention and disorganized thinking. She rejected care 1-3 days of 7 days. She required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for eating. She had no weight loss and was no on a therapeutic or mechanically altered diet. Record review of Resident #67's Weight Summary (undated) revealed she weighed 171 pounds on 3/5/25 when measured using a mechanical lift. Record review of Resident #67's POC Legend Report generated on 6/6/25 revealed the following: - It was documented that the resident ate less than 25% of her meal on 4 occasions between 3/1/25 and 4/30/25. - It was documented that the resident ate between 26% and 50% of her meal on 25 occasions between 3/1/25 and 4/30/25. - There was no record of percentage of meal eaten (missed documentation) for 3 morning meals, 11 noon meals, and 22 evening meals between 3/1/25 and 4/30/25. Record review of Resident #67's laboratory results dated [DATE] revealed she had a low albumin level of 2.7 g/dL (low albumin levels in the blood can be a result of liver disease, kidney disease or malnutrition). The reference range indicated it should have been between 3.5-5.7 g/dL. Her blood glucose level was critically low at 42 mg/dL (low glucose levels in the blood can be a result of hormonal imbalance, liver disease, kidney disease or malnutrition). The reference range indicated it should have been between 65-110 mg/dL. Her sodium level was high at 147 mmol/L (high sodium levels in the blood can be a result of dehydration or excessive sodium intake). The reference range indicated it should be between 136-145 mmol/L. Her potassium level was low at 3.2 mmol/L (low potassium levels in the blood can be a result of medication use, diarrhea, vomiting and eating disorders). The reference range indicated it should have been between 3.6-5.2 mmol/L. Record review of Resident #67 progress note dated 5/5/25 revealed the nurse practitioner was notified of the resident's laboratory results dated [DATE]. She ordered 40 milliequivalents (the note did not specify which medication) to be administered on 5/5/25, then another dose to be administered 5/6/25. Resident #67's blood sugar was taken again, and it was at 164 mg/dL. Record review of Resident #67's nursing progress note written by the DON dated 5/20/25 at 11:41am revealed Resident #67 refused to be weighed three times. It indicated the resident's RP and MD were notified, and there were no signs of weight loss observed. The note stated she consumed 80-100% of meals. Record review of Resident #67's nursing progress notes dated 4/5/25-6/4/25 revealed there were no progress notes regarding abnormal nutrition or weight loss. Record review of Resident #67's POC Legend Report generated on 6/6/25 revealed the following: - It was documented that the resident ate less than 25% of her meal on 14 occasions between 5/1/25 and 6/4/25. - It was documented that the resident ate between 26% and 50% of her meal on 25 occasions between 5/1/25 and 6/4/25. - There was no record of percentage of meal eaten (missed documentation) for 2 morning meals, 6 noon meals, and 11 evening meals between 5/1/25 and 6/3/25. In an observation and attempted interview on 6/3/25 at 10:12am, Resident #67 was in bed in her room with her breakfast of French toast and sausage patties. Her breakfast was untouched. She had a carton of milk in her right hand, holding it close to her body. Her hand was shaking. I did not see her bring anything to her mouth for 3 minutes. Her left hand was under the bedsheet. I attempted to interview Resident #67, but she did not answer my questions. She acknowledged that I was there and smiled at me. In an interview on 6/3/25 at 2:06pm, LVN A, when asked what her role was in nutrition monitoring, she said the CNAs monitor percentage of meals eaten and document it in the system. She said she monitored meal intake. She said the CNAs would report to her if a resident had poor meal intake. If she became aware of nutrition problems, she would call the doctor. When asked if anyone that she was caring for had nutrition problems, she said Resident #67 was not eating too much, and ate breakfast late. She said she was not aware of any weight loss, stating she weighed the same since she has known her. In an observation and interview on 6/3/25 at 3:22pm, Resident #67 was in her room with her lunch tray in front of her. Her spoon was dirty, but most of the food was untouched. Her breakfast tray was on a side table in her room, uneaten. CNA G walked into the room to pick up her meal trays. She said at times, Resident #67 did not eat, and only drank milk. In an observation and interview on 6/4/25 at 5:35pm, Resident #67 was asleep in her bed. She had her dinner tray in front of her that was untouched. It contained chicken and corn. Her meal ticket said to add milk to her tray, however there was no milk carton present. When the surveyor asked the DON about the milk, she said the milk is in the kitchen and she would get some for her now. She left and returned at 5:43pm. She placed the milk on her tray and left the room. In an observation and interview on 6/4/25 at 6:26pm, Resident #67 was in her room, awake, with her dinner in front of her. She was holding a cup of purple juice with her right hand and her hand was shaking, and she was spilling the juice on her bedsheets. Her dinner was untouched, and the silverware was wrapped in a paper bag. I asked her questions about her meal, and her need for assistance, but she did not respond. I asked if she could reach for her silverware, but she did not move her hands. Her left hand was under the bedsheet.In an observation and interview on 6/4/25 at 6:35pm, RN E stated his role in nutrition monitoring was to confirm a resident's diet and follow physician's orders. He said weight frequently is based on the physician's orders. He said if he noticed problems with a resident's nutrition, he would let the doctor know. He said if a resident had poor meal intake, he would interview the resident to determine why they were not eating and try to figure it out. When asked about Resident #67, he said she had not noticed any signs of weight loss. During the interview, we entered Resident #67's room. We saw her holding the cup of purple juice and her meal was untouched. RN E stated that Resident #67 fed herself at her own pace. He left to get some help pulling her up in bed. RN E returned with Medication Aide B. They pulled her up in bed, then RN E took her silverware out of the paper and placed it on the plate. Medication Aide B said they could not help feed her, and she ate what she wanted. She said it usually took her time to eat. In an interview on 6/5/25 at 