**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not provide adequate supervision to prevent accidents for 1 resident (R) (R1) of 3 sampled residents. On 6/8/24, R1 exited the facility without signing out and told staff when found that R1 intended to walk to a location in another city that was 37 miles from the facility. On 6/14/24, R1 exited the facility without signing out and told staff when found that R1 intended to walk to the same location. On 7/30/24, R1 left the facility and was found by police walking on a county highway that was 1.4 miles from the facility. On 8/6/24, R1 exited the facility without signing out and was found by police after 9:00 PM walking into on-coming traffic on an interstate highway off-ramp that was over 1.5 miles from the facility. On 8/18/24, R1 left the facility and was found by police walking on a country road approximately 4 miles from the facility. The road was on the opposite side of the highway from the facility and there were overpasses which R1 likely walked under. The facility did not provide adequate supervision to prevent R1 from exiting the facility without signing out on 6/8/24, 6/14/24, and 8/6/24. In addition, the facility did not have a system to monitor R1's whereabouts (including on 7/30/24 and 8/18/24) despite the fact R1 refused to wear a Wanderguard and continually left the facility. The facility's failure to implement safety interventions for a resident and provide supervision to prevent the resident from exiting the facility without staff knowledge created a reasonable likelihood for serious harm which lead to a finding of Immediate Jeopardy (IJ) that began on 7/30/24. Nursing Home Administrator (NHA)-A was notified of the IJ on 8/27/24 at 4:58 PM. The IJ was removed on 8/28/24, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Elopements and Wandering Residents policy, with a revision date of 9/16/23, indicates: This facility ensures that residents who exhibit 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 unique factors contributing to wandering or elopement risk .If a resident is determined to be at risk for elopement or known to wander or elope: i. The resident's picture will be placed in the Wander Communication Binder. ii. If an alert bracelet system is used and deemed to be appropriate the bracelet will be applied .4. The Interdisciplinary Team (IDT), together with the resident's representative, should attempt to determine situations that may trigger a desire to leave and individual expressions in which staff should know could be a sign the resident may wander .6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: a. Residents will be evaluated for risk of elopement and unsafe wandering upon admission and throughout their stay by the IDT. b. The IDT will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the risk or to minimize risks associated with hazards will be added to the care plan and communicated to appropriate staff. d. Adequate supervision in accordance with evaluations will be provided to help prevent accidents or elopements .f. The effectiveness of interventions will be evaluated, and changes will be made as needed .8. Procedure Post-Elopement: a. A nurse will perform a physical evaluation, document, and report findings to the physician .c. A Social Services Designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults . On 8/27/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including Huntington's disease (a neurodegenerative disease exhibited by problems with mood or mental abilities and a general lack of coordination), diabetes mellitus, chronic kidney disease, and depression. R1's Minimum Data Set (MDS) assessment, dated 6/3/24, stated R1's Brief Interview for Mental Status (BIMS) score was 12 out of 15 which indicated R1 had moderate cognitive impairment. R1's medical record indicated R1 was responsible for R1's healthcare decisions. R1's care plan, dated 6/25/24, indicated R1 had decreased safety awareness and insight and contained the following interventions: ~ Arrange for transportation if R1 requests to go to appointments, the Department of Motor Vehicles (DMV), [NAME] Bay, etc. (initiated 7/22/24); ~ Continue to remind R1 to sign out when leaving the facility (initiated 8/6/24); ~ Distract R1 if agitated by offering pleasant diversions, structured activities, food, conversation, television, or book (initiated 6/25/24); ~ Identify pattern of behaviors: Is R1 looking for something? Does it indicate the need for more exercise? Intervene as appropriate (initiated 6/25/24); ~ Staff will inform local police if R1 has been away from facility over 2 hours (initiated 8/5/24). R1's care plan also indicated R1 had impaired cognitive function or thought processes, had difficulty distinguishing between television and reality, lacked understanding of distance between places, had decreased safety awareness (initiated 6/3/24) and was at risk for self-inflicted, life-threatening injury related to a history of suicidal intent (initiated 6/10/24) (related to an attempted suicide in 2015). R1's medical record contained the following assessments: ~ On 2/27/24, R1 was assessed at high risk for falls and low risk for elopement. ~ On 6/1/24, R1 was assessed at moderate risk for falls and low risk for elopement. ~ On 7/31/24, R1 was assessed at low risk for elopement. ~ On 8/20/24, R1 was assessed at low risk for elopement. Surveyor reviewed a Wander Communication Binder at the nurses' station. The binder contained pictures and information regarding three residents, but did not include R1. ~ A progress note, dated 6/8/24 at 3:53 PM indicated R1 ambulated out the front door pushing R1's wheelchair. R1 sat outside talking to other residents and then decided to leave the facility. Staff found R1 down the street walking toward Main Street. R1 stated the food was salty and R1 was heading to an emergency room (ER) in another city. R1 was brought back to the facility. Staff redirected R1 several times but R1 was fixated on going to another city and was placed on 15 minute checks. A corresponding police report, dated 6/8/24 at 6:30 PM, indicated staff reported that R1 was at a location on Main Street approximately 0.4 miles from the facility attempting to buy soda and staff needed R1 to return to the facility. An officer transported R1 back to the facility. Staff stated R1 had Huntington's disease and randomly left the facility when no one was looking. ~ Progress notes, dated 6/14/24 at 8:02 AM and 2:05 PM indicated R1 exited the front door, walked toward the bridge, and stated R1 was walking to a hospital. R1 was transported to the hospital for evaluation. R1 returned from the hospital at 2:00 PM and stated R1 would go back to the hospital if R1 was given any more antibiotics. ~ R1's medical record indicated between 6/15/24 and 6/30/24, R1 refused most oral medications but allowed insulin administration. A progress note, dated 6/17/24, indicated R1 stated R1 hoped R1 got a super big infection that puts me in the hospital. ~ An Examining Physician's Report (Adult Guardianship), dated 6/26/24, completed and signed by R1's physician, indicated R1 had Huntington's disease which caused progressive dementia and physical impairments, worsening memory, a flat affect, wandering and aggressive behavior, and R1 did not understand R1's memory or judgement impairments. The report indicated R1's incapacity was permanent and progressive. A SLUMS (St. Louis University Mental Status) Examination, dated 6/26/24, indicated R1 scored 12 (a score of 1-19 indicates dementia). ~ A police report, dated 7/11/24 at 5:31 PM, indicated at approximately 5:15 PM, an officer was dispatched to a business approximately 1.5 miles from the facility for a welfare check for R1 who stated R1 was a customer and walked 4 miles with R1's wheelchair. While the officer was en route, the officer observed R1 walking with a wheelchair approximately 1 mile from the facility. Due to the heat and distance, the officer offered R1 a ride back to the facility. (There was not a corresponding progress note in R1's medical record.) ~ A progress note, dated 7/30/24 at 8:01 