9:20am, Unit Manager A said she had not noticed any nutritional changes of condition for Resident #67. She said Resident #67 did not like some meals and an alternate was offered. She said if a resident ate 10-25% of a meal, she would want to know immediately so they can offer an alternate meal. She said at times, she refused care. When asked if it was possible to reweigh the resident since she refused to be weighed in May 2025, she immediately asked Restorative Aide A to attempt to weigh Resident #67 who agreed. In an observation and interview on 6/5/25 at 9:55am, Resident #67 was in her room with her breakfast tray in front of her. There was a small bite of egg missing from her tray. There were two whole English muffins. Her fork was placed in her plate next to the eggs. She was holding a plastic cup of orange juice with a paper cover over it close to her body with her right hand. Her left hand was underneath the bedsheet. Her right hand was shaking. She stated, take off multiple times while I was in the room. Record review of Resident #67's Weight Summary (undated) revealed she weighed 146.2 pounds on 6/5/25 when measured using a mechanical lift. In an observation and interview on 6/5/25 at 10:14pm, Restorative Aide A exited Resident #67's room with a mechanical lift. She said she weighed the resident, and she was 146.2 pounds. She said the resident got a little scared when she was suspended in the air, but they were able to complete the weight today without refusal. In an observation on 6/5/25 at 11:51am, Resident #67 was in her room with her breakfast tray of eggs and 2 English muffins. Her fork was placed on her plate next to the eggs. There was a small bite of egg missing from her tray. The English muffins were untouched. She had a cup in her right hand. Her whole chest was covered in a beverage. The resident was sleeping. In an observation and interview on 6/5/25 at 12:10pm, Resident #67's guardian visited with Resident #67. Resident #67 repeatedly asked her, you need to pull me up? Resident #67's guardian stated she was not like this the last time she saw her on 5/9/25. She said she was usually more alert and more conversational. She said she was notified of any changes of condition, including weight loss or decline in ability to feed herself. In a telephone interview on 6/5/25 at 1:08pm, MD A, she said she saw Resident #67 about a month ago. She said she refused everything and told some staff not to touch her. She said she did not like to get out of bed and has some psychological issues. She said she can use both hands and can feed herself. She said she thought Resident #67 ate most of her meals, stating she had not heard anything. She said if a resident lost weight, she would want to be notified if they lost 10-15% of their body weight. She said if she was aware of this type of weight loss, she would want to see weekly weights for 4 weeks and write an order for nutritional supplements to ensure they received enough protein. She said if a resident lost weight, they would be at risk of malnourishment. In an interview on 6/5/25 at 1:19pm, the Dietician said she would typically not do an assessment of a resident until it was known they had weight loss. She said if a resident refused to be weighed, and she was aware of reports of someone not eating, she would complete a visual assessment. She said if there was no assessment in her chart, one was not completed. Record review of Resident #67's electronic medical chart revealed there was no nutritional assessment. In an interview on 6/5/25 at 1:45pm, CNA A stated Resident #67 ate very slow, and she would try to feed her something solid. She said she like to drink milk frequently. She said held her drinks in her hand and she would spill them on herself. She said she had noticed Resident #67 was eating about 25-50% of her meals. She said she documented meal intake percentages in the electronic medical record. In an interview on 6/5/25 at 1:50pm, CNA C said Resident #67 took a really long time to eat, and spilled food and drinks frequently on herself. She said Resident #67 ate about 25-50% of her meals. She said she has not been eating too much. She said she would report to the nurse in the same day if she noticed a resident was not eating more than 25-50% of their meals. She said she could not remember if she reported Resident #67's meal intake to the nurse. In an interview on 6/5/25 at 2:15pm, CNA B said Resident #67 spilt juice on herself at times. She said at times, Resident #67 refused to be lifted up in bed. She said she noticed a problem and notified LVN E last week. She said she noticed she lost weight in her midsection, and she was lighter when repositioning/turning. In an interview on 6/6/25 at 9:44am, CNA G said Resident #67 always asked for milk with her tray. She said she offered to feed her in the past, but the resident stated she can feed herself. She said when she picked up her tray, she noticed she hardly ate anything. She said when she dropped off the tray, she would open everything and gave her the spoon. She said she let the nurse know when she did not eat, which was normal for her. She said she could not recall who she told. She said over the last 3 months, Resident #67 looked the same. She said the last DON had a box at the nurse's station for meal tickets, but the box was no longer there. In an interview on 6/5/25 at 3:30pm, the DON stated she expected the CNAs to report to the nurse when a resident was eating less than usual throughout their shift. When asked about Resident #67's weight that was taken today, she said the weight could not be correct, because it seemed low. She said there was a possibility that cancer was causing weight loss. The DON said the dietician was not monitoring the resident. She said Resident #67 frequently refused care. She said Resident #67 was scheduled to receive monthly weights, and she was not on any type of special monitoring for weight loss. She said she refused to be weighed in May 2025 and she notified the guardian. She said without a weight value, they would monitor meal intakes and make visual observations of the resident to determine if there was weight loss. In an interview on 6/5/25 at 5:18pm, RN E stated none of the staff reported weight or nutrition concerns to him. He said he was surprised about Resident #67's new weight that was taken today because she did not look like she lost weight. In a telephone interview on 6/5/25 at 8:45pm, LVN T said he worked primarily from 10pm-6am and would occasionally work 2pm-10pm. He said Resident #67 was bedbound and was very particular about her care. He said he was not aware of any weight