PM, indicated a concerned citizen reported they saw R1 pushing a wheelchair far from the facility. The Assistant Director of Nursing (ADON) was notified. The note indicated staff would check for R1 at bedtime and notify the police if R1 was not there. ~ A progress note, dated 7/30/24 at 8:27 PM, indicated staff received a call from the police department that R1 was found in traffic outside the city. The writer informed the officer that R1 was R1's own person, signed R1's self out, and staff could not force R1 to return. The officer stated R1 did not want to return to the facility and the officer would bring R1 back to the city and call R1's emergency contact. A corresponding police report, dated 7/30/24 at 8:08 PM, indicated an officer was dispatched to an intersection of county highways approximately 1 mile from the facility. Dispatch stated R1 was alternating between pushing R1's wheelchair south on the highway and sitting in the wheelchair to take a break. A car with hazards lights was following R1 approximately 1.4 miles from the facility. The officer observed R1 on the side of the road. The citizen stated they called the police and tried to give R1 a ride back to the facility, but R1 refused. The officer identified R1 from previous contact. R1 stated R1 was going to a county psychiatric institution because the facility did not take care of R1. The officer informed R1 that walking on a county highway was a safety hazard. The officer called the facility, asked staff to pick up R1, and was told no. Staff stated there was nothing they could do because R1 was R1's own person. The officer contacted R1's emergency contact who stated they were in another city, recently had a medical issue, and couldn't drive. Approximately 15 minutes later, the officer convinced R1 to return to the facility. R1 whispered and some of R1's answers did not make sense. The officer requested an ambulance and R1 was transported to the hospital. ~ Progress notes, dated 7/30/24 10:45 PM and 11:30 PM, indicated the police found R1 in a traffic lane. R1 asked to be transported to a psychiatric institution or hospital. The police convinced R1 to go back to the facility, however, R1 refused to stay unless the facility gave R1 $25,000. R1 was transported to the hospital via ambulance at 9:00 PM and returned to the facility at 9:15 PM. R1 was treated for a urinary tract infection (UTI) with a one-time dose of antibiotics. ~ A Risk/Benefit Record, dated 8/1/24, indicated risk versus benefit education was provided by staff regarding R1 leaving the facility, notifying staff where R1 was going, and signing out. R1 was asked if staff could put a Wanderguard on R1's walker. R1 declined, but stated R1 would sign out and let staff know where R1 was going. ~ A progress note, dated 8/6/24 at 10:40 PM, indicated R1 returned to the facility at approximately 10:17 PM via police escort. R1 was found on the interstate near oncoming traffic. R1 had no apparent injuries, refused vital signs, refused medication, and stated R1's body works fine. A corresponding police report, dated 8/6/24 at 9:10 PM, indicated a welfare check was conducted for R1 at an intersection (one of the streets ran along a river) approximately 1.2 miles from the facility. The officer was not able to locate R1 upon arrival. Dispatch received a call a few moments later that R1 was on an interstate highway. The officer observed R1 walking on the fog line of an interstate highway off-ramp that was over 1.5 miles from the facility. R1 was self-propelling R1's wheelchair into head-on traffic and it was dark. The officer stated R1 was difficult to understand and R1's mental state was not 100%. R1 stated R1 was going to a county psychiatric institution and was taking back roads to get there. When the officer stated R1 was on a major highway and could not ride or walk on the side of the highway, R1 became argumentative and additional officers arrived. R1 was adamant about walking on the highway to get where R1 was going. R1 wanted to go anywhere but the facility and stated staff did not care if R1 came back. The officer spoke to R1 for less than twenty minutes, but determined R1's mental status was compromised. The officer brought R1 back to the facility. R1 apologized and stated R1 had a difficult time going back to the facility due to the way R1 was treated by staff. ~ A progress note, dated 8/18/24 at 3:10 PM, indicated R1 was R1's own person and signed out of the facility. An off-duty employee reported R1 was near a gas station and grocery store by a busy highway. Staff called the non-emergent dispatch line and asked police to check on R1. An officer reported that R1 stated R1 was taking a walk and would be back. The officer reinforced to R1 that R1 could not walk on the highway. A corresponding police report, dated 8/18/24 at 3:03 PM, indicated an officer was dispatched to an area near a grocery store where R1 was walking with a wheelchair and the officer located R1 near the store's driveway. Staff stated they were worried that R1 was trying to walk to a city that was 16 miles from the facility. R1 stated R1 wanted to go to the DMV in another city. The officer informed R1 that the DMV was closed and would reopen on 8/20/24. R1 stated R1 had a paper copy of R1's drivers license and wanted a card. The officer stated the officer didn't want to see R1 walk to another city and get hit by a car. R1 stated R1 would get food from the grocery store and go back to the facility. The officer called the facility and stated the officer would wait with R1 until staff picked up R1. Staff stated R1 was R1's own person and was free to walk around when R1 wanted. ~ A progress note, dated 8/18/24 at 5:50 PM, indicated a citizen called the facility and reported R1 was on a country road heading to the DMV in another city. The writer asked the citizen to stall and small talk with R1. The writer called the non-emergent dispatch line and updated them on R1's diagnosis of Huntington's disease, R1's location, and R1's description. The writer told dispatch they were concerned for R1's safety. A corresponding police report, dated 8/18/24 at 5:49 PM, indicated officer received a call that R1 was walking on a country road that was on the opposite side of an interstate highway from the facility. R1 left the facility several times recently attempting to go to other cities. R1's explanations for leaving the facility usually didn't make sense and R1 used a wheelchair to walk at a slow pace. Dispatch paged a county crisis worker and stated the officer was concerned that R1 would get lost in the dark and/or hit by a car. The crisis worker stated the facility was responsible for taking care of R1. The officer called the facility and asked staff to pick up R1. Approximately 30 minutes later, another officer responded to R1's location on the country road and transported R1 back to the facility. The officer reported R1 was walking down the middle of the road with no safety equipment to increase visibility for traffic. The report indicated there was continued neglect for R1's well-being as staff understood R1 was a potential threat to R1's safety but continued to let R1 leave unsupervised stating R1 was R1's own person. ~ Progress notes, dated 8/18/24 at 6:21 and 6:40 PM, indicated the writer spoke with an officer who contacted the county's Human Resources and stated there was nothing they could do because it was the facility's responsibility to make sure R1 returned. The writer contacted the Director of Nursing (DON) and made arrangements for staff to pick up R1 in the facility's van. A corresponding police report, dated 8/18/24 at 5:49 PM, indicated an officer was dispatched to a county road due to an elderly person wheeling northbound in the road in a wheelchair. R1 stated R1 was going nowhere in particular but did not want to be at the nursing home anymore. The officer transported R1 back to the facility. ~ A progress note, dated 8/20/24 at 12:28 AM, indicated R1 left the facility without signing out at approximately 8:10 PM. Non-emergency services were contacted at approximately 8:15 PM. R1 returned to the facility unescorted at approximately 8:20 PM. At approximately 8:25 PM, police arrived and stated the facility was not allowed to call the sheriff's department for this anymore. (There was no police report associated with the note.) ~ A progress note, dated 8/22/24 at 3:28 PM, indicated the writer spoke with R1 who stated R1 liked the facility and staff were nice and helpful, but R1 wanted to go to another city. R1 stated R1 liked to walk and needed 2 Diet Cokes per day but had no money. On 8/27/24 at 9:00 AM, Surveyor observed R1 in bed. On 8/27/24 at 9:12 AM, Surveyor interviewed Adult Protective Services Worker (APSW)-C via phone who verified APSW-C received information from the facility regarding guardianship for R1. APSW-C stated there was a residency concern regarding what county was responsible for R1. APSW-C stated the facility had not asked APSW-C for guidance on how to keep R1 safe while guardianship was in process. APSW-C stated APSW-C would have suggested the facility implement door monitors, walk with R1 outside for safety, encourage R1's return to the facility, and work with R1's physician on medication. On 8/27/24 at 9:45 AM, Surveyor interviewed R1 who was in bed. R1 expressed no concerns regarding staff treatment, stated I'm just getting older and stated R1 had no way to get anywhere because R1 had no money. R1 had a flat affect and provided short answers to Surveyor's questions. On 8/27/24 at 11:41 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who stated LPN-E worked at the facility for approximately nine months and could not recall if the facility did elopement drills. When asked about R1's elopement status, LPN-E stated R1 was R1's own person and could sign R1's self out. LPN-E stated when the police brought R1 back, staff checked R1 for injuries and reminded R1 to sign out and let staff know when R1 left. On 8/27/24 at 12:06 PM, Surveyor interviewed NHA-A who reviewed sign out forms for R1 since admission. NHA-A stated R1 starting exiting the facility in mid-June without signing out or letting staff know after R1's friend got sick and could no longer see R1 or take R1 out of the facility. When Surveyor indicated several sign-out entries by R1 contained illegible dates and times, NHA-A verified many of R1's entries were illegible. On 8/27/24 at 12:59 PM, Surveyor interviewed DON-B. When asked what the facility did to keep R1 safe, DON-B stated staff checked on R1 to see if R1 went where R1 said R1 was going and stated, If (R1) agrees to come with us, we'll give (R1) a ride back. DON-B stated staff spoke with the police department and agreed if R1 was gone for more than two hours, staff would call the police to check on R1. DON-B indicated there was no documentation of the conversation but stated the Fire Chief was there. DON-B stated in June of 2024, a Certified Nursing Assistant (CNA) was on a walk with R1 and called the facility because R1 wanted to go to another city. DON-B met the CNA and R1 at an elementary school approximately 0.5 miles from the facility. The CNA called the rescue squad and R1 was adamant with the Fire Chief that R1 wanted to walk to another city. R1 stated R1 knew the city was 45 miles away and it would take R1 a couple days to get there which was why R1 had water and a sweatshirt. DON-B verified walking on an interstate highway was a safety threat and stated, That's why we set up if gone for more than two hours to call police. DON-B verified a lot can happen in two hours and there were concerns for R1's safety. DON-B stated if R1 didn't sign out, staff were to re-educate R1 when R1 returned to the facility. On 8/27/24 at 4:16 PM, Surveyor interviewed Social Services Designee (SSD)-F who had been in SSD-F's current role for approximately one year. SSD-F stated a month or two ago, R1 stated R1 wanted to go to another city and reconnect with family. SSD-F set up a meeting with R1 and the Aging and Disability Resource Center (ADRC) who spoke to R1, but stated they were not done with their assessment yet and had 30 days. SSD-F stated the IDT talked about R1's safety daily but SSD-F could not recall specifics. SSD-F stated the facility felt guardianship should be pursued which is why R1's physician completed guardianship exam documents. SSD-F verified SSD-F did not document the discussion with R1 but should have. SSD-F stated, It (R1's safety) was always talked about, but the big thing was (R1) was (R1's) own person and able to sign (R1's) self out so everyone was not sure if we were allowed to keep (R1) here. I know a few times staff has brought (R1) back. The failure to supervise a resident with impaired safety awareness, impaired cognitive function, and a history of exiting the facility without signing out or letting staff know the resident was leaving created a reasonable likelihood for serious harm which lead to a finding of Immediate Jeopardy. The facility removed the jeopardy on 8/28/24 when it completed the following: 1. Educated residents who leave the facility independently to sign out with their location and when they will return. 2. Offered R1 transportation to locations not within walking distance. 3. Updated the Wander Communication Binder. 4. Initiated monthly elopement drills. 5. Reeducated staff on the elopement/wander policy, including care planning and identification of potential elopement risks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and record review, the facility did not ensure a safe environment that was free from abuse for 1 Resident (R) (R1) of 3 sampled residents. On 10/2/23 at approximately 7:45 PM, R1 told Certified Nursing Assistant (CNA)-C that R2 had inappropriately touched R1 and had tried to get into R1's brief. CNA-C indicated the incident didn't happen and no action was taken. Approximately fifteen minutes later at 8:00 PM, staff heard R1 yell. Staff entered R1's closed door and observed R2, who was completely disrobed, on top of R1 and inappropriately touching R1. The facility's failure to supervise a resident who allegedly sexually abused another resident created a finding of immediate jeopardy that began on 10/2/23 at approximately 7:45 PM. Surveyor notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on 10/19/23 at 3:15 PM. The immediate jeopardy was removed and corrected on 10/2/23 at 8:00 PM. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a copyright date of 2023, indicated: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation and misappropriation of resident property .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation . On 10/19/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (also known as stroke; a brain lesion in which a cluster of brain cells die when they don't get enough blood) which resulted in hemiplegia (paralysis/immobility of one side of the body) of left side, right hand amputation, anxiety disorder, and depression. R1's Minimum Data Set (MDS) assessment, dated 10/2/23, stated R1's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated R1 was not cognitively impaired. On 10/19/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia (a group of symptoms associated with a decline in memory severe enough to reduce a person's ability to perform everyday activities) with behavior disturbance and macular degeneration (an eye condition which causes blurred or reduced central vision). R2's MDS assessment, dated 9/15/23, stated R2's BIMS score was 6 out of 15 which indicated R2 had severe cognitive impairment. R2's medical record indicated R2's Power of Attorney for Healthcare (POAHC) was responsible for R2's healthcare decisions. On 10/19/23, Surveyor reviewed the facility's investigation regarding an incident that occurred on 10/2/23 between R1 and R2. The investigation indicated: When writer (NHA-A) arrived on 10/2/23, NHA-A took a statement from R1 at 9:45 PM. R1 stated R2 entered R1's room and put a call light around R1's neck. While R2 put the call light around R1's neck, R2 tried to go into R1's brief. R1 activated the call light and attempted to holler for assistance. CNA-C entered the room. R1 told CNA-C that R2 put the call light around R1's neck and was going through R1's brief, but CNA-C said R2 did not do that because R2 was not in the room and the call light was not around R1's neck. According to R1, R2 came back into R1's room, undressed and got into bed with R1. R1 stated R2 crawled over R1's body, touched R1's chest, and said, I want to put your (genital) in my mouth .