loss or her nutrition status. He said she ate well and had not skipped a meal. He said when he worked the evenings, he reminded her or insisted that she ate her meal. He said she was capable of feeding herself. He said the CNAs had not reported to him that she lost weight. If she had, he would have notified her physician. He said Resident #67 had cancer and knew her prognosis was poor and the cancer was advancing.In an observation and interview on 6/6/25 at 2:31pm, the DON said the facility had SOC (standards of care) meetings weekly to review trending weights and discuss residents. She said the CNAs document meal intakes in the electronic chart and they review the meal intake values in the SOC meetings. She said if they noticed a downward trend in meal intake, they would put the resident on a watch list. She said the facility took the following steps to communicate the watchlist to the staff: the nurse managers attend the SOC meetings, then the nurse managers report to the nurses, and the nurses report to the CNAs. When asked why Resident #67's weight loss went unnoticed, she said she was new and was not aware of Resident #67's baseline, and further stated her BMI was high and it did not look like she had failure to thrive. When asked about the residents discussed in the SOC meetings, she said they reviewed new admissions and any new incidents. She said the IDT selects who is discussed during the meeting. The DON reviewed the SOC meeting minutes from the time she started at the facility in late April 2025 to now and did not see Resident #67's name listed for weights. She then opened the binders for the SOC meetings before she started, and the binders were empty. She could not state where the SOC meeting minutes were located for the last year. She said residents were referred to the dietician when the MD wrote an order for a referral, notice weight trending down, or if a nurse requests it. She said nurses were required to monitor residents who ate in their rooms. She said she was not sure if they were doing it. She said the CNAs should report poor meal intakes so the nurse can put interventions in place. In an interview on 6/6/25 at 5:30pm, the Unit Manager A said if a resident lost or gained weight, they would notify the resident's physician and dietician, then try house supplements. She said if a resident refused to eat a meal, they should be offered an alternate meal. She said the CNAs should notify the charge nurse if residents are not eating. She said a resident would be referred to the dietician if there was a weight loss or weight gain. She said Resident #67 refused care at times, but she said it was all about the approach. She said if she refused for one person, let someone else try. She said the CNAs collected the resident's meal tickets (they were included on each resident's tray) and wrote down the percentage eaten on each ticket. They documented the percentage eaten in the electronic health record, then gave tickets that showed less than 50% eaten to the charge nurse. She said the charge nurses were to notify the resident's physician and try to determine why they are eating less than 50% and provide nutritional supplements or alternate meals. She said at times, there was a disconnect between the CNAs and the nurses in communication. She said nurses were required to monitor residents who eat meals in their rooms, and she was unsure if this was occurring. In an interview on 6/7/25 at 12:52pm, CNA T said he had worked at the facility for three weeks. He said Resident #67 rarely ate her meals. He said he mentioned it to the nurse but could not remember who he told. In an interview on 6/8/25 at 11:50am, the Administrator said he oversaw clinical services by asking questions and being aware of everything going on in the facility. He said if a resident was sick or did not seem well, he would ask the nurses questions. He said he started a few months ago, and the DON was new. He said it would take time to implement changes at the facility. This was determined to be an Immediate Jeopardy (IJ) on 6/6/25 at 3:16pm. The Administrator was notified. The Administrator was provide with the IJ template on 6/6/25 at 3:16pm and a Plan of Removal was requested.The following Plan of Removal submitted by the facility was accepted on 6/7/25 at 3:13pm:PLAN OF REMOVALF692The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding weight loss:o Regional Director of Operations re-educated Administrator on ensuring resident care to include nutrition and weight loss. 6/6/2025o Regional Nurse Consultant for facility educated Director of Nursing on ensuring resident care nutrition and weight status. 6/6/2025o Immediate interventions put in place for resident #67 including: weekly weights x4 weeks, labs drawn (prealbumin, CBC, CMP), speech therapy to evaluate and treat, Magic cup supplement three times per day, house supplement three times per day, fortified meal plan to all meal trays, large protein portions to all trays, snacks offered between meals, and resident to be up in dining room for all meals for needed assistance. If the resident refuses to come to dining area a qualified member of nursing staff, CNA or nurse, will assist resident in her room with meals. The resident's primary care practitioner and the dietitian were both notified of the resident's weight loss status with new orders noted as indicated above. The resident's careplan was updated to include weight loss and interventions implemented with direct nursing staff instructed on the plan of care developed to address the resident's weight loss. 6/6/2025o DON, ADON, and Unit Managers ensured completion of obtaining all resident weights in the facility and assessed for weight variances requiring immediate intervention. Two residents were identified as showing a trend in weight loss with MD and Dietitian notifications made and interventions implemented as ordered. 6/6/2025o DON/ADON, Unit Managers and/or designee to re-educate all nursing staff on nutrition, weights and reporting of decreased meal intake and/or inability for resident to independently feed themselves and intervene/assist. 6/6/2025.o Audit of prior 7-day meal intake documentation via EHR of all residents performed by facility nurse consultant to assess for decrease in intake of active residents. The results of the audit found 18 residents, including resident #67, that needed to be observed during meal service to note if assistance during meal service required. List of the residents identified given to DON for distribution to the nurse managers and nursing staff involved in resident care. This intake will be monitored by nursing staff in the dining room and on the units per the education received by the staff following the receipt of IJ status. 6/6/2025o Facility DON discussed findings from survey allegations with the medical director and dietitian to ensure continuation and participation of all practitioners with resident nutritional status and orders for interventions, as needed, to be implemented. 6/6/2025 Interventions and Monitoring Plan to Ensure Compliance Quickly:o The Administrator/Director of Nursing/Designee educating all facility staff on recognizing and immediately reporting to appropriate nursing staff any observed resident decrease in meal consumption noted. The nurse aides will report decreased intake by giving the resident meal tickets of residents consuming <50% of meals to charge nurse after documenting meal intake percentage in EHR. The charge nurse will sign each tray ticket given to them to initiate assessment and intervention if required as noted below and give signed tray tickets to DON/ADON, or Unit Manager daily. The DON/ADON and/or unit manager will ensure that appropriate follow-up, including MD and Dietitian notification if required, are instituted based on individual resident needs. The DON, ADON and/or Unit Managers will monitor this process by monitoring of meal intake records in EHR with staff trainings prior to the start of their next designated shift and resident care following the notice of Immediate Jeopardy as noted below. Initiated: 6/6/2025 Completion: 6/7/2025o Careplans will be updated to reflect current nutritional needs and functional needs related to nutrition, i.e. assisting with feeding, monitoring of residents needed, supplements, snacks, etc by the MDS Nurse and/or DON/ADON in the absence of MDS Nurse. These careplan changes/needs will be communicated to care staff through the resident Kardex available via EHR and changes in plan of care will be communicated with DCS, therapy, dietitian, primary care providers through SOC meetings, weight management meetings, QAPI, and/or directed communication [NAME] Interdisciplinary team comprised of DON, ADON, Administrator, Dietary Manager, Social Worker, and MDS Nurse to begin nutrition/weight meetings weekly assessing resident nutritional status and intake. Findings from meetings to be documented and reported to individual resident primary care providers as indicated as well as the Dietitian. Medical Director to be updated weekly during facility SOC meetings. Initiated: 6/6/2025 Completed: 6/7/2025o Implementation of residents requiring assistance with meal service and nutritional intake being brought to the dining room for oversight and assistance based on intake documentation and/or observed or noted changes in resident reported by staff or found during weekly weight meetings. This is to be overseen by DON, ADON and Unit Managers. Initiated: 6/6/2025 Completed 6/7/2025o Any resident showing signs of needing assistance as identified by staff who were educated as noted above, will be assessed by nursing staff for initiation of interventions which may include therapy services, physical assistance with feeding, and/or medical intervention as warranted. Nurses educated on steps to initiate following reporting of observation or reporting by other staff which may include: obtaining new weight on resident, assessing resident for change in condition or psychological factors/environmental factors, notifying the physician if decreased intake patterned and requires immediate orders, notifying DON and/or ADON/Unit Manager of decreased intake through the meal tickets of residents identified to have eaten less than 50% to ensure weight program initiated and/or changed if indicated. Initiated: 6/6/2025 Completion: 6/7/2025o Staff that are on leave from the facility will be re-educated by Administrator/DON/ADON/Designee on nutritional status including meal intake, assistance, documentation, reporting of change in nutritional/intake, and signs and symptoms of weight loss status prior to return to their next shift. This facility does not employ the use of agency personnel. The DON will ensure education performed via inservice documentation/signature. DON has ensured that MD notification and interventions are in place for resident identified in IJ and that MD notification was completed. Initiated: 6/6/2025 Completion: 6/7/2025o DON/ADON and/or designee to notify dietitian immediately of noted weight change, meal intake change, including changes in diet consistency, with response to be documented and primary practitioner notification initiated for orders and/or implementation of dietitian recommendations. The DON will be responsible for oversight of the weight program in the facility utilizing EHR documentation, including weekly and monthly weights obtained by designated nursing staff, intake documentation and nursing documentation. If the DON is unavailable for any reason, oversight of the weight program will be provided by the ADON and/or designated Unit Manager. Initiated: 6/6/2025 Completed: 6/7/2025o The facility has an alternative meal menu posted for each meal as well as an always available menu consisting of: chef salad, grilled cheese, hamburger, or hot dog. For documentation of alternative meal offering and acceptance or refusal, the follow-up question of alternative offered if less than 50% and acceptance or refusal of offering is added to EHR documenting process for each resident at each meal. Education of nursing staff including CNA's on the added documentation provided by Inservice with staff not on duty at time of inservice to be inserviced prior to start of next shift. This documentation will be checked by DON/ADON and/or designee along with intake monitoring as noted above. Initiated: 6/7/2025 Completed 6/7/2025o The policy and procedure already in place for nutrition and weight monitoring was reviewed by Regional [NAME] President of Operations and Regional Nurse Consultant with no revisions required. Initiated: 6/6/2025 Completed: 6/7/2025 o Facility Administrator and/or DON will ensure implementation and completion of interventions through individual communication with team members and medical practitioners, as well as weekly SOC meetings and QAPI meetings as indicated below. Initiated: 6/6/2025 Completed: 6/7/2025The QAPI Team, led by the Administrator, will meet weekly for 3 weeks to discuss that coordination and completion of all education, assessments, and interventions are utilized to ensure that appropriate nutritional and hydration monitoring and weight maintenance are followed and maintained per current facility policy. The Medical Director was notified of Immediate