(R2's spouse's name), I have never felt like this in a long time and you are making me hot .and Give me a kiss. You are teasing me. During that time, R1 kicked the wall to get staffs' attention. R1 stated R2 briefly had R1's (genital) in R2's mouth, but not for long because R1 turned away from R2 to get away. When CNA-D entered the room, CNA-D observed R2's head on R1's stomach facing R1's private area. CNA-D stated R1's brief was intact, but R2 was pulling at it. CNA-D attempted to separate R2 from R1, but R2 was combative and said, Leave me alone, this is my (spouse), (spouse's name). CNA-D stepped out of R1's room and yelled for assistance. Licensed Practical Nurse (LPN)-E arrived, assisted R2 into R2's wheelchair, and covered R2 with a blanket. CNA-D and CNA-C assisted R2 back to R2's room where they helped dress R2 and put R2 to bed. The facility initiated 1:1 supervision for R2 at 8:30 PM on 10/2/23. An Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting on 10/6/23 at 9:00 AM indicated the root cause was that R1's allegation was not taken seriously. Throughout the week, the Social Services Director met with R1. Progress notes indicated R1 felt safe, but wanted to speak with a telehealth psychiatric physician about the incident. NHA-A followed up with R1 on 10/6/23 to check on R1's well-being. R1 informed NHA-A that R1 was doing well, but had recurring thoughts about whether the police were going to arrest R1. NHA-A assured R1 that R1 did nothing wrong and that the police had already closed the case. On 10/19/23, Surveyor reviewed a documented interview with R1, dated 10/2/23, that contained the following: The first time (R2) came in, (R2) was in (R2's) wheelchair by the refrigerator, and I was looking for my call light. (R2) noticed I was looking for my call light and grabbed my call light and put it around my neck. While (R2) was giving me my call light, (R2) was also trying to go in my brief. I turned the call light on, and I was hollering for someone to come in. (CNA-C) came in and I told (CNA-C) that (R2) was trying to get in my brief and had the call light around my neck. (CNA-C) said, Nope (R2) did not do that. I responded by saying look at my brief. It is ripped I did not do that. (CNA-C) took (R2) out of the room and then (CNA-C) left. (R2) came into my room again and continued to put (R2's) hand in my brief. (R2) got out of the wheelchair and took all of (R2's) clothes off and started to rub my chest and said let me get in the bed with you. (R2) got in bed with me and was crawling all over me. (R2) sat on my legs and was crawling all over my body. (R2) said that I want to put your (genital) in my mouth. (R2) said take your pants off and then started to take my brief off. I told (R2) I did not have any pants on, and (R2) started taking the brief and throwing it on the floor. (R2) scratched my right arm and my right side with (R2's) rings. During this time, no one was answering the call light, so I attempted to kick the wall to see if someone would answer me. (R2) kept saying give me a kiss and kept saying stop teasing me. (R2) said, (R2's spouse's name), I never felt like this in a long time, and you are making me hot. (R2) then stated where is your other hand did you die too? I told (R2) I had a stroke and blood clots. I felt very uncomfortable the whole time. (R2) said if I don't get in your bed we are going across the hallway to other room across the hallway. Right before (CNA-D) came into the room, (R2) grabbed my (genital) and put a little bit of it into (R2's) mouth. I do not think it was for very long because I kept trying to turn to the wall side of the bed until (R2) was over there and then I turned to the other side of the bed. When (CNA-D) came in, (R2's) head was still over my crotch. (CNA-D) told the (R2) get out and do not go into the room. (CNA-D) assisted (R2) outside my room. On 10/19/23, Surveyor reviewed a documented interview with R1, dated 10/6/23, that contained the following: I will start with the first time (R2) came in here and came up beside my bed and I told (R2) I was looking for my call light. (R2) gave me the call light and then put it on the other side of the bed and then (R2) backed up with the cable in (R2's) wheelchair. The cable ended up around my neck and (R2) just kept backing up and it started to choke me, so I pushed the button. (CNA-C) came in and I told (CNA-C) (R2) had already started to pull at my brief and was choking me with my call light. (CNA-C) said, No (R2) did not. I then told (CNA-C) that I did not rip my brief or put the call light around my neck. After (CNA-C) left, (R2) came back into the room and said, I am going to get into the bed with you. (R2) then said, Give me a kiss. Don't you love me anymore? (R2) kept saying, Stop teasing me. I told (R2) this is a nursing home, and we are not allowed to do those kinds of things here. Then (R2) got undressed and got up in my bed and was rubbing my chest and climbing on me and going from one side of the bed to the other side of the bed. I hit the call light and started to holler. (R2) told me to be quiet so nobody would come in. I told (R2) I wanted someone to come in. Then (R2) said, You are making me hot (R2's spouse's name). (R2) also said, Where's your hand, did it die too? This freaked me out when (R2) asked about my arm because I did not know what (R2) meant by it. I got nervous and shaky and started kicking the wall. That is when (CNA-D) came in. (CNA-D) came in the door, and (R2) was ripping at my brief. (CNA-D) told (R2) to get out and not come into my room. On 10/19/23 at 10:40 AM, Surveyor interviewed R1 who declined to discuss the details of the incident. R1 indicated R2 had not been in R1's room since the incident and R1 felt safe at the facility. On 10/19/23, Surveyor reviewed an interview statement from CNA-C, signed and dated 10/4/23, that indicated: On 10/2/23 at approximately 7:45 PM, CNA-C provided care at the end of the 200 wing. When CNA-C exited the room, CNA-C noticed R1's call light was on, entered R1's room and asked what R1 needed. R1 said there was a little old lady in R1's room who pulled at R1's brief and put R1's call light by R1's neck. CNA-C noted R1's brief was intact and the top was folded over the way CNA-C left it, and R1's call light was draped over R1's shoulder and across R1's chest. CNA-C turned off the call light, went to the nurses' station, and reported what R1 said to Registered Nurse (RN)-F. CNA-C also told RN-F that CNA-C thought R1 made up the incident because there was no one in R1's room, R1's brief was intact, and the call light was draped across R1's chest. On 10/19/23 at 2:20 PM, Surveyor interviewed CNA-C who indicated CNA-C entered R1's room sometime before 8:00 PM on 10/2/23 in response to R1's call light. CNA-C indicated there was no one in R1's room at that time. CNA-C stated, Nothing (R1) said was visible. Call light was where I put it, not around (R1's) neck. Brief was as I put it (when CNA-C assisted R1 earlier in the shift). CNA-C indicated CNA-C looked at R1's brief and saw nothing wrong. When asked if CNA-C looked for R2, CNA-C stated, (R2) was kinda on a roll that night, roaming (R2's) hall and out front by TV. I believe I saw (R2) by TV area (when CNA-C left R1's room). CNA-C indicated RN-F was in the front office when CNA-C reported what R1 said and also told RN-F that CNA-C saw no observation that it was true. On 10/19/23, Surveyor reviewed an email from RN-F to Director of Nursing (DON)-B, dated 10/9/23, that contained RN-F's statement regarding the incident on 10/2/23 at approximately 8:00 PM and indicated: RN-F finished charting and went to find LPN-E to tell LPN-E goodbye. RN-F saw the medication cart on the 200 hall, called for LPN-E, and heard LPN-E tell RN-F from R1's room to hurry up and get