Jeopardy on 6/6/2025 and will be part of the QAPI intervention meetings. Procedures on resident rights, including investigation process and outcomes, as well as ensuring resident safety to be added to the QAPI monthly for 3 months following the initial 3 weeks to monitor program progress.The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following:In an interview on 6/8/25 with the DON at 1:15pm and with the Administrator at 11:50am, they both confirmed that they were in-serviced on nutrition status and weight loss and confirmed they could articulate the policy and procedures in the plan of removal. Record review of Resident #67's care plan revealed it was updated on 6/6/25 to include additional interventions for a focus of nutritional problem. Interventions included encourage resident to attend meals in the dining room, explain and reinforce the importance of maintaining diet, invite the resident to activities that promote additional intake, obtain and monitor lab/diagnostic work as ordered, provide and service supplements as ordered, dietician to evaluate and make diet change recommendations, and monitor weights monthly and weekly.Record review of Resident #67's physician orders dated 6/5/25 revealed orders for the following: weekly weights for 4 weeks, speech evaluation and treatment, magic cup (a high-calorie ice cream/pudding dessert) three times a day, house supplement three times daily, large portion diet and basic metabolic panel (lab work to test for substances in the blood). Record review of Resident #67's Nutrition assessment dated [DATE] initiated by the Dietician revealed it was 'in progress.' In an observation and interview on 6/7/25 at 8:25am, Resident #67 was in bed eating breakfast with the assistance of LVN A. LVN A had fed her a few bites of her pancakes and 3/4 of a breakfast sausage link. Resident #67 asked for her milk carton. LVN A left to get a straw. While LVN A was gone, Resident #67 reached for her milk carton on her tray, but could not reach it. When LVN A returned with the straw, she drank the whole carton of milk. LVN A left to get another milk carton. In an interview on 6/7/25 at 11am, LVN A said Resident #67 ate about 50% of her breakfast in the morning, including 1 pudding cup, 2 sausage links, some of the grits and 2 milk cartons. In an observation on 6/8[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #43) reviewed for respiratory therapy in that:The facility failed to ensure Resident #43 received continuous oxygen and nebulizer treatments to meet her respiratory needs, resulting in Resident #43 experiencing oxygen saturations of 90 on 6/3/25 and 80 on 6/5/25. Resident #43 was experiencing anxiety and a change to her daily routine as a result. The facility failed to ensure Resident #43 was administered oxygen per the physician's order resulting in the resident receiving oxygen at a rate higher than what was prescribed placing her at risk of medical complications. An Immediate Jeopardy (IJ) was identified on 6/26/25. The IJ template was provided to the facility on 6/26/25 at 12:00pm, While the IJ was removed on 6/27/25, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm the facility continued to monitor the implementation and effectiveness of their corrective systems. This failure could place residents at risk of respiratory distress, anxiety and decline in quality of life. The findings included:Record review of Resident #43's admission Record generated on 6/8/25 revealed she was admitted to the facility on [DATE] with diagnoses of respiratory failure, schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), parkinsonism (characterized by tremor, rigidity and postural instability), dementia (decline in mental ability severe enough to interfere with daily life), dysphagia (difficulty swallowing foods or liquids), insomnia (a sleep disorder where people struggle to fall asleep), tremor, cellulitis (bacterial skin infection), morbid obesity, generalized anxiety disorder, chronic obstructive pulmonary disease (COPD .a progressive lung disease that makes it difficult to breath). She was [AGE] years of age. Record review of Resident #43's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 10, indicating moderate cognitive impairment. She had a PHQ-9 score of 6, indicating she had mild depression symptoms. She had behaviors of delusions and verbal behaviors that occurred 1-3 days of 7 days. It further indicated she required partial/moderate assistance with person hygiene tasks, including combing hair, shaving, applying makeup and washing/drying face and hands. She used a wheelchair for mobility and required partial/moderate assistance with transfers from sitting to standing, chair to bed, toilet and tub/shower transfers. She did not have signs of shortness of breath. Record review of Resident #43's care plan (undated) revealed the following focuses, goals and interventions: - Focus: Resident #43 had a diagnosis of COPD. Goal: Resident #43 would be free from signs and symptoms of respiratory infections. Target Date: 6/1/25. Interventions: Give oxygen therapy as ordered by the physician, monitor for difficulty breathing on exertion. Remind resident not to push beyond endurance. - Focus: Resident #43 exhibited signs and symptoms of anxiety. Goal: Resident #43 would have no side effects from medication. Target date: 6/1/25. Interventions: Administer medications as ordered, monitor for side effects of medications. - Focus: Resident #43 had oxygen therapy related to hypoxia. Goal: Resident #43 will have no signs or symptoms of poor oxygen absorption through the review date. Interventions: Give medications as ordered by physician. Monitor for signs and symptoms of respiratory distress and report to physician as needed. - Focus: Resident #43 had shortness of breath. 