in there. When RN-F reached R1's doorway and looked in, RN-F witnessed LPN-E assist R2, who was completely disrobed, and encourage R2 to sit down in R2's wheelchair. LPN-E told RN-F what was reported to LPN-E by CNA-D and what LPN-E saw when LPN-E entered R1's room. RN-F immediately went to the nurses' station and called DON-B to report the incident while LPN-E removed R2 from R1's room. On 10/20/23 at 11:11 AM, Surveyor interviewed RN-F via phone. RN-F indicated CNA-C did not tell RN-F about the first allegation from R1. RN-F indicated RN-F did not know anything occurred until RN-F was called into R1's room by LPN-E as stated in RN-F's email to DON-B. RN-F indicated if CNA-C would have told RN-F about the first allegation, RN-F would have immediately informed DON-B or NHA-A and made sure R2 stayed away from other residents. On 10/19/23, Surveyor reviewed R1's medical record which indicated R1 did not have a history of similar allegations against other residents. During the investigation, Surveyor noted the care plan interventions implemented to protect other residents from R2 were in place. The failure to supervise a resident following an allegation of sexual abuse by another resident led to serious harm for R1 which created a finding of immediate jeopardy. The facility removed and corrected the jeopardy on 10/2/23 when it completed the following: 1. Put R2 on 1:1 supervision when out of room; Motion sensor on while in room to alert staff if R2 exits the room. 2. Moved R2 to a room further down the hallway from R1. 3. Offered telehealth psych services and a meeting with R1's physician. 4. Social Worker will meet with R1 once or twice daily. 5. Completed individual education with CNA-C and all staff education on abuse/reporting requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Between 02/14/22 and 02/17/22, Surveyor reviewed the medical record for R24. R24 most recently readmitted to the facility on [DATE] with diagnoses to include, but not limited to, dementia and hypertension. R24's most recent quarterly Minimum Data Set (MDS) assessment, dated 12/25/21, documented that R24 required set-up assistance for eating. R24's MDS documented that R24's weight was 128 pounds, and that R24 had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months that was not desirable through a weight loss program. R24's Brief Interview of Mental Status (BIMS) score documented a 3 out of 15, indicating severe cognitive impact. R24 is [AGE] years old. Surveyor located and reviewed the nutritional assessment on file for R24, dated 04/05/21. Surveyor was unable to locate any additional nutritional assessments completed for R24 since initial admission on [DATE]. R24's nutritional assessment documented that R24 was at moderate nutritional risk secondary to multiple medical diagnoses including dementia, history of COVID-19, hypertension; need for oral supplement and snacks to meet nutritional needs, variable meal intakes and weight fluctuations. MDS criteria for significant weight loss had not been identified in the 04/05/21 nutritional assessment. After indicators of weight loss were triggered via the MDS process, no additional nutritional assessment was completed. Current physician orders for R24 were reviewed with the following pertinent orders to weight loss and supplementation of weight: ~4 ounce House Shake, three times a day. Start date 01/30/22 (The MAR does not reflect the actual amount of fluids R24 drank of the supplement instead all supplements and medications for nutrition were simply documented as administered) ~Encourage to get up for meals three times a day. Start date 05/30/21 ~Weekly skin check with weight, vital signs, head to toe assessment, ear check and nail care. Document exceptions or abnormalities from baseline in progress note, if applicable. Every Saturday. Start date 08/15/20 ~ 20 milligram Furosemide (diuretic) tablet once a day for hypertension (high blood pressure). Start date 07/01/19. ~Regular diet, regular texture, and regular consistency Surveyor reviewed documented weights for R24. Over the last six months prior to survey, the following weights were noted: 08/11/21-142.5 09/22/21-135.1 10/04/21-135.6 11/15/21-137.9 12/15/21-128.3; 7.48% weight loss since previous month, no documentation of reweight in record, no dietary progress note located, no update to care plan noted 01/19/22-128.5 02/01/22-130.2 02/13/22-128.9 02/14/22-128.0; 10.18% loss from 8/11/21 weight. Additionally, R24's weights were documented monthly versus, as outlined in the physician orders, to complete weekly skin check with weight. Refusal of meals or meal intake tracking for R24 was reviewed for the past thirty days prior to survey. The following dates included missing intake documentation or missing refusal documentation: 01/20/22 - two missing intakes/documentations of refusal 01/21/22 - two missing intakes/documentations of refusal 01/22/22 - two missing intakes/documentations of refusal 01/23/22 - one missing intake/documentation of refusal 01/24/22 - one missing intake/documentation of refusal 01/25/22 - one missing intake/documentation of refusal 01/31/22 - one missing intake/documentation of refusal 02/01/22 - two missing intakes/documentations of refusal 02/03/22 - no documented intakes/refusals 02/05/22 - two missing intakes/documentations of refusal 02/06/22 - no documented intakes/refusals 02/07/22 - one missing intake/documentation of refusal 02/09/22 - two missing intakes/documentations of refusal 02/10/22 - no documented intakes/refusals 02/14/22 - two missing intakes/documentations of refusal R24's Activities of Daily Living (ADL) Self Performance Care Plan indicated the following approaches in regards to R24's eating function: -I am able to eat without assist after my meal has been set-up for me. At times I require prompts to continue. (Revised 03/07/21) -I am to be encouraged to be seated up in my wheelchair for all meals. (Revised 01/11/22) Surveyor completed observations of R24 during select mealtimes at the facility. Surveyor noted R24 was provided set-up assistance but inconsistent encouragement during dining. Additionally, Surveyor observed R24 to be lying in bed for all observed meals. On 02/15/22 at 11:10 AM, Surveyor observed R24's breakfast tray on R24's side table. The meal tray was noted to be uncovered and alongside R24's bed out of R24's reach. CNA task documentation noted 26-50% of meal eaten. On 02/16/22 at 8:23 AM, Surveyor observed facility staff bring R24 a breakfast tray in R24's room. Surveyor noted R24 was lying in bed with eyes closed. Staff set R24's tray on R24's over-the-bed table, uncovered the plate, and exited the room. At 8:54 AM, Surveyor observed R24 still lying in bed with eyes closed. R24's breakfast tray remained untouched. CNA task documentation noted R24 as having refused breakfast. On 02/16/22 at 12:07 PM, Surveyor observed NA-N bring the noontime meal tray to R24. R24 was lying in bed. Surveyor observed NA-N ask R24 which items on the tray R24 would like to eat, offer alternative food options, and provide set-up assistance with the tray before exiting the room. Surveyor observed R24 consume the noon meal with no concerns noted. CNA task documentation noted 26-50% of meal eaten. On 02/17/22 at 8:16 AM, Surveyor observed CNA-O bring R24 a breakfast tray in R24's room. Surveyor noted R24 was lying in bed, positioned drooping down in bed. CNA-O placed R24's meal tray on R24's over-the-bed table and uncovered R24's plate before exiting the room. CNA task documentation for meal intake was not entered into the facility record system for this meal. On 02/16/22 at 9:33 AM, Surveyor interviewed DM-F related to R24's level of assistance with eating. When asked if R24 requires assistance in eating, DM-F stated, Yes, very much so. Lots of cueing, encouragement. On 02/16/22 at 10:50 AM, Surveyor interviewed Dietician-D who stated Dietician-D performs the initial nutrition assessment within the first week of admission and annually. DM-F would perform the nutritional history that includes preferences and weights. DM-F also performs quarterly nutritional assessments. Dietician-D would add into the resident's care plan if they expect weight loss or add goals like BMI (body mass index) to stay within normal limits. 5. Between 02/14/22 and 02/17/22, Surveyor reviewed the medical record for R37. R37 admitted to the facility on [DATE] with diagnoses to include, but not limited to, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, and gastro-esophageal reflux disease (GERD). R37's most recent annual Minimum Data Set (MDS) assessment, dated 01/26/22, documented that R37 required set-up assistance for eating. R37's MDS documented that R37's weight was 153 pounds with no known weight loss. Surveyor located and reviewed the nutritional assessment on file for R37, dated 07/28/19. Surveyor was unable to locate any additional nutritional assessments completed for R37. R37's nutritional assessment documented that R37 was on a general diet. Additionally, R37's assessment did not indicate risk for nutrition, did not include recommendations or plans for weight maintenance, and did not include a recommended body weight range. R37 is [AGE] years old. R37's nutrition care plan, with a revision date of 04/28/21, included a focus area which stated, I need Dietary staff to Offered (sic) a Moist Mech Soft Avoid foods high in Potassium, Nectar Liquids diet plan. Note not to use salt sub.[substitute]. Observe weights and intakes. Observe skin and labs. Honor food preferences. Offer all meals in main dining room daily. Surveyor noted that the mechanical soft diet noted on the care plan was not reflected on the initial nutritional assessment on file for R37. Surveyor completed dining observations for R37. Surveyor noted meals were eaten in R37's room each day. On 02/16/22 at 8:39 AM, Surveyor observed R37 sitting in R37's room in a recliner eating breakfast independently. Surveyor noted the meal tray included mechanically soft food. Additionally, at 8:30 AM on 02/17/22, R37 was observed eating breakfast in R37's room. Surveyor reviewed MDS indicators for R37's annual/initial MDS nutrition evaluations and noted consistent weight loss year-over-year: 07/25/19-188 pounds 04/09/20-168 pounds 01/30/21-149 pounds 01/26/22-153 pounds Surveyor reviewed documented weights for R37 and noted: 01/04/22-152.9; 5.56% weight loss since previous month, no documentation of reweight in record, no dietary progress note located, no update to care plan noted 02/14/22-144.4 3. R32 was admitted [DATE] with pertinent diagnoses including Diabetes Mellitus (DM) Type 2, dementia, metabolic encephalopathy (alteration of brain function or consciousness due to failure of other internal organs,) CKD (chronic kidney disease) Stage 3, failure, anxiety disorder, and major depressive disorder. R32's most recent Basic Interview for Mental Status (BIMS) on 01/14/22 was 3 indicating severely impaired cognition. R32's BIMS at admission was 12 indicating moderately impaired cognition. R32 is [AGE] years old. On 02/15/22 at 11:16 AM, Surveyor interviewed R32's activated Healthcare Power of Attorney (HC-POA). HC-POA stated R32 did have weight loss and could see R32 appeared to look like R32 had weight loss when HC-POA visited. R32's medical record contained one Nutritional assessment dated [DATE] performed by Dietician-D. The Nutritional Assessment included: Diet Order: consistent carbohydrate, cardiac diet, regular consistency with thin liquids Food Allergy or Intolerance: NKFA (no known food allergies) Most recent height in inches: 68 Most recent weight: 220.2 lbs Recommended Weight Range: 140 lbs +/- 10% Adjusted Body Weight: 160 lbs Status: Obese Diuretic Therapy: Yes Planned Weight Changes: No Medications (Nutritional impact): furosemide (diuretic), Flomax (urinary retention), potassium chloride, metformin (anti-diabetic), sitagliptin phosphate (anti-diabetic.) Skin Breakdown: No Other/Comments: 05/12/21 Braden scale score (scale for predicting pressure injury risk) = 19, low risk Edema: No Estimated Nutritional Needs: Adj wt (adjusted weight) 73 kg (kilograms) (160.6 lbs) .Total kcal 1679-1825 .Total Protein 58-73 .Total Fluids, Total mls (milliliters) 1679 - 1825 Nutritional Assessment/Recommendations: Assessment: Resident admitted to SNF (Skilled Nursing Facility) for therapies and skilled nursing care s/p (status post) hospitalization for fall at home, altered mental status, and UTI (urinary tract infection). Resident [named individual] POA (Power of Attorney) however resident is able to make simple nutritional needs and preferences. Resident appears to be tolerating current diet well with no chewing or swallowing difficulties. Variable meal intakes noted, 25-75% with occasional acceptance of snacks. Dehydration score=3, low risk. Weight trend reviewed, stable since admission. BMI=33.4 obese. Resident is currently at moderate nutritional risk secondary to multiple medical diagnosis including DM, metabolic encephalopathy, dementia, hyperlipidemia, anxiety disorder, CKD-stage 3, major depressive disorder, hypertension; need for therapeutic diet, variable meal intakes, and high BMI (body mass index.) Goals: Diet compliance. Consume and tolerate >50% of meals, consistently to help maintain good skin integrity with no s/s (signs and symptoms) of dehydration or malnutrition. No significant weight changes per MDS criteria however gradual weight loss desired which may be beneficial for multiple medical diagnoses. Plan/Recommendations: Monitor meal intake, labs prn (as needed), weight trend, skin integrity, diet compliance and plan of care. R32's medical record contained one Nutritional History dated 05/26/2021 by DM-F. The Nutritional History included: Diet Order: Offered Consist[[NAME]] Carb (carbohydrate) - Diabetic, Cardiac -Low Fat, Low chol (cholesterol) NAS (no added salt) Supplements: blank Diagnosis: Dem (dementia), Kid Fail (kidney failure), Hyperlip (hyperlipidemia), HTN (hypertension), UTI, Edema Medications: blank Most Recent Height: 66 Most Recent Weight: 281.6 Recommended weight range: blank Skin Breakdown: No Allergies: No Food intolerances: No Cultural, religious, ethnic food restrictions: No List Resident's daily food preferences (such as type of eggs, cereal, etc.): blank List the Resident's least favorite foods: blank List Resident's beverage choices for each meal: blank Will meals be eaten in dining room: No Is assistance required: No Does Resident have dental problems which will affect intake: No Are there difficulties chewing or swallowing: No Does Resident have a good appetite? Yes Have there been recent changes in intake/appetite? No Does Resident complain of changes in food taste? No Has there been a recent weight loss? No Has there been a recent weight gain? No Are there complaints of diarrhea or constipation? No Comments: Seeing ST (Speech Therapy) at this time. Observe weights and intakes. Observe skin and labs. Honor food preferences. Offer all meals in room at this time. Offer set-up of meals as needed daily. Observe for meal refusals and meal satisfaction. Offer snacks and fluids. Encourage fluids w/ (with) and between meals daily. Offer meal time reminders as needed daily. Observe appetite and eating abilities. Encourage nutrition as able as needed daily. RD (Registered Dietician) review PRN. Record food intakes. Offer alternate food items for all meals as requested. R32's Meal Ticket (contains a resident's diet and specific instructions) dated 02/16/2022 for breakfast stated: Dislikes: Egg; Likes: blank. R32's quarterly care conference dietary notes documented by DM-F included: 05/08/21 - Elder is seeing ST (Speech Therapy) at this time. Offered a Diabetic, Cardiac diet plan. Aware of meal times-no nutritional concerns at this time. Snacks between meals as she pleases daily. Makes needs known. 08/03/21 - Offered a General, Consistent Carb diet plan. Weight is slightly down since admission. Select preferences and patterns. Skin intact. Makes needs known. Aware of meal times - independent. Snacks between meals as (R32) pleases daily. 