11/4/24 Albuterol Sulfate Inhalation solution as ordered. Goal: Resident #43 would have no complications related to shortness of breath. Target date: 6/1/25. Interventions: Monitor/document changes in orientation, increased restlessness, anxiety, and air hunger, monitor/document breathing patterns, report abnormalities to physician including nasal flaring, respiratory depth changes, altered chest excursion, use of accessory muscles, pursed-lip breathing, or prolonged expiratory phase. Record review of Resident #43's Order Summary Report generated on 6/4/25 revealed she had an order for Oxygen at 3 L/min by nasal cannula continuously for a diagnosis of hypoxia (an absence of enough oxygen in the tissues to sustain bodily function), and an order for Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3mL) 0.083%, inhale 3 mL orally by nebulizer every 4 hours as needed for shortness of breath. Record review of Resident #43's Progress Note completed by NP B dated 5/28/25 revealed her baseline oxygen saturations were above 93% (oxygen saturations refer to the percentage of hemoglobin in your blood that was carrying oxygen, and was a measure of how well oxygen was being transported to your body's tissues. Normal oxygen saturation levels for healthy individuals typically range from 95% to 100%). Record review of Resident #43's Treatment Administration Record dated May 2025 revealed Albuterol Sulfate Inhalation Nebulization Solution was not administered during the month of May 2025. Record review of Resident #43's Treatment Administration Record dated June 2025 revealed the nurse checked oxygen placement every shift between 6/1/25 and 6/4/25. In an observation and interview on 6/3/25 at 10:45am, Resident #43 was in a wheelchair sitting in the hallway. She had an oxygen tank on the back of her wheelchair that was not empty, and the nasal cannula was in place under her nose. She approached CNA A and asked if she could help her go to bed. CNA A told her she could not assist right now. Resident #43 approached the surveyor and said she was short of breath and wanted to go to bed. She then saw Medication Aide C and asked her if she could help her to bed. Resident #43 was breathing with her mouth and taking deep, quick breaths with pursed lips. Medication Aide C said, no, ma'am, go to the front. I'm going to find you some lunch .go to the dining room. In an observation and interview on 6/3/25 at 11:09am, Resident #43 saw the surveyor in the hallway and asked if I could help her to bed. She was taking deep, quick breaths using her mouth with pursed lips. Surveyor asked CNA A about Resident #43's breathing, and CNA A said she could not understand my question since she spoke primarily Spanish. She took Resident #43 to her room to assist her with transferring to her bed. Resident #43 stated she was feeling bad and did not want to go to the dining room. In an observation and interview on 6/3/25 at 2:06pm, LVN A said Resident #43 had an order for a breathing treatment that she received when she was short of breath. She said she was not aware of Resident #43 experiencing shortness of breath today, but said she had been anxious. She said she would go check on her now. She went in the room and Resident #43 was breathing deep breaths using her mouth with pursed-lips. LVN A checked her oxygen saturations with a pulse oximeter (a devise that measure the percentage of oxygen in your blood), and it was 90%. Her oxygen concentrator was on and her nasal cannula was in place. LVN A said she would administer a breathing treatment now. Record review of Resident #43's Treatment Administration Record dated June 2025 revealed LVN A administered Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3mL) once in June 2025 on 6/3/25 at 2:08pm. In an interview on 6/4/25 at 6:35pm, RN E said to monitor Resident #43's respiratory status, they check her oxygen saturations. He said if she rested in bed, her oxygen saturation was higher, and if she was ambulating with her wheelchair or stressed, it would be lower. He said if her oxygen saturation was 89 or 90 and below, he would be concerned and call the doctor. He said she had a scheduled breathing treatment and she received it regularly. He said the signs of shortness of breath were flaring nose, using abdominal muscles to breathe and high number of breaths per minute. He said Resident #43 was at her baseline yesterday and he did not notice any concerns. In an observation and interview on 6/5/25 at 8:52am, Resident #43 was in bed only wearing a brief and a shirt. She was taking deep breaths and pursing her lips. She was struggling to get words out when I asked her questions. She said she was not able to sleep last night and said for the last 2-3 days she could hardly breath. An observation of her oxygen concentrator revealed it was set at 2 L/min and the bottle that contained water was on the floor and the tubing that was attached to the bottle was not connected to the concentrator. The concentrator was on. Surveyor left to find the charge nurse. LVN A entered Resident #43's room and said her oxygen concentrator was not working because the tubing was disconnected. She said she last saw her about an hour ago. When she checked her oxygen saturation it was 80. She placed the nasal cannula on Resident #43 that was connected to the oxygen tank on the back of her wheelchair. She said she turned the oxygen tank up to 5 L/min. Her oxygen saturation gradually went up and at 9:04pm it was 95. LVN A said 92-95% was her baseline. She said typically the CNA will report to the nurses if the resident was showing signs of shortness of breath. When asked about the bottle being on the floor, Resident #43 said she did it. In an interview on 6/5/25 at 10:00am, Unit Manager A said Resident #43 removed her oxygen nasal cannula at times. She said her oxygen saturation dropped really low without the oxygen in place. She said if she was short of breath, she would breath with pursed lips. She said she was not aware of signs of shortness of breath recently. She said she had a breathing treatment every 4 hours if needed. She said they were utilizing the breathing treatment. She said she was unsure why Resident #43's oxygen concentrator was set at 2 L/min since her order was for 3 L/min. In an interview on 6/5/25 at 12:10pm, Resident #43's guardian said she was usually out in facility running the place. She said if she was reserved or quiet, they need to check on her. She said she was not aware of her having shortness of breath. In an observation and interview on 6/5/25 at 12:52pm, Resident #43's guardian entered Resident #43's room and said, What's wrong. Resident #43 stated she had not been feeling very good. The guardian asked her how long it had been since she has been feeling this way and she said, a while. The guardian told the surveyor that this was not her norm. Her oxygen was on and nasal cannula was in place. In an interview on 6/5/25 1:50pm, CNA C said she was caring for Resident #43 this morning. She said she saw Resident #43 at 6am when she arrived, and she did not want to get up and looked tired. She said around 9am, she noticed Resident #43 was short of breath, and it was worse than the previous day. She said she tried to get her dressed but she was not receptive. She said when she asked her questions she did not respond right away, and she would breathe and not really answer. She said she told LVN A about her condition before breakfast. In an interview on 6/5/25 at 1:45pm with the