11/03/21 - Offered a Consistent Carb - Diabetic, Cardiac - Low Fat, Low Chol, NAS diet plan. (R32) has had a weight loss since admission. (R32) has fluid concerns nursing deals with. (R32) keeps to self in room as preferred. (R32) has lived a rather extensive wealthy lifestyle prior to admission with a daily routine that (R32) stuck to. Aware of meal times - feeds self, snacks between meals as (R32) pleases. Makes needs known. 12/27/21 - Offered [Vit] D3, Oyster supplement. Offered Consistent [Carb] - Diabetic, Cardiac - Low Fat, Low [Chol], NAS diet plan. Aware of meal times - independent. Snacks between meals as (R32) pleases daily. Small appetite and intakes. Weight loss fluctuation. Makes needs known. Select patterns and preferences and odd behaviors. R32's MDS contained the following weights: 05/12/21: 220 lbs. 06/01/21: 219 lbs. 09/01/21: 206 lbs. 11/24/21: 192 lbs. MDS section K0300 indicated a loss of 5% or more in the last month or loss of 10% or more in last 6 months as 2. Yes, not on physician-prescribed weight-loss regimen. 12/21/21: 185 lbs. 12/31/21: 179 lbs (6.77% weight loss in one month from 11/24/21.) Not identified in MDS as weight loss. 01/14/22: 179 lbs. Identified in MDS as weight loss. R32's medical record dated 02/14/2022 contained R32's most recent weight as 153.7 lbs which was a 25.39% weight loss in 5.5 months and 14.13% weight loss in one month. R32's medical record included weight summary and warnings as weights were documented in electronic medical records as indicated below: *05/05/2021, 220.2 lbs, Scale: Standing, no warnings *05/16/2021, 218.6 lbs, Scale: Standing, no warnings *06/04/2021, 218.2 lbs, Scale: Standing, no warnings *06/08/2021, 217.1 lbs, Scale: Standing, no warnings *07/09/2021, 218.0 lbs, Scale: Standing, no warnings *07/13/2021, 215.8 lbs, Scale: Standing, no warnings *08/11/2021, 206.0 lbs, Scale: Standing Warnings: -5% change [Comparison Weight 07/09/2021, 218 lbs, -5.5%, -12.0 lbs] *09/28/2021, 200.7 lbs, Scale: Standing Warnings: -7.5% change [Comparison Weight 07/09/2021, 218 lbs, -7.9%, -17.3 lbs] *10/14/2021, 198.3 lbs, Scale: Standing, no warnings *11/02/2021, 191.8 lbs, Scale: Standing Warnings: -10% change [Comparison Weight 05/16/2021, 218.6 lbs, -12.3%, -26.8 lbs] *12/09/2021, 185.3 lbs, Scale: Standing Warnings: -7.5% change [Comparison Weight 09/28/2021, 200.7 lbs, -7.7%, -15.4 lbs], -10% change [Comparison Weight 07/09/2021, 218 lbs, -15.0%, -32.7 lbs] *12/24/2021, 185.3 lbs, Scale: Mechanical Lift Warnings: -7.5% change [Comparison Weight 09/28/2021, 200.7 lbs, -7.7%, -15.4 lbs], -10% change [Comparison Weight 07/09/2021, 218 lbs, -15.0%, -32.7 lbs] *12/25/2021, 185.5 lbs, Scale: Mechanical Lift Warnings: -7.5% change [Comparison Weight 09/28/2021, 200.7 lbs, -7.6%, -15.2 lbs], -10% change [Comparison Weight 07/09/2021, 218 lbs, -14.9%, -32.5 lbs] *12/26/2021, 178.6 lbs, Scale: Mechanical Lift Warnings: -7.5% change [Comparison Weight 09/28/2021, 200.7 lbs, -11.0%, -22.1 lbs], -10% change [Comparison Weight 07/09/2021, 218 lbs, -18.1%, - 39.4 lbs] *01/01/2022, 179.4 lbs, Scale: Mechanical Lift Warnings: -7.5% change [Comparison Weight 10/14/2021, 198.3 lbs, -9.5%, -18.9 lbs], -10% change [Comparison Weight 07/09/2021, 218.0 lbs, -17.7%, -38.6 lbs] *02/14/2022, 153.7 lbs Scale: Mechanical Lift Warnings: -7.5% change [Comparison Weight 12/09/2021, 185.3 lbs, -17.1%, -31.6 lbs], -10% change [Comparison Weight 09/28/2021, 200.7 lbs -23.4%, -47 lbs] R32 lost 66.5 lbs. in 10 months, a loss of 30%. R32's MDS Section G contained the following Activities of Daily Living (ADL) Assistance: 05/12/2021: H. Eating - how resident eats and drinks, regardless of skill . Self-Performance: 0. Independent - no help or staff oversight at any time Support: 1. Setup help only. 09/01/2021: H. Eating - how resident eats and drinks, regardless of skill . Self-Performance: 1. Supervision - oversight, encouragement or cueing Support:1. Setup help only. 11/24/2021: H. Eating - how resident eats and drinks, regardless of skill . Self-Performance: 0. Independent - no help or staff oversight at any time Support:1. Setup help only. 12/31/21: H. Eating - how resident eats and drinks, regardless of skill . Self-Performance: 0. Independent - no help or staff oversight at any time Support:1. Setup help only. 01/14/2022: H. Eating - how resident eats and drinks, regardless of skill . Self-Performance: 1. Supervision - oversight, encouragement or cueing Support: 2. One person physical assist. On 02/16/22 at 9:32 AM, Surveyor interviewed Dietary Manager (DM)-F regarding R32's weight loss. DM-F stated it was challenging meeting everyone's individual needs compared to when group dining was allowed to happen. DM-F stated the nutritional intervention in place for R32 was nurses provided house shake to R32 as a nutritional supplement. DM-F stated R32 had a lot of behaviors that could make it difficult to eat. DM-F stated R32 can feed self and at times will allow staff to assist with eating. DM-F stated R32 wants to be independent, but that is not in R32's best interest. DM-F stated the interventions in place are to provide the house shake to R32 and assist if R32 allows. Review of R32's medical record did not include an order for house shake. House shake was not included in R32's care plan. R32's dietary care plan included: Focus: I have an alteration in my nutritional status secondary to multiple diagnoses . need for therapeutic diet, variable meal intakes suspected due to my mood swings and behaviors, and high BMI (body mass index.) 05/06/21 revised 02/16/22. Goal: I will be compliant with therapeutic diet as recommended by MD/NP (Medical Doctor/Nurse Practitioner.) I will consume and tolerate >50% of meals, consistently to help maintain good skin integrity with no s/s (signs and symptoms) of dehydration or malnutrition. I will have no significant weight changes per MDS criteria however gradual weight loss desired which may be beneficial for multiple medical diagnosis. Weight goal: BMI to remain WNL (within normal limits.) Date initiated 05/06/21 revised 02/16/22. Interventions: Diet - Consistent carbohydrate, cardiac diet, regular texture, regular consistency. Date initiated 09/02/21. Revision on 12/01/21. Discuss nutritional approaches with IDT (interdisciplinary team) as needed. Review with nurse prn (as needed) for changes in medical status that may impact nutritional status. Encourage diet compliance. Date initiated 07/15/21. Obtain weight per facility protocol using same weight method for weight trend accuracy. Report significant weight changes to MD/NP and RD/DM (Registered Dietician/Dietary Manager.) Date initiated 05/14/21. Dehydration Risk Screener: 05/06/21 low risk 3 - states no weight loss 06/01/21 low risk 3 - states no weight loss 09/01/21 low risk 3 - states no weight loss 12/25/21 mild risk 6 - states no weight loss. On 02/16/22 at 10:50 AM, Surveyor interviewed Dietician-D who stated Dietician-D performs the initial nutrition assessment within the first week of admission and annually. DM-F would perform the nutritional history that includes preferences and weights. DM-F also performs quarterly nutritional assessments. Dietician-D would add into the resident's care plan if they expect weight loss or add goals like BMI (body mass index) to stay within normal limits. On 02/16/22 at 3:33 PM, Surveyor interviewed Dietician-D who stated if Dietician-D needs to make a dietary recommendation for a resident, Dietician-D would sent the recommendation to DM-F through email or if in the facility, would discuss in person. Dietician-D stated it would be up to the MD or facility to implement the recommendations. Dietician-D verified Dietician-D did not have any communication or emails pertaining to R32. Dietician-D did not recall any communication regarding R32 and weight loss. Dietician-D stated R32's weight loss was a significant weight loss according to MDS. Dietician-D stated it was not necessarily desired to have R32 lose that much weight, but is still expected to see some desirable weight loss. Dietician-D stated communication could always be better and went on to explain Dietician-D oversees six facilities and the company is in the process of outsourcing this facility and another facility due to substantial drive times. Dietician-D stated if the facility had notified Dietician-D of R32's significant weight loss, Dietician-D would perform an assessment on R32 which would trigger new dietary interventions. Dietician-D stated the expectation is Dietician-D and DM-F should know about weight loss in residents. Dietician-D stated the MD or Nurse Practitioner (NP) should also be informed. Dietician-D stated if a resident had desired weight loss, Dietician-D would not expect MD to know, but MD or NP know that a resident had significant weight loss. Dietician-D would expect re-weigh from R32's last weight taken on 02/14/22 due to weight loss from previous weight. Dietician-D verified R32 did see weight loss while reviewing R32's medical record with Surveyor. Dietician-D stated resident's needs are calculated and if they eat more than 50% of what they are provided for meals they are getting what they need because meals are calculated to be 2000 calories per day. Residents are also offered snacks. Dietician-D stated Dietician-D would also look to see if R32 was breathing better after weight loss considering R32's current health. R32's meal intake between 01/19/22 through lunch 02/17/22 had an opportunity for 89 meals to be documented. Documentation was as followed: What percentage of the meal was eaten? 0-25% - 6 meals 26% - 50% - 9 meals 51% - 75% - 21 meals 76% - 100% - 12 meals Resident Not Available - 1 meal Resident Refused - 4 meals Not Applicable - 0 meals 36 meals not documented. R32's HS (bedtime) snack acceptance between 01/18/22 through 02/15/22 had an opportunity for 29 snacks to be documented. Documentation was as followed: Did resident accept snack? Yes - 13 No - 6 Resident Not Available - 0 Resident Refused - 0 Not Applicable - 3 7 snacks not documented. On 02/16/22 at 3:56 PM, Surveyor interviewed Director of Nursing (DON)-B who stated R32 may have had weight loss because R32 goes through spurts of throwing food and not eating. DON-B stated R32 refuses many things, like weights, and had many behaviors. DON-B stated Dietician-D will send resident specific nutrition recommendations to DON-B, and will then forward to the MD and ask if MD wants to implement the recommendation, to send the order. DON-B also stated that meal percent eaten should be documented for all meals. On 02/17/22 at 12:54 PM, Surveyor interviewed DON-B who stated on Fridays when the MD rounds, MD will talk to nurses and go through the facility's list of resident concerns. If MD adds an order for a resident, the orders are transcribed into the resident's medical record. DON-B stated a lot of R32's weight loss is due to R32's mood. DON-B stated R32 generally will eat breakfast but will throw or dump out lunch and dinner. Based on observation, interview, and record review, the facility did not ensure residents maintained acceptable parameters of nutritional status for 5 Residents (R) (R13, R17, R32, R24, and R37) of 8 reviewed for nutrition concerns. R17 sustained a severe weight loss of 25.51% from 09/06/21 to 02/05/22. The facility did not implement Dietician-D's recommendations for monitoring nutritional status. Additionally, the facility did not have a systemic process to record, monitor, and assess R17's intake when R17 developed a stage IV pressure injury. R13 sustained a severe weight loss of 16.43% from 08/11/21 to 02/17/22. The facility did not properly assess, evaluate, and address R13's nutritional status. The facility did not have a systematic process to record, monitor, and assess R13's intake needs and implement corrective actions to prevent malnourishment for R13. The facility did not accurately assess, evaluate, and address the nutritional needs of R32. R32 sustained severe weight loss. R32's medical record dated 02/14/22 contained R32's most recent weight as 153.7 lbs which was a 25.39% weight loss in 5.5 months and 14.13% weight loss in one month. R24 sustained a severe 10.18% weight loss between 08/11/21 and 02/14/22. The facility did not provide timely assessments or interventions to ensure R24 maintained nutrition status or was maintaining R24's usual body weight. R37 sustained a severe weight loss of 5.56% between 01/04/22 and 02/14/22. The facility did not provide timely assessments or interventions to ensure R37 maintained nutrition status or was maintaining R37's usual body weight. Additionally, observations were made whereby R37 was not provided dining assistance when assistance was required per resident care plan. These failures created a finding of Immediate Jeopardy that began on 08/11/21. NHA (Nursing Home Administrator)-A was notified of the Immediate Jeopardy on 03/02/22 at 12:45 PM. The Immediate Jeopardy was removed on 03/03/22, however the deficient practice continues at a scope and severity of E (potential for more than minimal harm, pattern) as the facility continues to implement its action plan. Findings Include: The facility policy and procedure titled, Weight Assessment and Intervention, states; Weight Assessment: 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Weights will be recorded in residents medical record. 3. Any weight change of 5% or more since the last weight assessment a weight will be retaken for confirmation. If the weight is verified, nursing will notify the Dietician. 4. The Dietician will respond after notification. 5. The Dietician will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. 7. If the weight is desirable, this will be documented and no change in the care plan will be necessary. 1. R17 was admitted to the facility with diagnoses to include hypertension, dementia, and osteoarthritis. R17 also has a Stage IV Pressure Injury on the left heel along with a Stage II and an Unstageable Pressure Injury to the left toes. R17's most recent MDS assessment, dated 02/01/22, indicates R17 requires one staff assist along with supervision during eating. R17 is [AGE] years old. R17's nutritional care plan, revised 07/11/19, states: I Have: Potential for Alteration in nutrition. Weight Fluctuation. Potential for Skin Problems and or breakdown. BECAUSE I: Adjustment to the nursing facility. Loss of husband - adjusted from that. Elder is on the go walks all over facility as she pleases. Dietary staff: Observe weights and intakes. Observe skin and labs. Honor food preferences. Offer all meals in the main dining room daily or room trays as requested. Offer set-up of meals as needed daily. Observe for meal refusals and meal satisfaction. Offer snacks and fluids. Encourage fluids w/and in between meals daily. Offer meal time reminders as needed daily. Observe appetite and eating abilities. Encourage nutrition as able as needed daily. RD review PRN. Offer alternate food items for all meals requested. I will have no significant weight changes per MDS criteria. Weight goal: BMI to WNL. Gradual weight loss expected with disease progression and overall decline. I will consume and tolerate >50% of meals, consistently to help promote healing with no s/s of dehydration or malnutrition. I will not experience negative effects related to dehydration/fluid deficit. Discuss nutritional approaches with IDT as needed. Review with nurse, prn for changes in medical status that may impact nutritional status. Obtain weight per facility protocol using same weight method for weight trend accuracy. Report significant weight changes to MD/NP and RD/DM. Offer and encourage NT fluids throughout the day to help maintain hydration status. Monitor for s/s of dehydration and report significant changes to MD/NP. Offer HS snack. Report acceptance. provide oral supplement per MD order I need my nurses to observe weights and intakes. Observe skin and labs. Observe for meal refusals and meal satisfaction. Encourage fluids w/ and in between meals daily. Offer meal time reminders as needed daily. Observe appetite and eating abilities. Encourage nutrition as able as needed daily. I need my aides to obtain weekly weights. Observe skin report any skin redness to CN promptly. Offer set-up, assistance, cues and encouragement for all meals as needed daily. Observe for meal refusals and meal satisfaction. Offer snacks and fluids.