assistance of CNA W acting as a Spanish translator, CNA A said she did not have any concerns about Resident #43's condition, including her respiratory status, when she cared for her on 6/3/25. She said when she had heavy breaths, she would sit her up or pull her up in bed. She said if residents had difficulty breathing, she would let the nurse know. In an interview on 6/5/25 at 3:30pm, the DON said for residents receiving oxygen, their oxygen saturation should be checked every shift and observe for any changes. She said any oxygen saturation below 89-90 would warrant a nursing assessment. She said the nurses should follow physician's orders. She said the CNAs should report symptoms of shortness of breath to the nurses. She said a breathing treatment should be administered as needed for shortness of breath. She said Resident #43's oxygen saturation baseline is 90-95%. She said because the resident had COPD which affects her oxygen levels. In a telephone interview on 6/5/25 at 8:24pm, LVN T said he had not noticed any changes of condition in Resident #43's respiratory status. He said he checked her oxygen saturations and respiration rates, and she received a breathing treatment at midnight and 6am during his shift. He said he would be concerned about her respiratory status if her oxygen saturations were lower than 93 or 92%. In a telephone interview on 6/5/25 at 9:54am, MD B said Resident #43 had COPD, and her oxygen saturations should be around 92% since breathing could cause carbon dioxide toxicity. He said the resident's Albuterol nebulizer should be administered when she exhibited signs of respiratory hunger, shortness of breath and using ancillary muscles to breath. He said anytime she experienced these symptoms, she should get a nebulizer treatment. He said they could not overuse the Albuterol nebulizer. He said the first thing a nurse should do if resident was experiencing signs of distress was to check the oxygen saturations. He said it would take a long time for her oxygen levels to be so low that she had a change of condition because, due to her condition, she was used to low oxygen levels. In an interview on 6/24/25 at 2:35pm, NP B said she would want to keep Resident #43's oxygen saturations above 90%. She said staff should call her if her oxygen saturations falls below 90%, and would like to be notified even if it rebounds back up after it drops. She said if someone at the facility turned up her oxygen to a higher rate than the order, she would want to be notified. She said it would be okay if staff increased Resident #43's oxygen rate to 5 L/min if her oxygen saturation dropped to 80%. She said after an incident like this, she would prefer staff to call her so they can talk about interventions. She said it could be harmful because it may increase the level of carbon dioxide. She said she was not aware of a situation when facility staff increased the oxygen rate. Record review of the facility's policy regarding Oxygen Administration (undated) read in part, The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure .before administering oxygen, and while the resident is receiving oxygen therapy as indicated, assess for the following: .2. Signs or symptoms of hypoxia (i.e. rapid breathing, rapid pulse rate, restlessness, confusion) .check the mask, [NAME], humidifying jar, etc. to be sure they are in good working order and are securely fastened .observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated . This was determined to be an Immediate Jeopardy (IJ) on 6/26/25 at 12:00pm. The Administrator was notified. The Administrator was provided with the IJ template on 6/26/25 at 12:00pm and a Plan of Removal was requested.The following Plan of Removal submitted by the facility was accepted on 6/27/25 at 8:06am:PLAN OF REMOVAL F695The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding respiratory care and services resulting from the failure of facility staff to immediately address resident respiratory needs as communicated and noted in the resident careplan: Regional Director of Operations re-educated Administrator on ensuring resident care to include respiratory care and services. Completed 6/26/2025. Regional Nurse Consultant for facility educated Director of Nursing on ensuring resident care to include respiratory care and services. Completed 6/26/2025. Immediate interventions put in place at 6/5/2025 during full book survey for Resident #43 including: Practitioner notification and assessment as well as chest x-ray found to have no acute problems noted and labs which were unremarkable; monitoring to ensure oxygen nasal cannula in place and at appropriate setting and oxygen saturation levels within baseline for resident. The resident's careplan was updated to include interventions for keeping her nasal cannula in place including increased monitoring of placement documented on the eMAR as well as a new order from the practitioner to allow for resident to have nasal cannula removed for periods of time while resident has staff in the room. The resident was interviewed for noncompliance with progress note and careplan updated. Completed 6/26/2025. Interventions also put in place to include pre and post assessment documentation with each nebulizer treatment on the eMAR; 02 sats to be obtained on all residents requiring oxygen therapy and/or nebulizer treatments. Education of all licensed nursing staff performed by DON/ADON/Unit Managers with no care provided relating to above education prior to inservicing. Completed 6/26/2025. DON, ADON, and Unit Managers ensured assessment of all residents requiring respiratory therapy to include 02 sats and lung auscultation to ensure compliance with respiratory services with no other respiratory concerns noted upon assessment. Completed 6/26/2025. DON/ADON, Unit Managers and/or designee re-educated all nursing staff on change of condition, respiratory care and services as well as notification to appropriate nursing staff and practitioners. Completed 6/26/2025. DON/ADON, Unit Managers and/or designee educating all nursing facility personnel on respiratory distress/issues with residents and notifying nursing personnel upon observation. Completed 6/26/2025 Facility Regional Nurse Consultant discussed findings from survey allegations with the medical director to ensure continuation and participation of all practitioners with resident respiratory services and orders for interventions, as needed, to be implemented. Completed 6/26/2025. Education will be completed prior to any direct care staff providing care pertaining to respiratory services with staff not on duty to have education prior to first shift back as noted below.Completed 6/26/2025.Interventions and Monitoring Plan to Ensure Compliance Ouickly: The Administrator/Director of Nursing/Designee educating all facility staff on recognizing and immediately reporting to appropriate nursing staff any observed resident respiratory distress or verbalizations of breathing difficulty. Initiated:6/26/2025 Completion: 6/27/2025 o Respiratory documentation to be reviewed in morning medical stand-up meetings with Medical Director to be updated weekly during facility SOC meetings of findings requiring further direction. Initiated: 6/26/2025 Completed: 6/27/2025 o Implementation for residents requiring respiratory services including oxygen therapy and/or nebulizer treatments, of respirator)' assessment and monitoring of apparatus in place as noted above. Initiated: 6/26/2025 Completed 6/27/2025 o Any resident showing signs of needing assistance will be assessed by nursing staff as is within general nursing practicum, with primary practitioner notification for initiation of interventions which may include, but is not limited to, increased monitoring, labs and/or xrays as ordered by primary practitioner in accordance with facility policy for notifying and receiving orders following assessment of resident.Initiated: 6/26/2025 Completion: 6/27/2025 o Staff that are on leave from the facility will be re-educated by Administrator/DON/ADON/Designee on respiratory services and distress, and the reporting of change in respiratory status prior to return to their next shift with no direct care delivery on education items prior to education performed. This facility does not employ the use of agency personnel. Initiated: 6/26/2025 Completion: 6/27/2025 o Review of careplans for residents requiring oxygen therapy and nebulizer treatments initiated by DON/ADON/Regional Nurse and/or designee for accuracy as to status and compliance with no negative findings noted at time of POR submittal but remains ongoing until completion date of 6/27/2025. Initiated 6/26/25 Completed6/27/25 o DON/ADON and/or designee to notify primary practitioner of any change in respiratory status for residents found to have distress for orders and/or implementation of recommendations or monitoring. Initiated: 6/26/2025Completed: 6/27/2025 o The policy and procedure already in place for respiratory services was reviewed by Regional [NAME] President of Operations and Regional Nurse Consultant with no revisions required. Initiated: 6/26/2025 Completed: 6/27/2025o Facility Administrator and/or DON will ensure implementation and completion of interventions through individual communication with team members and medical practitioners, as well as weekly SOC meetings and QAPI meetings as indicated below. Initiated: 6/26/2025 Completed: 6/27/2025The QAPI Team, led by the Administrator, will meet weekly for 3 weeks to discuss that coordination and completion of all education, assessments, and interventions are utilized to ensure that appropriate respiratory services including notification and care of, are followed and maintained per current facility policy. The Medical Director was notified of Immediate Jeopardy on 6/26/2025 and will be part of the QAPI intervention meetings. Procedures on respiratory services, monitoring and care of, as well as proper notification to be added to the QAPI monthly for 3 months following the initial 3 weeks to monitor program progress.The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following:Record review of an in-service training report dated 6/5/25 revealed nursing staff were educated on oxygen administration and signs and symptoms of respiratory distress, including monitoring for shortness of breath, restlessness, nasal flaring, use of accessory muscles, and decreased oxygen saturations. Further, staff were educated on ensuring residents receiving oxygen have their nasal cannula in place and the cannister is not empty, monitoring oxygen saturations and ensuring oxygen orders are correct. Record review of an in-service training report dated 6/26/25 revealed all nurses were educated on the oxygen procedures, notifying the physician and documentation of notification, oxygen administration and oxygen saturations. Record review of an in-service training report dated 6/26/25 revealed all nurses were educated on administration of nebulizer treatments. Record review of an in-service training report dated 6/26/25 revealed all staff were educated on notifying charge nurse of any change of condition, including shortness of breath. Record review of an in-service training report dated 6/26/25 revealed all staff were educated on the symptoms of shortness of breath and notification to charge nurse. Record review of a document dated 6/26/25 (untitled) signed by the Regional VPO and Administrator revealed the Administrator was educated on respiratory services policies and procedures. Record review of a document dated 6/26/25 (untitled) signed by the Regional Nurse Consultant and the DON revealed the DON was educated on respiratory services policies and procedures. In an interview on 6/27/25 with the Administrator, DON and ADON revealed they received in-services regarding respiratory distress, shortness of breath and change of condition and confirmed they could articulate the policy and procedures in the plan of removal.Interviews with facility staff on 6/27/25, including Dietary Aide A, Housekeeping Supervisor, Restorative Aide A, MA T, Medication Aide B, CNA Y, CNA R, CNA U revealed they could reiterate the in-services received regarding signs of shortness of breath and procedures for nurse notification. Interviews with facility nurses on 6/27/25, including LVN Q, LVN E, LVN R, LVN I, LVN M revealed they could reiterate the in-services received regarding shortness of breath, breathing treatment administration, and procedure for notifications after a change of condition. Record review of 18 residents receiving respiratory treatments including oxygen revealed they were assessed by the DON, change nurse and/or the ADON. The residents had no additional orders. Record review of Resident #43's medical record revealed she was assessed by NP B on 6/6/25 with no adverse findings. She had an x-ray completed on 6/6/25 with no adverse findings. Record review of Resident #43's care plan revealed it was updated on 6/26/25 to include additional interventions for episodes of shortness of breath. On 6/27/25 at 3:06pm the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a scope of pattern and a severity level of potential for harm that was not immediate due to the facilities need to evaluate the effectiveness of corrective systems.